Inspection on 01/02/06 for Leycester House

This inspection was carried out on 1st February 2006.

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

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

Other inspections for this house

Leycester House 26/09/07

Leycester House 27/09/06

Leycester House 28/07/05

Leycester House 03/11/04

Leycester House 10/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Leycester House Edensfield Road Mobberley Knutsford Cheshire WA18 7JG Lead Inspector Bronwyn Kelly Unannounced Inspection 1st February 2006 09:45 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 Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leycester House Address Edensfield Road Mobberley Knutsford Cheshire WA18 7JG 01565 872496 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) www.clsgroup.org CLS Care Services Limited Stephen Maddock Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (40) Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 40 service users to include: * Up to 40 service users in the category of OP (old age, not falling within any other category) * 1 named service user in the category of DE(E) (dementia over the age of 65) * 1 named service user in the category of MD (mental disorder, excluding learning disability or dementia, under the age of 65) The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 28th July 2005 2. Date of last inspection Brief Description of the Service: Leycester House is a purpose built home providing care and accommodation for 40 older people. The home is part of CLS Care Services Limited, a not for profit organisation that owns a number of care homes in the Northwest area. Leycester House is in the village of Mobberley, close to the local shops, GP, pub, chemist and bus stop. Mobberley is approximately mid-way between the towns of Knutsford and Wilmslow. Leycester House is a two-storey building and there is a passenger lift for access between floors. Residents accommodation consists of 40 single bedrooms all with wash hand basins. There are sufficient communal rooms such as lounges, dining rooms, activities area and a smoking lounge. The home also provides day care for up to 5 people per day and a separate lounge is available for this purpose. A central courtyard includes a pleasant garden area with outdoor seating for residents and visitors to use and a new raised patio area. This is fully accessible to service users. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over six hours on one day. A tour of the building took place, and with the permission of the residents, a number of bedrooms were seen. A variety of records were examined as part of the inspection. Part of the process of the inspection is to listen to the views of the residents that live in the home and listen to the views of their relatives and visitors. On this occasion, four residents were spoken with privately and group discussions took place in lounge and dining areas with a number of other residents. One visiting relative was happy to give his views of the home during the inspection. The views of three care staff, care team leader, cook and manager were also listened to. What the service does well: What has improved since the last inspection? Staff vacancies have continued to be filled over the last six months, including two permanent cooks. Training for care and housekeeping staff continues to be provided. A number of bedrooms have been re-decorated or provided with new carpets. Care plans are now developed sooner for new residents moving into the home, ensuring staff have the correct information to meet the residents’ needs. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 6 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. Leycester House DS0000006512.V266932.R01.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 Leycester House DS0000006512.V266932.R01.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): 1 and 3. Standard 6 does not apply, as intermediate care is not provided. Residents’ needs are assessed before they move into the home to ensure they can be met. Good information is available for service users to help them make a decision about moving into the home. EVIDENCE: The service user guide has recently been updated, and a copy has been placed in each resident’s bedroom. This is called ‘Your Guide To Living In Leycester House’. A copy is available in the hall for any visitors to see. This guide provides information about what the home offers to residents living there and the range of facilities and lifestyle residents can expect. It also contains the results of a recent satisfaction questionnaire survey that the home completed with the residents. This is useful for prospective residents to see what those who live in the home think of the services and care provided. The admission procedure ensures that new residents are fully assessed prior to moving into the home. Records were seen of this on care plans plus evidence Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 9 of liaison with social work and health professionals as part of the assessment procedure. Staff members confirmed that either the manager or care team leader visits each resident prior to them moving into the home, except in emergency situations. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 10 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, 9 and 10 There is a clear care planning system in place to provide staff with the information they need in order to meet the needs of the residents. The procedures for administering medication have not always been followed. Personal support is provided in a way that ensures residents’ privacy, dignity and independence. EVIDENCE: Four residents’ plans of care were seen and each showed what staff need to do to meet their needs. A recommendation was made to the manager to include more information in the care plans of residents who have diabetes. The recording of residents’ hobbies, interests and how their leisure needs are met is being developed, and has improved since the last inspection. The residents’ care plans are well written, up to date and reviewed on a regular basis. This ensures that residents’ changing needs are always recorded in the plans of care so that all staff are aware and can meet individual needs. Although there are policies and procedures for the safe administration of medication to residents, some procedures were not being followed. No record Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 11 was being kept of any medicines returned to the chemist, and changes to dosages in the controlled drugs book were not properly accounted for. Some of the administration records in this book were being completed before the administration of the medication. There were also very large stocks of medication for some residents in the storage room. These factors could be a risk to residents. The care staff spoken with gave examples of the way in which they work to ensure that residents are treated with respect and enabled to have some dignity and choice in their lives. The residents confirmed that staff knock on their doors before entering. A number of residents prefer to live and take their meals in their own rooms. Residents said staff respect this decision and do not pressure them to sit in the lounge or dining room with others. