Inspection on 06/09/05 for Loudoun House

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Loudoun House 18/10/07

Loudoun House 13/06/06

Loudoun House 29/06/05

Loudoun House 01/12/04

Loudoun House 03/08/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE Loudoun House Ridgeway Road Ashby-de-la-Zouch Leicestershire LE65 2PJ Lead Inspector Mrs Carole Burgess Unannounced 6 September, 2005 10:00 am th 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. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Loudoun House Address Ridgeway Road Ashby-de-la-Zouch Leicestershire LE65 2PJ 01530 412184 01530 412184 surjit@rushcliffecare.co.uk karen@rushcliffecare.co.uk Rushcliffe Care Limited 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) Mrs Susan Roberts Care Home (CRH) 35 Category(ies) of Dementia - over 65 years of age (DE(E)) 20 registration, with number both, Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (MD(E)) 4 both, Learning disability over 65 years of age (LD(E)) 4 both, Physical Disability over 65 years of age (PD(E)) 10 both, Sensory Impairment over 65 years of age (SI(E)) 4 both, Old Age not falling within any other category (OP) 35 both. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within category DE(E) may be admitted to the home when 20 persons who fall within category DE(E) are already accommodated within the home. 2. No person falling within category MD(E) may be admitted to the home when 4 persons who fall within category MD(E) are already accommodated within the home. 3. No person falling within category LD(E) may be admitted to the home when 4 persons who fall within category LD(E) are already accommodated within the home. 4. No person falling within category PD(E) may be admitted to the home when 10 persons who fall within category PD(E) are already accommodated within the home. 5. No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated within the home. 6. Servise users between the the age of 55-65 years who fall within the above catagories and were residents in the care home at the date of registration continue to reside there. 7. To be able to admit the person named on variation application 49975 dated 24th June under PD into the home. Date of last inspection 29th June 2005 Brief Description of the Service: Loudoun House is a residential care home for thirty-five older persons of both sexes. It was opened in 1959 and refurbished in 1999. The home provides care for a limited number of older persons with learning disability, mental disorder, physical disability and sensory impairment. It also provides a small number of day or part day care placements whereby a limited number of older persons spend a few hours and have lunch at Loudoun House before returning home. Accommodation is on two floors and can be accessed by stairs or passenger lift. The home is bright and clean with a high standard of décor throughout and provides a safe and caring environment for all of the residents. Bedrooms are mostly single, with a hand washbasin; with one double bedroom, and there are adequate toilet and assisted bathing facilities throughout the building. There are a number of lounges and kitchenettes for the use of residents and their visitors. In addition, there is a large dining room, with a bar. The home is surrounded by well-maintained gardens and there is a patio and seating at the front and side of the home. The home is accessible by public transport and there is sufficient parking for visitors. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours. An opportunity was taken to look around the home, view records, policies and care plans and to talk to staff residents and their relatives and visitors. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through a review of their records, discussion with them (where possible) and the care staff, and observation of care practices. Many of the residents were seen during the inspection and four of the residents and two relatives spoken with gave the Inspector their impressions of the home. What the service does well: What has improved since the last inspection? As identified at the previous inspection areas of the garden have been tidied and bushes trimmed to ensure ease of access for residents who are wheelchair users. As identified at the previous inspection the medicines fridge has been defrosted and well maintained to ensure that residents’ medicines, which require refrigeration, are stored at the correct temperature. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 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. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 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 Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 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) 2 & 3. The admission process is well managed and residents are given clear information regarding the service; thereby ensuring that the residents’ health and welfare needs are met. EVIDENCE: Residents’ files did not have a copy of the resident’s contract/Terms and Conditions). These are kept at the administration office at Epinal Way Care Centre in Loughborough. However, it was recommended following the previous inspection that a copy be provided for the resident’s file in the home to facilitate inspection. The Registered Manager said that this was being attended to. The pre-assessment process is detailed and robust and reflective of the health and welfare needs of the residents. The remaining standards were inspected during the previous inspection in June 2005 and found to be satisfactory. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 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 standard(s) 7, 8, 9,10 & 11. Residents are looked after very well in respect of their health and personal care needs. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 10 EVIDENCE: Care plans were detailed and reflective of residents’ specific and individual needs. Contact with other healthcare professional is well documented. The quality of record keeping is reflective of the high standard of care observed during the inspection; however, further work needs to be done to evidence the involvement of residents and/or their relatives/representatives in the care planning and review process to ensure that the needs of the residents are fully met. Three residents and two relatives said that residents were well cared for by the staff although one resident said that staff were not always mindful to place things, such as drinks and her ‘nurse call’, within easy reach and that some of her intimate care needs had not been fully met. This was discussed with the Senior Manager and Registered Manager at the time of inspection. Medication policies and procedures are sound. Whenever possible residents are able to remain in their own room during the end stages of their life following discussions with the family, GP and other healthcare professionals. