Inspection on 15/06/05 for Leylands Rest Home

This inspection was carried out on 15th June 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Leylands Rest Home 01/11/07

Leylands Rest Home 06/02/07

Leylands Rest Home 07/02/06

Leylands Rest Home 20/01/05

Leylands Rest Home 29/07/04

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

CARE HOMES FOR OLDER PEOPLE Leylands Rest Home 16/18 Leylands Lane Heaton Bradford BD9 5PX Lead Inspector Steve Marsh Unannounced 15th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leylands Rest Home Address 16/18 Leylands Lane Heaton bradford BD9 5PX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 543935 01274 770035 Ms Annette Nerteley France Ms Annette Nertleley France Care Home Only 17 Category(ies) of Mental Disorder Over 65 (1) Dementia over 65 registration, with number (17) Physical Disability Over 65 (1) Dementia of places (1) Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20/01/05 Brief Description of the Service: Leylands Rest Home is a large four-storey inner through terraced property located in the Heaton area of Bradford, close to the local shops and other community facilities. The home is primarily a dementia care unit although the present registration allows for one service user with a mental disorder and one service user with a physical disability to be cared for. Bedroom accommodation at the home consists of both single and double rooms situated on three floors of the building.There are stair lifts to the bedrooms on the first floor of the home, however the accommodation on the second floor can only be reached by climbing a number of steps and is therefore unsuitable for service users with mobility problems. All the communal areas used by the servic users are situated on the ground floor of the home and include two lounges (one non smoking) and a dining room. The home is situated in a main road position and is on a bus route from Bradford City centre. There is a small garden area to the front of the propertyand ramped wheelchair access is available to the main entrance. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection for the year 2005/06, and was carried out by one Inspector over a period of approximately eight hours. The last inspection of this service was in January 2005 and the main purpose of this inspection was to assess the homes progress in meeting the requirements highlighted in the inspection report. The methodology used in this inspection included the examination of records, observation of work practices, discussion (group and individual) with residents, visitors, staff and management and a partial tour of the premises. Due to their illness some residents found it difficult to express their opinions about the home, however those that where able felt the staff provided a very good standard of care. Comment cards were provided for residents and/or their relatives to enable them to share their views of the service with the Commission; comments received in this way will be fed back to the registered provider/manager of the home without revealing the identity of the respondents. Feedback was given to Ms Annette France (registered provider/manager) at the end of the visit. The Inspector has visited Leylands Rest Home over a period of approximately four years and therefore drew on information already known about the home when completing this report. People living at the home confirmed that they like to be referred to as residents in inspection reports. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home provides a safe and comfortable environment for the residents, and all concerns/complaints are taken seriously by the manager and acted upon. The manager and members of the staff team are approachable, have a caring attitude and create a homely atmosphere for the residents in their care. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 6 Staff morale appears good, with staff working as a team for the benefit of the residents The admission procedure for the home is thorough and the manager will not admit a resident unless she feels that the staff team can provide the level of care/service they require. The resident’s healthcare needs are fully met, and any problems are identified at an early stage and a referral made to the appropriate professional agency. There is a genuine commitment to staff training and this reflected in the level of National Vocational Qualification (NVQ) training made available to the staff team. Recognised quality assurance monitoring systems are in place at the home and the views and opinions of the residents and their relatives are sought and acted on if appropriate. What has improved since the last inspection? What they could do better: The home could record pre-admission assessment information in a more user friendly format, to enable the information to be more easily accessed. Care plans must be completed for all new admissions to the home as soon as it is practical to do so, especially if the resident begins to exhibit behavioural problems and/or as specific care needs. Senior members of staff need to be more vigilant when recording and/or administering medication and ensure that procedures are followed. The manager must review the daily routines carried out by the care staff to ensure that they are flexible and allow the residents freedom of choice. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 7 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. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5, Residents are provided with sufficient information to enable them to make an informed decision about the home. The admission process is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: A copy of the homes brochure given to all prospective residents was seen, and found to be comprehensive, containing sufficient information to enable the resident and/or their relatives to make an informed decision about the home. The records examined provided evidence that pre-admission assessments are carried out, and the needs identified during this assessment are reflected in individuals care plan. The manager was, however, asked to review the way pre-admission assessment information is recorded to see if a more user friendly system could be put in place. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 10 The majority of admissions are planned, although the home continue to respond to crisis situations and will take emergency admissions providing the staff team are able to meet their needs. In addition to the pre-admission assessment visit, all prospective residents and/or their relatives are invited to visit the home prior to admission. A visitor confirmed that the staff had been very helpful when members of the family had initially visited the home looking for a place for their elderly relative and had shown them around the home and provided general information. Staff training continues to be encouraged at the home both to meet the needs of the residents and for personal development. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. Care plans are in place for all residents, however the manager must ensure that they are started/reviewed as soon as problems are identified to safeguard the residents and staff. Records and reports about the residents welfare show that their healthcare needs are fully met, and any problems are identified at an early stage and a referral made to the appropriate professional agency i.e. general practitioner, district nurse etc. The manager must ensure all members of the senior staff team follow the procedures in place for the administration of prescribed medication, to safeguard the residents from possible mistakes being made. EVIDENCE: Care plans have been completed for all residents and cover all aspects of their welfare. The care plans are reviewed on a monthly basis or sooner if the needs of individual residents change significantly. It is normal practice for the home to complete the care plans for new admissions following their initial assessment period, however the manager was Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 12 advised that for residents exhibiting behavioural problems during this period care plans must be implemented immediately, and reflect how the staff team are going to manage their behaviour. All the residents are registered with a general practitioner, and have access to the full range of NHS services. The residents confirmed that prompt medical assistance was provided if required and a record is kept of visits made to the home by general practitioners and other healthcare professionals. Residents also confirmed that medical examinations were carried out in private, they were treated with respect at all times, and members of staff maintained their dignity while assisting them with personal care. Evidence of this was seen throughout the day of the visit as staff dealt the needs of the residents in a discreet and sensitive manner. On reviewing the medication system three discrepancies were noted whereby medication had not been signed for appropriately on the medication administration record sheet. Concerns were also raised regarding the failure of a member of staff to record a change in a resident’s medication, which caused some confusion and could have lead to mistakes being made. The staff team continue to monitor the general health of residents taking long term medication and advice is sought from their general practitioner and/or the pharmacist Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 13 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 standard(s) 12,14,15. The manager must review the daily routines of the home to ensure that they allow the residents to have freedom of choice and are appropriate to their needs. Meals appear nourishing and are well presented. EVIDENCE: The home does not employ an activities co-ordinator therefore it is the responsibility of the care staff to organise activities/outings for the residents. A list of daily activities is displayed on the wiper board and time is designated for activities to take place both in the morning and afternoon. The manager confirmed that due to the residents illness (dementia) their concentration span can be limited and therefore activities usually last for about twenty minutes per session, although staff obviously engage with them throughout the day. Residents appeared happy with the level of activities/outings arranged for them although one relative who visited the home on a regular basis said that she did not often see activities taking place, but acknowledged this may just be due to the time she visited. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 14 The daily routines of the home recorded by the care staff continue to show that the home has a structured regime, with little flexibility. Although the manager said this was due to the way the reports were being written, evidence gained through discussion with the staff did indicate that some practices including assisting some residents to get ready for bed early were carried out just because they had always been done that way. The manager was therefore asked to review the routines/practices in place at the home to ensure that they are appropriate to the needs of the residents. The meals at the home were described by the residents as good, and they confirmed that an alternative was always provided if they did not like what was on the menu. Hot and cold drinks are freely available to the residents both day and night. Due to the size of the dining room the home continue to have two sittings at meal times, and staff where observed to help and assist more dependant residents in a discreet and sensitive manner. The kitchen area has recently been fully refurbished to a high standard, with new stainless steel fitting and equipment, as part of the homes ongoing programme of refurbishment and renewal. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 15 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 standard(s) 16,18. Residents and their relatives have their views listened to, complaints are taken seriously and prompt action is taken to resolve issues. The home has detailed complaint and adult protection procedures, and therefore residents can be sure that their rights are protected, and they are safe from any form of abuse. EVIDENCE: The home has a complaints procedure, and the manager confirmed that no complaints had been received since the last inspection visit. Relatives spoken too confirmed that they were aware of the complaints procedure and knew what to do if they were unhappy with anything. The relatives also said that the manager and staff were approachable and listened to their concerns, so that things did not get to the stage of making a formal complaint. Policies and procedure are in place at the home in relation to adult protection and all members of the staff have attended, or are enrolled to attend an appropriate training course. Members of the staff team confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to safeguard the residents from any form of abuse. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 16 A policy document is also available in relation to handling the resident’s financial affairs, which ensures members of staff cannot become involved in the making of, and/or benefiting from their wills. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 17 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 standard(s) 19,20,21,24,26. The home provides a pleasant and comfortable environment for the residents, and there is an ongoing programme of refurbishment and renewal to ensure that present standards are maintained. Residents are able to furnish their rooms with personal belongings, and emphasis is place on providing a homely atmosphere, to make moving into a care home setting easier for them. EVIDENCE: The home has a planned programme of refurbishment and renewal and since the last inspection visit three bedrooms and the kitchen have been refurbished to a high standard. All the communal areas used by the residents are located on the ground floor of the home and consist of two lounges, one of which is the designated smoking area and a dining room. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 18 Bedrooms are located on three floors of the home, with four rooms having ensuite facilities. Bedrooms are well furnished and the there is an on going programme of decorating and renewing furniture, carpets etc. Residents and relatives confirmed that they are encouraged to bring personal possessions into the home, making each room looks homely and individual. In addition to the en-suite facilities in four bedrooms there are also communal assisted bathrooms and toilet facilities located throughout the building close to the bedrooms and lounges/dining room. Grab rails are fitted in all bathrooms and toilets and handrails are available throughout the home to assist residents with mobility problems. On the day of the visit the home was clean and tidy and no odour problems were noted. Infection control policies and procedures are in place at the home, and to safeguard the residents all visitors are requested to wash their hands with an alcohol based solution on entering and leaving the premises, which represents good practice. Externally there is a small garden to the front of the property where the residents can sit out during the summer months, and ramped wheelchair access to the main door. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Residents are supported and protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. Staffing numbers and the skill mix within the staff team ensures that the resident’s needs are met. EVIDENCE: The home has recently held a successful recruitment campaign and has been successful in filling staff vacancies. A staff rota was taken which showed that sufficient care, cooking and cleaning staff are employed both to meet the needs of the residents, and to ensure they receive a balanced diet and the home is kept clean. The home does not employ agency staff and therefore any shortfall in staffing hours due to leave are sickness is covered by permanent members of staff, which ensures that the residents are cared for by familiar faces. All members of the care staff providing personal care are over eighteen years of age and all senior members of staff are over twenty-one years of age in line with the National Minimum Standards. A number of staff files were reviewed and they contained all the relevant information, including Criminal Record Bureau (CRB) checks, to ensure a safe recruitment and selection procedure is in place. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 20 Members of staff confirmed that training continues to be encouraged by the manager, and all new members of staff receive induction and foundation training. There is also an expectation that all members of the care staff team achieve a National Vocational Qualification (NVQ) at level two or above depending on their post. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37,38. The home is well managed, and the manager provides good leadership to the staff and ensures the residents are protected and cared for correctly. Quality assurance procedures are in place and the views and opinions of the residents and their relatives are taken on board by the manager and acted on if appropriate. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team. EVIDENCE: Ms Annette France is the registered provider/manager of Leylands Rest Home and she communicates a clear sense of direction and leadership to the staff team. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 22 Members of staff confirmed that Ms France has an open and approachable management style and supports them in their work. Staff also said they enjoyed working at the home, and all the staff worked together as a team for the benefit of the residents. The manager ensures clear channels of communication with the staff by holding regular staff meetings, and one to one supervision is carried out with individual members of staff on a two monthly basis. Ms France works within the home and is therefore able to seek the views and opinions of the residents, relatives and visitors about the service, on a daily basis. The home also has recognised quality assurance monitoring systems in place and on the day of the visit was being inspected for the ISO 9002/2000 quality management award, which they currently hold. On reviewing the reports completed by the staff, it was noted that there had been a significant improvement in the standard of report writing, and the manager has made the care staff on both day and night duty more aware of the importance of keeping accurate reports/records. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and they are audited and reviewed on a regular basis to ensure they meet with present legislation. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 4 3 3 Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) Requirement Timescale for action Immediate as agreed on day of inspection Immediate as agreed on day of inspection 2. OP9 13(2) 3. OP12 12 4. OP14 12 The registered manager must ensure that care plans are completed and reviewed as soon as problems are identified. The registered manager must ensure that senior members of staff follow the policies and procedures in place for the administration of medication. The registered manager must 30/08/05 ensure that the daily routines of the home are based around the assessed needs of the residents. The registered manager must 30/08/05 review the procedures in place at the home to to ensure that they allow the residents to exercise personal autonomy and choice. 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 the format used for recording preadmission assessment information is reviewed. Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Leylands Rest Home CS0000001228.V186440.R01.doc Version 1.30 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!