Inspection on 30/11/06 for Musgrave Court

This inspection was carried out on 30th November 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

Musgrave Court 29/12/05

Musgrave Court 18/01/05

Musgrave Court 13/07/04

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

CARE HOMES FOR OLDER PEOPLE Musgrave Court Crawshaw Road Pudsey Leeds LS28 7UB Lead Inspector Hebrew Rawlins Key Unannounced Inspection 30th November 2006 09:00 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 Musgrave Court DS0000033196.V320041.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. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Musgrave Court Address Crawshaw Road Pudsey Leeds LS28 7UB 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) 0113 2146186 0113 2477228 Leeds City Council Department of Social Services Mrs Judith Levine Care Home 36 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (35) of places Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th December 2005 Brief Description of the Service: Musgrave Court is owned by Leeds City Council Social Service Department, and managed by Mrs J Levine. It is a care home providing personal care and support to thirty-six older people with dementia. District nurses provide services to those service users with nursing needs. Three places are allocated for respite services. It is situated in Pudsey a suburb of Leeds and close to the shops and amenities. The home is on two levels and has a passenger lift to the second floor. All rooms are single occupancy without en-suite facilities. The home has mature enclosed gardens and car parking facilities. Information for prospective residents is available in the form of a brief statement of purpose together with a service user guide. As of April 2006 the current fees are £94.45 per week minimum to £458.86 per week maximum with additional charges for hairdressing, chiropodist and toiletries. This information was provided by the manager as part of the preinspection questionnaire completed before this inspection. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced key inspection took place between 9.00am – 4.00pm on the 30th November 2006. The purpose of the visit was to monitor standards of care in the home and to look at progress in meeting the requirements and recommendations made at the last visit. The manager completed a preinspection questionnaire and the administrator provided additional information. The information provided has been used in the preparation of this report. During the inspection I spoke to residents, visitors and staff on duty, I looked at records and made a tour of the building. Some comment cards were left with the manager providing the opportunity for residents and/or visitors to comment on the home, if they wish. Information provided in this way may be shared with the manager but the source will not be identified. Feedback at the end of this inspection was given to the manager. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: The home is well managed and promotes independence for the residents. They are treated with respect and included when possible in decision making within the home. Good relationships between staff and residents were seen and the home offers a very positive place to live. The home provides a warm and homely environment in which residents are treated as individuals. All residents have their needs assessed before being admitted to the home and staff were knowledgeable about how to care for the Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 6 residents. Families can be as involved in the care of their relatives as they choose and visitors are made welcome at the home. Training is very important and takes a high priority at the home with staff encouraged to attend suitable courses. 50 of the staff have already completed the National Vocational Qualifications at different levels. The atmosphere in the home is very lively, friendly and welcoming. 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. The summary of this inspection report can be made available in other formats on request. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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 Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families are provided with sufficient information to enable them to decide whether to move into the home. All prospective residents have their needs assessed before admission. Prospective residents have the opportunity to visit the home, stay for a meal before making any decisions about admission. EVIDENCE: There is plenty of written information about the home for people to read. Copies of the statement of purpose and service user guide were and copies of previous inspection reports are made available to all. The manager assesses the needs of all prospective residents before admission to the home so that all concerned can be assured that needs can be met. Copies of these pre-admission assessments and signed copies of contracts are Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 9 held within individual records. There was documented evidence that residents and their families are supported throughout the admission process and care is taken in helping residents settle at the home. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Medication practices are good and the home always follows safe guidelines and return unused medication to the pharmacy. Care plans provide clear detailed instructions for staff to follow and provide evidence that care needs are met. Staff shows a good awareness of residents’ needs and they are treated with respect. EVIDENCE: All residents have a care plan which contain detail of the support they need. The plans are clear and easily understood. They include information about physical, social and emotional needs. In all of the care records sampled there was evidence of health needs being met, by dental appointments, chiropody, visits, optical prescriptions and visits Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 11 from GPs and district nurses. Input from other healthcare professionals is clearly documented within the records. Detailed and effective risk assessments are in place and provide staff with instruction on how to manage an identified risk. Medication records were sampled and found to be in order. The home makes sure that any unused medication that has been prescribed for a resident is returned to the pharmacy and is not put into stock as a homely remedy. Through observation on the days of the inspection, and by speaking to residents and staff it is clear that the privacy and dignity of residents is respected. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good, varied and nutritious diet is provided at the home that takes into account individual choice. Visitors are made very welcome at the home and residents are encourage to make choices in their daily lives EVIDENCE: Time was spent talking to several residents, those able spend their day how they choose. On the day of the visit staff and residents were playing bingo and later ball games. The programme of planned events for the Christmas period including entertainers, Christmas party, a concert to be put on by staff and outings for able residents were up on the home notice board. Visitors spoken with on the day of the visit said they were always made welcome and staff looked after their relative very well. Time was spent with the residents over lunchtime and all enjoyed their meal. The meals are well presented. The cook is aware of the likes and dislikes of the Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 13 residents and takes these into account when preparing meals. Drinks are available throughout the day. From observations during the day it was apparent that good interaction was ongoing between staff and residents. When residents became anxious due to the number of people in the communal area they were reassured. Requests to accompany staff for personal care was with regard to dignity and confidentiality. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have their views listened to, taken seriously and action taken to resolve issues. Residents feel safe at the home. EVIDENCE: The home has a complaints policy and procedure in place. The manager has close contact with residents and their relatives and feels confident that anyone who has any worries or concerns will speak to her about them. Relatives said residents are safe and well cared for at the home. Staff are able to recognise the signs and symptoms of abuse and are aware of the home’s policy and procedure to deal with this. Adult protection procedures are in place as well as whistle blowing procedures for staff. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained and offers comfortable facilities for its residents. EVIDENCE: All parts of the home were clean and free of unpleasant odours. The residents’ rooms are welcoming and they are able to bring small personal items to help personalise their rooms. Space is limited in the residents lounge on the ground floor. The manager said she has acquired funding for a conservatory in the New Year. The communal rooms are furnished and decorated in a style appropriate to the needs of residents. The kitchen and laundry is suitably equipped to meet residents’ needs. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 16 The home has a varied range of adaptations and equipment that assist residents in a number of ways. Staff were seen to knock on doors before entering residents bedrooms. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Well-trained and competent staff meets the needs of the residents. Residents are protected by the recruitment procedures. However the numbers of staff on night duty should be increased to meet the needs of resident during the night EVIDENCE: Duty rotas indicated that there is sufficient care staff on duty during the day to meet the needs of the residents. However there is two waking night staff, which appears low for 36 residents with dementia and the layout of the building. The pre-inspection questionnaire returned from the home to the Commission for Social Care Inspection (CSCI) state it takes two or more staff to undertake a resident care. With this in mind it is required the home looks at the Good Practices Guide to make sure at least three staff are on night duty this ensuring other residents are not put at risk whilst staff are engaged with one resident. Over 50 of the care staff have achieved a National Vocational Qualification (NVQ) in care at level 2. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 18 The recruitment files looked at on the day of the visit for recently employed staff were up to date. All the necessary checks are carried out before staff state work at the home. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 19 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, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The manager provides strong leadership and support to the staff team. She is highly respected and committed to providing a quality service for residents. The interests of the residents are very important to the manager and staff. The health and safety of residents and staff is promoted. EVIDENCE: There is an established system in place for the supervision of staff and the person carrying out supervision has been trained to do so. The format used Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 20 indicated that personal development; training and goal setting are amongst the topics covered. Staff says the manager offers them good support and is always ready to listen to their ideas. They are able to speak up in meetings and are encouraged to do so. The home has policies in place to make sure that the interests of the residents are safeguarded at all times. Record keeping at the home is of a good standard. Financial records were seen, where residents cannot look after their finances themselves, good records were in place, which are designed to protect the residents’ interests. The home appears to provide practices that protect resident’s health and safety. The testing of emergency lights and fire alarms was up to date. Staff fire training is carried out and is recorded in a register. Record shows the fire extinguishers are checked annually. Health and Safety in managed by the manager and she showed a good understanding and awareness of this. Nothing was seen at the inspection that could cause a hazard to the residents or visitors. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 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 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 22 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 OP27 Regulation 18 Requirement Night staff must be increased to at least three to ensure residents are not at risk at nights. Timescale for action 01/02/07 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. 2. Refer to Standard OP2 OP20 Good Practice Recommendations Respite service users should be issued with a contract of the providers terms and conditions of occupancy. The home would benefit from additional communal space. The manager stated this will be addressed in January 2007. Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 23 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 Musgrave Court DS0000033196.V320041.R01.S.doc Version 5.2 Page 24 - 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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