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 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 standard(s) 12 & 15. Residents experience a stimulating and varied lifestyle at the home with visitors encouraged and a variety of activities made available. Meals are well presented and nutritious and staff are caring and supportive of residents and their relatives. EVIDENCE: Visitors came and went during the time of the inspection. An activities officer provides a programme of daily activities for the residents. Details of daily activities are recorded. Residents enjoyed listening to music played on the accordion and joined in with the songs provided by an entertainer who regularly visits the home. Menus are balanced and appealing, and are flexible enough to accommodate individual preferences and healthcare needs. They are freshly prepared and are of a good standard and the residents said that they enjoyed their meals, which were always ‘very good’ and with choices. The remaining standard was inspected during the previous inspection in June 2005 and found to be satisfactory. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 12 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. Arrangements for receiving and responding to complaints are sound. EVIDENCE: Residents, their relatives and staff comments demonstrated that people feel at ease discussing any concerns with the Registered Manager and staff ensuring an open ethos in the home. The home has not received any complaints since the last inspection. All complaints are dealt with appropriately. The remaining standard was inspected during the previous inspection in June 2005 and found to be satisfactory. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 13 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 & 26 A comfortable, clean, homely and safe standard of accommodation is provided for the residents. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 14 EVIDENCE: The home is safe and well maintained with many adaptations to suit residents’ specific needs. It is decorated and furnished to a high standard that creates a comfortable and homely environment, and there is a system of maintenance and refurbishment. The Senior Manager and Registered Manager had identified two rooms that required refurbishment in the near future. Residents’ rooms were clean and well decorated, and residents are able to bring items of their own furniture and possessions with them to personalise their rooms. Hot water temperatures are checked to ensure they comply with Health and Safety legislation and were satisfactory when checked during the inspection. The remaining standards were inspected during the previous inspection in June 2005 and found to be satisfactory. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 15 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 & 30. Staff at the home are well trained and supported, but some staff appear to be working unacceptably, long hours which may compromise the care provided for the residents. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 16 EVIDENCE: Staffing hours, at the point of inspection were satisfactory and in line with the Department of Health Residential Forum Guidelines and were sufficient to meet the residents’ needs. Residents did not identify any ‘thin’ times. It was noted during a review of the staffing rota that two staff work one or two very long days per week – up to 14 hours - and that on rare occasions staff work an early shift, finishing at 13.30hrs, returning at 21.00 hrs to commence a night shift. This is not best practice and has the potential to compromise the health and safety of the residents if not managed correctly. The Senior Manager and the Registered Manager acknowledged that this was unsatisfactory and said that additional staff were being recruited. Training for staff is well planned and supports staff in providing for the varied needs of the residents. Extensive ‘in house’ training supports staff in meeting the residents’ health and welfare needs. The remaining standards were inspected during the previous inspection in June 2005 and found to be satisfactory. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 17 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) 33 & 38. The Registered Manager, with effective supervision of staff, manages the home efficiently to protect the rights and needs of the residents. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 18 EVIDENCE: The home has a Registered Manager with 8 years of experience in care. She is currently undertaking the Registered Managers Award and the NVQ Assessors qualification. There is an ethos of openness in the home; staff are friendly and helpful towards the residents, their relatives and each other. Health and Safety Policy and Procedures are robust. Regular recorded fire drills and fire alarm tests are completed, to ensure the health and safety of the residents and staff. The remaining standards were inspected during the previous inspection in June 2005 and found to be satisfactory. Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 19 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 x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 x 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 x x 4 x x x x 4 Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 20 NA 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 Regulation NONE 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 2 Good Practice Recommendations The Registered Person(s) are recommended to ensure that all residents are provided with a contract/Terms & Conditions (Regulation 5 (1) (b) (c) & (3)) and that a copy is retained in the residents file, as identified at the previous inspection in June 2005. The Registered Person(s) are recommended to ensure that residents care plans are drawn up with the involvement of the residents or their representative. The Registered Person(s) are recommended to ensure that care staff maintain the personal hygiene of each resident and, wherever possible, support the resident own capacity for self-care. The Registered Person(s) are recommended to ensure that they ensure that staff comply with Regulation 19(5)(c) he is physically and mentally fit for the purposes of the work which he is to perform at the care home, - and that they comply with the Working Time Regulations 1998. 2. 3. 7.6 8.2 4. 28 Loudoun House 20050906 Loudoun House X00015 Un Stage 4 S58947 V246565 C51.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX 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. 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