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 12 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): 12,13 and 14 Social activities provided in the home are well organised and provide stimulation and interest for the residents. Visits to the home by family and friends are encouraged at any time, helping to ensure that residents maintain contact with their family. Support is offered to residents in such a way as to promote choice and control over their lives. EVIDENCE: A part time activities co-ordinator arranges a weekly programme of activities that is displayed on posters around the home. One lounge area of the home has been turned into a reminiscence area. The activities co-coordinator spends some time on a one-to-one basis with residents as well as organising group inhouse activities. Plans are underway for residents to attend a regular Tea Dance at the Civic Centre and a pub lunch is being organised. Residents meetings are held monthly, and the minutes seen by residents or read to them. There are opportunities for residents to join in with some of the daycare clients’ activities. Many are acquainted with each other, having lived in the area for a number of years. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 13 Residents are able to have visitors at any time, and a visitor to the home confirmed this. Residents are encouraged to be as independent as possible and have choice and control in their lives. One resident said she liked to be vocal at residents’ meetings and raise any issues she had concerns about. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 14 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): 18 Arrangements for protecting residents from abuse are satisfactory so that residents are not at risk from harm or poor practice. Policies and procedures regarding the handling of residents’ finances protect them, as far as possible, from abuse. EVIDENCE: The correct policies and procedures are in place to ensure residents are protected from abuse, and many of the staff have attended a training session in the past. The manager is planning further training to update their knowledge. Systems are in place to help residents with their financial affairs, which are in line with CSCI recommendations. Residents who are unable to look after their own affairs may keep their money centrally in a CLS residents’ savings bank account and accrue interest. Details can be accessed for each resident at any time on the home’s computer. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 15 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): 19 and 26 The home provides a comfortable and safe standard of accommodation for those living there. EVIDENCE: The home is reasonably well maintained and suits the needs of the residents. It is decorated and furnished in such a way as to create a homely environment for the residents. A programme of refurbishment is in place, and bedrooms are refurbished on change of occupier. Since the last inspection, a number of bedrooms have been decorated and new lounge chairs have been ordered. The manager was able to identify various areas of the home that are now in need of refurbishment, and has plans to action these. The residents’ bedrooms looked comfortable and homely, as they are able to bring in items of their own furniture and possessions with them. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 16 All areas of the home seen were clean with no unpleasant odours identified. There is a courtyard and a new raised patio provided for residents outside, furnished with chairs and brollies for the warmer weather. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 17 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): 27,28,29 and 30 Although there are less than the recommended numbers of qualified care staff working in the home, the residents’ needs are met by a caring staff team. Staff morale is good and in-house training is continuing, ensuring staff are competent to do their jobs. EVIDENCE: The home has continued to fill vacant posts over the past few months, so that less agency staff are required to work in the home. This has continued to provide continuity of care for the residents. The care staff group are continuing with their training, and hope to reach the government’s December 2005 target of 50 trained care staff this year. To date, 7 of the 25 care staff hold an NVQ qualification (28 ) and 5 are working towards it, due to complete in the near future which will bring the total to 48 . Many of the general staff have commenced NVQ training in housekeeping. CLS have a good commitment to NVQ training. The staff files of the two latest members of the care team to be employed were checked. Both contained two references and evidence of an interview. Evidence was seen to show that all staff working in the home have had a Criminal Records Bureau check completed, with only one not yet returned. The manager is following up this delay. These procedures and checks help Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 18 ensure that only the right people are employed in the home to care for vulnerable elderly people. When new members of staff commence work, they have an induction course. Staff spoken with confirmed that further training is available to all staff to enable them to do their jobs. Staff were seen to enjoy working in the home and communicate well with the residents. One member of the care team said, “We all get on and work as a team”. The residents gave many complimentary comments about the staff group. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 19 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 and 35 The home is well run by a qualified manager, ensuring the residents are safeguarded. EVIDENCE: The manager holds the Registered Managers Award, and has had a number of years experience as a manager. The staff spoken with describe him as approachable and supportive. Residents also spoke highly of the manager. As discussed in standard 18, systems and safeguards are in place to assist residents who do not wish or are unable to care for their own money. Small amounts of money are sometimes left for safe keeping by relatives. The accounts and receipts for this were seen to be in good order. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 20 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 21 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 OP9 Regulation 13(2) Requirement Proper arrangements must be made for the recording, safekeeping and disposal of medicines. Timescale for action 28/02/06 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 Refer to Standard OP28 Good Practice Recommendations A minimum of 50 of the care staff should be trained to NVQ level2 or equivalent. Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Leycester House DS0000006512.V266932.R01.S.doc Version 5.0 Page 23 - 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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