Inspection on 30/08/06 for Rearsby Home

This inspection was carried out on 30th August 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

Rearsby Home 24/08/05

Rearsby Home 20/04/05

Rearsby Home 09/02/05

Rearsby Home 08/11/04

Rearsby Home 09/02/04

Similar services:

St Marys Nursing Home

Thornham Grove

Chater Lodge

Conifer Lodge

Tixover Care Home

Toynton College (Cluster Five)

Egerton Lodge Care Home

Cedar Court Nursing and Residential Home

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

CARE HOMES FOR OLDER PEOPLE Rearsby Home 34-36 Station Road Rearsby Leicestershire LE7 4YY Lead Inspector Debbie Williams Unannounced Inspection 30th August 2006 11:00 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 Rearsby Home DS0000001820.V309840.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. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rearsby Home Address 34-36 Station Road Rearsby Leicestershire LE7 4YY 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) 01664 424519 01664 424519 Rearsby Home Limited Mrs Sairendri Jawahar Care Home 27 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24), Physical disability over 65 years of age (3) Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No one under 55 years of age falling within categories MD or DE may be admitted into Rearsby Residential Home No person to be admitted into Rearsby Residential Home in categories MD or DE when 24 persons in total of these categories/combined categories are already accommodated within the home No person to be admitted into Rearsby Residential Home in categories MD(E) or DE(E) when there are 24 persons in total of these categories/combined categories already accommodated within the home. No one falling within category PD(E) may be admitted into Rearsby Residential Home where there are 3 persons of category PD(E) already accommodated within the home No persons to be admitted to Rearsby Residential Home in categories MD, MD(E), DE, DE(E) or PD(E) when there are 27 persons in total of these categories/combined categories already accommodated within the home 24th of August 2005 4. 5. Date of last inspection Brief Description of the Service: Rearsby Residential home is a purpose built property in a quiet residential area of Rearsby village. This moderately sized home has space for 27 frail elderly residents, and specialises in residents suffering with Mental Health issues and Dementia. The home has a range of accommodation over 2 floors, both being serviced by a passenger lift. The home has a secluded garden that offers a level access from the home. The home is not situated near shops, though is well placed to access a local bus route to both Melton Mowbray and Leicester. At the time of this inspection the fees ranged from £317 per week to £425 per week. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The main method of inspection used was ‘case tracking’ which involved selecting residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The inspector also spoke with care staff and with one visitor. This was a positive inspection, residents spoken with were mostly happy with the service provided. What the service does well: What has improved since the last inspection? What they could do better: The strong odour in the reception area could be eradicated. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 6 Care records should reflect the current needs of residents and should include any cultural/religious or spiritual needs, this would assist staff in meeting residents needs. A fire risk assessment would minimise risk to residents. The introduction of a quality assurance programme would assist the providers to monitor the quality of care provided. 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. Rearsby Home DS0000001820.V309840.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 Rearsby Home DS0000001820.V309840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents are provided with the information they need to make an informed choice about where they live. Resident’s needs are assessed before they enter the home. EVIDENCE: The registered manager assesses the needs of residents before they move into the home. Care records included assessment records and risk assessments. Social work assessments were seen where applicable. All prospective residents and or their families are provided with a copy of the home’s Statement of Purpose. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care needs of residents are met and residents are treated with respect. EVIDENCE: Care plans for the three case tracked residents were seen. Care plans appeared to meet all assessed needs. The care plan for one resident did not reflect their current needs and a recommendation was made that care plans be reviewed on at least a monthly basis and should reflect the current needs of each resident. Records of GP and community nurse visits were seen in the care records of case tracked residents. Medication records seen were in good order and medications stored securely. Records of medication administration training and the home’s medication policy were seen. The interactions observed between staff and residents appeared positive and respectful. A visitor to the home spoken with said that staff always treated residents with kindness and respect. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 10 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Routines of daily living are made flexible to meet resident’s individual needs. Resident’s lifestyle expectations and preferences are met EVIDENCE: During this inspection residents who were able moved freely around the home, some residents choosing to spend time in their rooms and others in the lounge. One visitor spoken with said that they could visit at anytime and were made to feel welcome in the home. The lunchtime meal was served during this inspection and this appeared well presented and nutritious. Residents and visitors spoken with were happy with the meals provided. A four-week menu is in place and an alternative is always available. Extra sandwiches and snacks are also available. At the time of this inspection there were no residents with specific cultural or religious needs living in the home. There is a local convent in the village and the nuns will visit residents if requested. Social activities available included games and residents being taken out in the village for walks. Details of how to contact advocacy services were seen in the home’s reception area. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 11 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Policies and procedures in place minimise risk and offer protection to residents. EVIDENCE: A record of all complaints received is maintained. The registered provider had received one compliant since the last inspection. The registered manager was aware of the correct procedures to follow in the event of suspected mistreatment of vulnerable adults. One visitor spoken with said they would feel comfortable making a complaint to any member of staff and felt that their concerns would be listened to. Staff receive training regarding the protection of vulnerable adults as part of their induction training. One staff member spoken with was aware of correct procedures to follow. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 12 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Accommodation provided is mostly clean, comfortable homely and safe. EVIDENCE: A guided tour of the premises was provided by one of the case tracked residents. While the majority of areas seen appeared clean and well maintained, there was a strong odour in the reception area. A maintenance person is employed for three days a week at the home. The home has an infection control policy and staff have received training in this area. Toilet and bathing areas are clearly marked to enable residents to locate them easily. There was no fire risk assessment as required by the local fir authority; a requirement was made regarding this. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 13 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 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Staff are trained and competent to do their jobs. Recruitment procedures protect residents. EVIDENCE: The staffing roster for the week in which this inspection took place was inspected. There were fourteen residents living in the home and there were three care staff employed in the morning, two in the afternoon/evening and two at night. Records were maintained of all staff training. All but one of the care staff employed have achieved a National Vocational Qualification level two in care. Staff files contained the necessary references and Criminal Records Bureau checks. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 14 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is run and managed in a way that protects and serves the best interests of residents. EVIDENCE: The Registered manager is qualified, competent and experienced. It was recommended that a quality assurance programme be introduced in order to audit the quality of the services provided. Small amounts of resident’s personal money can be stored securely; records were maintained for all transactions. Health and safety policies were in place and staff training in this area provided. A record of all accidents is maintained. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 15 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 x x x x x x 2 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 3 x 2 x 3 3 x 3 Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 16 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. 2. Standard OP26 OP19 Regulation 23 23 Requirement The strong odour in the reception area must be eradicated. The provider must complete a fire risk assessment which complies with local fire service requirements. Timescale for action 30/09/06 30/09/06 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. Refer to Standard OP33 OP7 OP3 Good Practice Recommendations It is recommended that an effective quality assurance and monitoring system be introduced. It is recommended that care plans reflect the current needs of residents and are reviewed on at least a monthly basis. A record of the cultural/spiritual religious needs of each resident should be made and incorporated into the care plan. Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 17 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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. Extracts may not be used or reproduced without the express permission of CSCI Rearsby Home DS0000001820.V309840.R01.S.doc Version 5.2 Page 18 - 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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