Inspection on 21/06/05 for Londesborough Court Care Home

This inspection was carried out on 21st 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 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

Londesborough Court Care Home 28/06/06

Londesborough Court Care Home 27/10/05

Londesborough Court Care Home 19/10/04

Londesborough Court Care Home 25/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Londesborough Court Care Home Londesborough Road Market Weighton East Yorkshire YO43 3AZ Lead Inspector Diane Wilkinson Unannounced 21 June 2005 09:30 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. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Londesborough Court Care Home Address Londesborough Road Market Weighton East Yorkshire YO43 3AZ 01430 873954 01430 873051 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) Londesborough Court Limited Position Vacant Care Home 30 Category(ies) of OP Old Age registration, with number DE Dementia of places Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th October 2004 Brief Description of the Service: Londesborough Court Care Home is a privately owned care home that is situated in the small town of Market Weighton. The registered providers own another care home in the nearby town of Beverley. The home is registered to care for and accommodate thirty older people, including those with dementia. The property consists of a large old house and a modern extension. The accommodation is provided on two floors, and the second floor is accessed via a passenger lift. The home is located within pleasant grounds and is close to local amenities such as churches, hairdressers, shops, cafes and public houses. The home is close to a bus route and has ample parking space for visitors and staff. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours, including an hours preparation time. The inspection included a tour of the premises and examination of records, including care plans. The inspector spoke to several service users, a relative, staff members and the acting registered manager. What the service does well: What has improved since the last inspection? Many of the requirements and recommendations highlighted at the previous inspection have been actioned. The statement of purpose and the service user guide have been updated and now accurately inform service users and others of the care that the home intends to provide. The provision and recording of activities undertaken by service users has improved. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 standard(s) 1 and 3 The updated statement of purpose and service user guide provide accurate information that enables people to make an informed choice about where to live. Service users are assessed prior to any decision being made about admission to the home and admission only proceeds if their needs can be met. EVIDENCE: The statement of purpose and the service user guide have been updated and now meet the requirements of the National Minimum Standards. Copies of the updated service user guide are located in the reception area to be given to prospective service users and relatives, and copies have been offered to existing service users and relatives. The May/June 2005 newsletter records that the new service user guide is now available at the reception area. The acting registered manager and inspector discussed a prospective service user and this discussion evidenced that service users are assessed prior to any decision being made about admission to the home. The acting registered manager visits prospective service users at home or in hospital, and service Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 9 users and/or relatives are invited to look around the home. This was confirmed by the examination of service users’ records. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 standard(s) 7, 9 and 11 There are systems in place to ensure that a service user’s individual care plan is reviewed regularly, ensuring that current care needs are met. The systems for the administration of medication are good and ensure that a service user’s medication needs are met in a safe way. There is evidence that deteriorating illness and death are dealt with sensitively by staff and that changing needs are met. EVIDENCE: Care planning at the home has improved and there is now evidence that service users are involved in this process. Care plans are based on a comprehensive assessment and record the care needs of service users. Care plans are reviewed monthly by staff, and a six monthly in-house review is now being held in addition to the review organised by the local authority. A copy of this review record is sent to relatives. Service users attend their reviews whenever this is possible, and records seen by the inspector had been signed by all participants, including the service user. The home’s policy on the administration of medication includes all of the required information, including specific arrangements for the administration of controlled drugs and details about a service user’s right to self medicate. Staff that administer medication are currently undertaking accredited training. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 11 Sample signatures of these staff are included with medication records. A quarterly report is compiled by the pharmacist – the most recent report recorded ‘oxygen is stored and labelled well’. The acting registered manager has completed a risk assessment and a COSHH assessment for the use of medication in the home. The Royal Pharmaceutical Society policy is also in use. Records examined by the inspector were satisfactory. There is an appropriate policy in place about death and terminal care. The current needs and future wishes of service users are recorded in the biographical assessment section of the care plan. Staff supervision records evidence that staff have read and understood the policy that is in place at the home. Some service users with deteriorating health are permanently in bed and special pressure care mattresses and other equipment has been provided to ensure the comfort and safety of these service users. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 standard(s) 12 and 14 Service users are supported and encouraged to maintain their chosen lifestyle following admission to the home. Service users are encouraged and supported to make informed choices. EVIDENCE: Care plans record a service user’s personal history, hobbies and interests, and whether service users prefer group or individual activities. A record is kept of group activities (including who has taken part) and these include ‘market day’, movement to music, ‘film of the week’, gardening and a walk outside. Activities taken part in are also recorded in service users’ care plans. Service users are asked in the quality survey if the social activities offered by the home meet their needs, and the home’s newsletter gives details of forthcoming events. These are also advertised on the notice board. Service users spoken to expressed satisfaction with the activities on offer – they enjoyed watching the TV and reading their newspapers and magazines, as well as organised activities. Service users tend to sit in lounge areas with other service users with similar interests and capabilities. Residents and relatives meetings are held – records evidence that service users are encouraged to express their views and make suggestions. Six relatives attended the most recent meeting. There is also a note of the action taken following the meeting by the acting registered manager. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 13 Service users stated that they are able to choose what time to get up and go to bed, and what to have to eat at mealtimes. Service users can sit in the dining room, lounge or bedroom to take their meals. Service users stated that they are able to choose how to spend their day. The statement of purpose records details of available advocacy services and the home now subscribe to the organisation Care Aware. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 standard(s) 16 and 17 Service users and relatives know how to make a complaint to the home, and are confident that their complaints will be listened to and dealt with appropriately. Service users and relatives have information about how to contact advocacy services should legal or other advice be needed. EVIDENCE: The statement of purpose includes details of the complaints procedure at the home and there is a copy on display. There is a complaints log in use and this is a thorough record of the complaint made, the action taken and the outcome. Relatives and service users are aware of the complaints procedure and informed the inspector that they would use it if needed. Three complaints have been received by the Commission for Social Care Inspection since the last inspection and these were dealt with satisfactorily by the acting registered manager. There is evidence that service users’ legal rights are protected. Service users and relatives are now informed about available advocacy services and service users are supported to vote if they wish to do so. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 standard(s) 19, 20, 22, 24, 25 and 26 Specialist equipment has been provided to enable service users to retain as much independence as possible. The home is well maintained and provides a safe environment for service users. Bedrooms have been personalised by service users to an extent chosen by them. The home is clean and hygienic with the exception of some bedrooms where the presence of odours needs to be addressed to create pleasant surroundings for service users. EVIDENCE: The home provides comfortable, homely and attractive accommodation for service users. There is a refurbishment and maintenance programme in place and a record of all maintenance undertaken and repairs done is kept. Bedrooms are now arranged to ensure the safety of service users, i.e. service users are able to reach the call bell system and to have access to a bedside or ‘over bed’ light. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 16 There has been an ongoing issue at the home about access for wheelchair users – the inspector observed that work has now commenced on a path from the pavement to the entrance of the premises. The premises have now been assessed by a suitably qualified person to evidence that recommended disability equipment has been secured and environmental adaptations made. Work has commenced work at the home to provide service users with two double electric sockets in their bedroom. Bedrooms are provided with the items required by service users and reflect the use of the bedroom. Service users have been consulted about what items of furniture they wish to have in their bedroom. Bedrooms have been personalised depending on the wishes of service users and their families. All bedrooms have access to sunlight and windows that open to let in fresh air. One bedroom is shaded by a large tree (that has a preservation order on it) but the service user is happy with the room, as there is a view of the main road and people walking by. Central heating can be controlled in individual bedrooms. All radiators are covered to protect service users from the risk of burning. Water temperatures are tested in bedrooms and bathrooms to control the risk of scalding. The home has purchased some small safes to provide service users with lockable storage. These are given to service users on request - the home should aim to eventually provide all bedrooms with a safe or other form of lockable storage. Some bedrooms are fitted with locks and keys – the home should aim to have locks and keys available on all bedrooms doors so that new and existing service users can immediately be provided with a key (unless a risk assessment suggests otherwise). Some bedrooms have a smell of urine – it is evident that action is being taken by staff to try to alleviate this. On the day of the inspection there was no smell at the entrance to the home, as there had been on previous occasion. Laundry services meet required standards. Service users are asked about the effectiveness of the laundry service in the quality survey. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 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) 28 and 29 Current NVQ training achievement and future training plans evidence that staff should be suitably qualified to meet the care needs of service users. The home’s recruitment and selection policies and practices fully ensure the safety of service users. EVIDENCE: The home is on target to achieve the requirement for 50 of care staff to achieve NVQ Level 2 in Care by the end of 2005. The inspector saw evidence confirming that three members of staff are registered to commence NVQ Level 2 or 3 with a local training organisation, and some staff have already achieved this award. New staff at the home undertake the home’s own induction programme. Every effort is being made to protect service users via recruitment procedures at the home. A POVA ‘first’ check was undertaken for a recently appointed member of staff. In records seen by the inspector, two written references and a CRB check had been obtained for staff prior to them commencing work at the home. Application forms include a career history and a criminal record declaration. Induction takes place during the period between the interview and the receipt of the CRB check, so that staff have received this training by the time they are included on the staff rota. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 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, 34, 37 and 38 The home is managed effectively and the manager is well supported by the staff team. Financial and accounting procedures, record keeping and policies and procedures safeguard service users. The arrangements in place at the home protect the health, safety and welfare of service users. EVIDENCE: The acting registered manager is experienced and competent to run the home. She is a registered nurse and has almost completed the NVQ Level 4 Registered Manager’s award. The acting registered manager has a keen interest in nutrition for older people and obtains a lot of information from the Internet that she shares with the staff group. Meetings are held between the acting registered manager and care managers to ensure that there is a consistency of approach with staff and service users. The acting registered manager has recently submitted her application for registration to the Commission for Social Care Inspection. The acting registered manager intends Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 19 to undertake the NVQ Assessor’s award so that she is able to assist care staff with achieving their award. The inspector examined the business and financial plan and this evidences that the home is a viable business and that service users are safeguarded by financial and accounting procedures at the home. There is appropriate insurance cover in place. The registered provider was reminded that the business and financial plan should be on the premises and available for inspection at all times. There is evidence that policies and procedures are reviewed on a regular basis. All of the necessary records are in place. There is evidence that service users have access to their records. In-house fire tests are satisfactory (there is a weekly fire alarm and emergency lighting test) and the fire alarm system has been tested by a qualified contractor. There is a fire risk assessment in place. The electrical installation has been tested and gas appliances were serviced in September 2004. The testing of water temperatures in bedrooms and bathrooms is ongoing to control the risk of scalding, and a test to detect the presence of Legionella was undertaken in February 2005. The passenger lift and mobility/bath hoists were serviced in April 2005. Portable appliances are tested on an ongoing basis. An asbestos survey was carried out in June 2005. Accident records were examined by the inspector and these cross reference to records in care plans. The home has produced a written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments and significant findings. Appropriate health and safety training is undertaken by staff. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x 3 x 3 3 3 STAFFING Standard No Score 27 x 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 2 x x 3 x x 3 3 Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 21 No 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. 2. 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. 2. 3. 4. 5. Refer to Standard 24 26 28 31 Good Practice Recommendations The inspector recommends that lockable storage is provided in all bedrooms, and that locks and keys are provided for all bedroom doors. Every effort must be made to prevent unpleasant odours in the home. Training should continue to ensure that 50 of care staff achieve NVQ Level 2 in Care by the end of 2005. The acting registered manager should continue with training to ensure that NVQ Level 4 in Care and Management is achieved by the end of 2005. Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Londesborough Court Care Home J53_s19691_Londesborough Court_v226237_210605_Stage 4.doc Version 1.30 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. 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