Inspection on 07/02/06 for Leylands Rest Home

This inspection was carried out on 7th 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

Leylands Rest Home 01/11/07

Leylands Rest Home 06/02/07

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 Steve Marsh Unannounced Inspection 09:30 7 February 2006 th 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.V269046.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. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 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.V269046.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2005 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. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit for the year ending 31st March 2006, and was carried out by one Inspector over approximately seven hours. No additional visits to the home have been made. The methods used during this inspection included the examination of records, observation of care practices, discussion’ (group and individual) with residents, staff and management and a tour of the premises. Due to their illness (dementia) some residents found it difficult to express their opinions of the home, however those that were able felt that the staff continue to provide a good standard of care. Comment cards were left for the residents and/or relatives to enable them to share their views of the service with the Commission. Relatives returned ten comment cards. Feedback was given to Ms Annette France (Proprietor/manager) at the end of the inspection visit. What the service does well: The home continues to provide a warm and comfortable environment for the residents and there is an ongoing programme of refurbishment and renewal. The admission procedure is thorough and the manager will not admit a resident unless she feels the staff team can provide the level of care they require. Residents confirmed that they are always treated with respect and found the staff to be friendly and approachable. Residents are encouraged to make as many decisions and choices as possible in relation to their daily lives within the limitations of their illness. There continues to be a genuine commitment to staff training and this is reflected in the level of National Vocational Qualification (NVQ) made available to the staff team. The manager takes all complaints seriously and ensures immediate action is taken to resolve matters. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 6 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. Leylands Rest Home DS0000001228.V269046.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 Leylands Rest Home DS0000001228.V269046.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): These standards were not reviewed on this inspection visit. EVIDENCE: These standards were not reviewed on this inspection visit. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 9 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): 7,8,9,11 The new care plans are completed to a good standard and give clear guidelines to the staff on how to meet the individual resident’s needs. Records and reports indicate that the residents’ healthcare needs are met in line with their care plan and any problems are identified and dealt with at an early stage. EVIDENCE: A new care planning system has recently been introduced at the home, which covers all aspects of the resident’s health and general welfare. Care plans and supporting documentation continue to be reviewed at least monthly or sooner if the resident’s needs change significantly. The four care plans reviewed were completed to a good standard and there was evidence to show that the residents and/or relatives are involved in the care planning process. All residents are registered with a general practitioner and have access to the full range of NHS services. The input of other healthcare professionals is clearly recorded in the residents care plans and specialist equipment is provided if required. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 10 Residents said that they were very pleased with the medical attention they received and confirmed that medical examinations are always carried out in their own rooms. On reviewing the medication system in place no discrepancies were noted. The manager confirmed that following the concerns highlighted in the last inspection report the system is now audited on a weekly basis to ensure that any problems are identified and dealt with quickly. At present no residents have the capacity to manage their own medication and therefore it is the responsibility of the senior staff team to ensure medication is administered as prescribed. The home has policies and procedures in place in relation to the dying and death of a resident and the manager confirmed that comfort and support is offered to all parties during this very difficult period. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 11 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): 12,13,14 The daily routines of the home now appear more flexible and are based around the needs of the residents. Residents are offered a range of activities and are encouraged by the staff to make informed decisions about their daily lives. EVIDENCE: The manager confirmed that since the last inspection visit the staff team has reviewed the daily routine in place and records/reports reviewed now indicate that the home has a more flexible and less structured approach to work practices. The home does not employ an activities co-ordinator and therefore it continues to be the responsibility of the care staff to organise activities and outings for the residents. A list of activities is displayed on the wiper board in the dining room and time is allocated both in the morning and afternoon for activities to take place. The interests and hobbies of individual residents are recorded in their care plan and they are encouraged to pursue them for as long as it is practical for them to do so. The manager confirmed that visitor are welcome at any time and relatives confirmed that they were always made to feel welcome when they visited the Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 12 home and offered light refreshment. The manager confirmed that visiting restrictions would only be imposed at the resident’s request and/or if it was in their best interest. Residents are able to receive visitors either in one of the communal areas or in the privacy of their own room if they wish to do so. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 13 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): 16,18 Robust complaint and adult protection procedures ensure that the residents are listened to and protected from abuse. EVIDENCE: The home has a complaints procedure and the residents/relatives confirmed that if they had any concerns they would feel able to raise them with the manager or the senior staff team. They were also confident that their concerns would be taken seriously and resolved without them having to make a formal complaint. Four of the ten comment cards returned by relatives did however indicate that they were not aware of the home’s complaints procedure even though it appears to be well publicised. The manager confirmed that no complaints had been received by the home since the last inspection visit. Policies and procedures are in place in relation to adult protection and all members of staff have either attended or enrolled to attend an appropriate training course. Staff appeared aware of the homes policy on “whistle blowing” and were able to detail what they would do if they felt any practices were not in the residents best interest. The manager is aware of the Protection Of Vulnerable Adults register and the procedures to be followed should a referral have to be made. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 14 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): 19,20,24,26 The home continues to provide a comfortable and safe environment for the residents in a friendly and homely atmosphere. EVIDENCE: Both internally and externally the home is generally well maintained and there is an ongoing programme of refurbishment renewal, which is clearly evident in the homes business plan. All the communal areas used by the residents including the lounges and dining room are situated on the ground floor of the home, conveniently close to bathroom and toilet facilities. The home now operates a no smoking policy within the building and the manager confirmed that the service user guide made available to prospective residents would be amended to reflect this. What was the designated smoking lounge is to be decorated and a re-carpeted in the near future to eliminate the smell of smoke. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 15 Bedrooms are located on three floors of the home, with four rooms having ensuite facilities. Bedrooms are well furnished and it was noted that some new furniture and soft furnishings had recently been purchased. There was also evidence of resident’s personal belongings in every room making them look homely and individual. Residents/relatives confirmed that the rooms were comfortable and staff respected their right to privacy by never entering their room without first asking permission. On the day of the visit the general standard of hygiene and cleanliness throughout the building was good and no odour problems were noted. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30 Residents are protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. The level of training made available to the staff is commendable and the skill mix within the staff team ensures that residents’ needs are met. EVIDENCE: Sufficient care and auxiliary staff are employed at the home both to meet the needs of the residents and to ensure that the home is kept clean and free from offensive odours. All staff providing personal care are over eighteen years of age and all senior staff are over twenty-one years of age in line with the National Minimum Standards. Two staff files were reviewed and they contained all the relevant information, including Criminal Record Bureau (CRB) checks, to evidence that a safe recruitment and selection procedure is in place. The manager confirmed that all new members of staff receive induction and foundation training, and additional training both to meet the needs of the residents and for personal development is encouraged. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 17 There is also an expectation that all care staff will achieve a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. At present all members of the staff team including auxiliary staff have either achieved or are studying for a NVQ, which is commendable. Although individual training records are available it was recommended to the manager that a full training audit be carried out to more clearly evidence the level of training made available to the staff team. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 18 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): 33,34,35,36,37,38 There has been a significant improvement in the standard of records and reports completed by the staff and they now more accurately reflect the level of care received by the residents. Recognised quality assurance monitoring systems are in place and the views and opinion of the residents and/or relatives is sought and valued. All policies and procedure in use at the home are reviewed on a regular basis to ensure the health and safety of the residents, visitors and staff. EVIDENCE: The home has recognised quality assurance monitoring systems in place and it is the responsibility of the deputy manager to carry out regular audits to ensure that they are affective. The home continues to seek the views and opinions of the residents and/or relatives and an annual quality assurance Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 19 survey is carried out. The home has also achieved the ISO 9002/2000 quality management award, which is commendable. Residents and/or relatives confirmed that they were kept informed of any changes in policies and procedures, which affect the running of the home and felt that their views and opinions were listened to and valued. Staff meetings are also held on a regular basis to ensure that information is made available to the staff team and formal one-to-one supervision continues to be held at least every two months in line with the National Minimum Standards. Wherever possible relatives are encouraged to manage the resident’s financial affairs although the home will hold money in safekeeping if requested to do so. Only senior staff deal with the resident’s finances and receipts are always obtained for purchases made on their behalf. Suitable financial procedures are in place to demonstrate the homes financial viability and a copy of the business plan for 2006/07 was provided on the day of inspection. Appropriate insurance cover is in place and a current certificate of insurance is on display within the home. Records and reports relating to the care of the residents and the management of the business are well maintained and used in accordance with the Data Protection Act 1998. In relation to care management records there continues to be a significant improvement in the quality and content of the reports completed and they now give a very clear picture of the residents life at the home. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and are reviewed on a regular basis to ensure that they meet with present legislation. Leylands Rest Home DS0000001228.V269046.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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 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 X X 3 3 3 4 3 3 Leylands Rest Home DS0000001228.V269046.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. 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 OP30 Good Practice Recommendations It s recommended that a full staff training audit is carried out to more clearly evidence the level of training made available to the staff team. Leylands Rest Home DS0000001228.V269046.R01.S.doc Version 5.0 Page 22 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 DS0000001228.V269046.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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