Inspection on 06/02/07 for Leylands Rest Home

This inspection was carried out on 6th February 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

Leylands Rest Home 01/11/07

Leylands Rest Home 07/02/06

Leylands Rest Home 15/06/05

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 West Yorkshire BD9 5PX Lead Inspector Stephen French Key Unannounced Inspection 6th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Leylands Rest Home DS0000001228.V305247.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. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leylands Rest Home Address 16/18 Leylands Lane Heaton Bradford West Yorkshire BD9 5PX 01274 543935 01274 770035 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) Ms Annette Nerteley France Mrs Annette Nerteley France Care Home 17 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (17), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Physical disability over 65 years of age (1) Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 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 service users are situated on the ground floor of the home and include two lounges and a dining room. The home is situated on a main road and is on a bus route from Bradford City centre. There is a small garden area to the front of the property and ramped wheelchair access is available to the main door of the property. The provider informed the Commission for Social Care Inspection on 6/02/07 that fees range from £356.76 to £415.31 per week. Additional charges include hairdressing, private chiropody, newspapers and some selected activities. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide, copies of which can be obtained by contacting the home. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 6th February 2007. The inspector arrived at the home at 9:30 am and left 14:30pm. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management. The inspector read care records, audited a sample of medication, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the inspection 10 service user questionnaires were sent to the home to obtain service users’ views about living at the home. Some service users in the home are very frail and would not be able to complete a questionnaire. Ten questionnaires were also sent to relatives and four were returned. There were sixteen service users resident in the home on the day of this visit. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider and a pre inspection questionnaire completed by the manager. The inspection has concluded that residents’ needs, both personal and recreational are met. Residents reside in a relaxed and informal homely environment. What the service does well: The home offers a friendly, homely environment in which the service users live. Each service user has their needs assessed before being admitted to the home to ensure the home and its staff can meet those needs. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 6 Service users, who are able, and their relatives, contribute towards the review and evaluation of their care plans. A dedicated and competent team of staff supports the service users. The service users spoken to spoke highly of the staff saying they are kind, caring, and pleasant. There are systems in place to protect the service users, such as vulnerable adults, medication and complaints policies and procedures Positive interaction was observed between service users and staff. The manager has systems in place to monitor the standards of care the home provides to make sure these meet the service users expectations. What has improved since the last inspection? What they could do better: Although the service users health, personal and social care needs are set out in a plan of care these could be further developed by ensuring there are individual care plans for each problem identified. This will ensure that the staff are aware of the specific care to be given to the service users. Staff should make sure that previous stock balances of medication are carried over onto the new medication sheets to ensure the stock balances of medication held in the home can be easily audited. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 7 Staff should receive an annual update on the protection of vulnerable adults so that they are aware of the actions they need to take should they suspect any form of abuse taking place. Before any new staff commences employment a POVA check must be carried out to make sure that the member of staff does not appear on the adult protection register, which would prevent them from working with vulnerable adults. 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. Leylands Rest Home DS0000001228.V305247.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 Leylands Rest Home DS0000001228.V305247.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): 3,6 service users needs are fully assessed and they have the information they need. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said prior to a service user being admitted to the home she or her deputy would visit the service user and complete a pre admission assessment. This assessment covers, amongst other things the service users physical and mental health needs. Following this assessment the manager would then decide if these needs could be met by the home. The home also receives a community care assessment, which has been completed by the service users social worker and which Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 10 decides on the level of care the service user requires. Completed pre admission and community care assessments were seen for two recently admitted service users, confirming that the home is following their admission procedures. The manager said that the home does not offer Intermediate care Leylands Rest Home DS0000001228.V305247.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 Service users heath care needs are met but they could be compromised if specific care plans are not in place. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has an individual support plan which has been developed from information gathered from the community care assessment, members of the multidisciplinary team, service users and relatives. Four service users care plans were examined and care plans were in place for problems identified in the assessments. Risk assessments were in place for such things as nutrition, oral health, moving and handling and skin integrity. On the whole where assessments identified that the service user was at risk a care plan was in place, however these were grouped together in one plan. One care plan identified a service user as having a sore sacral area but there was not a specific plan in place to say how staff are managing this. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 12 There was evidence that the staff had accessed other members of the multidisciplinary team such as GP’s district nurses, opticians and chiropodists. Although the content and detail of the service users care files was good and there was no risk to the service users, there are still areas, which need to be addressed to ensure that the staff are aware of the care to be given to the service users. A service user spoken to said that the staff were marvellous and were always willing to help. Service users seen on the day of the visit were well groomed and their personal appearance had been attended to. Four relatives questionnaires received by the Commission said that the staff consulted them about their relatives care. Senior care staff are responsible for the administration of medication within the home and they have received training in this. Four amounts of service users medication was checked against the administration records held within the home. The medication stock balance did not tally with the medication administration records held by the home. On further investigation it was found that the previous stock of medication had not been carried forward and recorded onto the medication sheet. Further examination concluded that the stock balances of medication held by the home were correct and discussion took place with the manager and it was confirmed that this did not pose a risk to service users. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users are able to have control over their lives. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff at the home are responsible for arranging social activities on a daily basis. These include arts and crafts, visits by outside entertainers and trips out to places of local interest. There was evidence within the care files examined of what activities each service user has joined in with. Service users spoken to said they were very happy with the social activities on offer within the home. One relative’s questionnaire stated “ I would like to see more social activities to stimulate residents and help keep their mind active” The home has a four-week menu in place and all the service users spoken to said how nice the food was. On the day of the visit the lunch consisted of fisherman’s pie with potato croquets and a selection of vegetables, followed by lemon pie. Although there was not an alternative choice recorded on the menu Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 14 the manager and service users informed the inspector that an alternative is always available and this was seen recorded on the board in the dining room. Service users are able to eat in the dining room or their own room if they wish. The home caters for specialist diets, which include vegetarian and West Indian. The manager said that following the admission of a service user who enjoyed west Indian food she had purchased a west Indian cook book and had taken advise from a cook who specialises in this type of food. A recent survey carried out by the home identified that 100 of service users and relatives said the food was very nice and that there was always plenty of choice. A tour of the kitchen was conducted and there appeared to be adequate stocks of fresh fruit and vegetables. The manager said that relatives and visitors are welcome to visit at any time and this would only be restricted if the service user wished. There are facilities available to enable visitors to make themselves a drink if they wish and the manager said that she and the staff try to encourage relatives to treat the home as a home from home. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users are safe and complaints are acted up on. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy, which is displayed in the reception area and accessible to anyone who enters the home. The manager said that service users and their families are given a copy of the policy on admission. Complaints are recorded in a complaints book and the manager or her deputy investigates these. Evidence was seen that two complaints received in 2004 had been handled appropriately and the complainant made aware of the outcome of the investigation. Due to the service users illness (Dementia) it was difficult to confirm that they were aware of the homes complaints policy. Four comment cards received from relatives confirmed that they were aware of the homes complaints policy. There have been no further complaints made to either the home or the Commission for Social Care Inspection since 2004. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 16 The manager informed the inspector that new staff receive training in the protection of vulnerable adults as part of their induction. This training enables staff to recognise different forms of abuse, which can take place and their responsibilities in reporting any suspicions they may have. One care assistant spoken to gave good responses to questions asked about what she would do if she suspected any abuse was taking place. Through examination of staff training records and discussion with staff it was identified that this training is not delivered regularly. On discussion with the manager it was determined that herself and her deputy had received training in the protection of vulnerable adults and were putting together a training plan for staff. In the past the home has relied on the local authority to deliver this training but this was often limited to only a couple of places therefore some staff had not received a yearly update in this area. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Service users live in a safe, well maintained home where their bedrooms are comfortable bright and airy. The home is clean and fresh. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the visit a tour of the building was conducted, this included a number of service users’ bedrooms, communal lounges, dining room and bathrooms and toilets. Service users bedrooms were personalised with their own things such as ornaments and pictures. Double rooms had screens dividing the room to ensure the privacy of the service user when personal care was being delivered. New bedroom furniture has been provided in most of the Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 18 bedrooms. Some minor redecoration and replacement of carpets is required in two of the bedrooms seen. There are two lounges, both of which have been recently decorated, and a dining room, which the manager said was to be redecorated that week. The furniture in the lounges is domestic in type and the service users are happy with the decor. There are a number of communal bathrooms and toilets within close proximity to service users bedrooms and communal areas. During a tour of these it was noted that the bathrooms contained used bars of soap, and it had to be assumed that they are being used communally. The manager was informed that these could be a source of cross infection and were removed as soon as it was brought to her attention. There is a laundry, which is responsible for washing service users’ personal clothing. The standard of cleanliness throughout the home was very good and there were no unpleasant odours detected. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There are adequate numbers of trained competent staff on duty who meet the needs of the service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty rota was examined for January and February and this confirmed the number of staff as being adequate to care for the needs of the service users living at the home. The manager said that as the service users like to see familiar faces agency staff are never used and staff holidays and sickness are covered by staff doing overtime. A service user spoken to, and four relatives comment cards received said that there where adequate numbers of staff available and a recent questionnaire sent out by the home scored 100 for the amount of staff the home provides. Staff were observed interacting with service users in a friendly appropriate manor. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 20 Three staff details were examined to ensure the home was carrying out the correct procedures to protect the service users from abuse prior to employing new staff. Evidence was seen that, amongst other things, two references and checks with the criminal records bureau (CRB) were undertaken before an offer of employment was made. However it was noted that although new staff are supervised at all times until the CRB check has been returned, the home has not carried out a POVA first check which would identify if the member of staff appears on the adult protection register. Discussion took place with the manager who was aware that these checks should have been made and following the inspection she said she was going to ensure these were completed. Staff are recruited from a varied cultural background. There was evidence of staff completing induction training as well as ongoing training. Staff members confirmed that training is available. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The home is well managed and the views of the service users are sought and any shortfalls are addressed. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager who is also the registered provider has completed her registered managers award. She is aware of the aims and objectives of the home and has continued to maintain the standards within the home. Service users and staff said she was very approachable. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 22 The manager and her deputy conduct formal supervision of staff on a bi monthly basis, this ensures that staff are aware of the aims and objectives of the home and any training needs are discussed, records seen confirmed that this is taking place. The manager said that she has systems in place to check that the standard of care, which the home provides meets the expectations of the service users. Evidence was seen that audits have been completed in areas of care such as pre admission procedures, care planning, medication, privacy and dignity and the internal environment. If there are any shortfalls then action plans are drawn up and acted upon. The home also seeks the views of the service users and relatives about the care that they receive by sending out service users questionnaires annually; the results of the April 2006 surveys were seen and they contained very positive comments. Staff have received training in moving and handling, fire prevention and health and safety. The homes fire alarm system is checked weekly and contracts are in place with outside contractors for the servicing of the fire alarm system and fire fighting equipment. Accidents to service users and staff are recorded, and the inspector saw a copy of the accident book. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 19 Requirement New employees must not commence employment until a full and satisfactory POVA check has been carried out. Timescale for action 31/03/07 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 OP7 Good Practice Recommendations Problems identified through the risk assessment process should have an individual care plan. These should contain specific instructions to staff on what they are to do to meet the health/personal care needs of the service user. Stock balances of medication from the previous month should be carried over and the total amount of medication recorded on the medication administration record to ensure these can be audited correctly. Staff should receive update training in the protection of vulnerable adults at least yearly. To prevent cross infection the bars of soap should be removed from the bathrooms to prevent staff using these for communal use. The areas identified during the visit should be redecorated. DS0000001228.V305247.R01.S.doc Version 5.2 Page 25 2. OP9 3. 4 5 OP18 OP21 OP24 Leylands Rest Home 6. OP30 The staff training records should be brought up to date. Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Leylands Rest Home DS0000001228.V305247.R01.S.doc Version 5.2 Page 27 - 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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