Inspection on 01/11/05 for St Leonards Court

This inspection was carried out on 1st November 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

St Leonards Court 03/03/09

St Leonards Court 21/02/07

St Leonards Court 19/05/05

St Leonards Court 25/10/04

St Leonards Court 29/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Leonards Court 6 St Leonards Street Mundford Thetford Norfolk IP26 5HG Lead Inspector Mrs Geraldine Allen Announced Inspection 09:30 1 November 2005 st 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 St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Leonards Court Address 6 St Leonards Street Mundford Thetford Norfolk IP26 5HG 01842 878225 01842 878238 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) Manorcourt Care (Norfolk) Ltd Mrs Annette Nelson Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25) of places St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 25 people of either sex who have dementia may be accommodated Maximum number of 25 may be accommodated 25 Elderly people of either sex may be accommodated Date of last inspection 19th May 2005 Brief Description of the Service: St Leonards Court is a care home providing personal care and accommodation for up to 25 older people who have a dementia. St Leonards Court is owned by ManorCourt Care, which has other homes and resources within Norfolk. The home is situated in the village of Mundford, close to the town of Thetford. St Leonards Court is located on the village green and is in the centre of the village. Accommodation consists of 19 single and 3 shared bedrooms. All bedrooms have en-suite facilities. Bedrooms are located on the ground and first floors. There is level access throughout the home and a shaft lift is installed for access between floors. There is ample communal space, including 2 lounges, a period reminiscence lounge and dining room on the ground floor. There is a small sitting area on the first floor. The home has an enclosed rear sensory garden, which is easily accessed by service users. The garden has a ramped pathway and lawns, together with sitting areas and appropriate garden furniture. There is parking space available to the rear of the building. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place during the day. Not all of the National Minimum Standards were inspected on this occasion. Those standards not inspected will be reviewed on a future inspection. The focus of this inspection was on the staffing arrangements and protection of the residents. Information was gathered from various sources. The manager Mrs Nelson, returned a completed pre-inspection questionnaire before the inspection was due. During the inspection, a range of records was seen. Staff were discreetly observed going about their duties and 3 visiting relatives were spoken to. Staff were also spoken to and lunch was eaten with residents. A brief tour of the home was undertaken. A total of 10 comment cards were completed and returned by relatives and visitors to the home. All comments were complimentary and supportive of the home and standard of care provided by staff. Evidence was gained throughout the day that this home provides a very high standard of care. The following elements of the summary were completed following this inspection. What the service does well: The manager and staff are very knowledgeable about the causes of dementia and how it affects each resident. As a result, they provide very good care that is right for each of the residents at the home. Staff are sensitive to the needs of the residents and treat everyone with dignity and respect. The home has very good recruitment processes that ensure people who are sensitive and caring care for residents. The processes make sure that the residents are not put at risk and the home obtains a range of references. Residents receive nutritious and varied food. Staff provide discreet support and guidance as necessary. Mrs Nelson and the maintenance worker have worked hard to provide an excellent sensory garden. The result is an attractive area that addresses all the senses. This has been done in an imaginative way, with the use of fruit plants, herbs, colourful flowers, water features and wind chimes. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9 & 10 Residents’ health care needs are met appropriately and in a timely way. The home operates safe procedures in respect of medicines. Residents are treated with dignity and respect. EVIDENCE: The arrangements for the healthcare needs of the residents were discussed with Mrs Nelson. Two surgeries, based in Brandon, provide medical support and the Community Nurses are also based in Brandon and visit the home as necessary. Mrs Nelson described very good relationships with the GP’s and Nurses that is both timely and supportive. The healthcare needs of all residents at the home have recently been reviewed by the GP’s. Additional support is obtained when necessary from the Community Psychiatric Nurse and referrals to Consultants occur as required. All medical interventions are recorded. None of the residents’ self-medicates and the home controls and administers any medicines required. Medicines are properly stored in a locked cabinet in the locked office. The senior carer responsible for dispensing medicines on the day of inspection was discreetly observed during the lunchtime medication St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 10 “round”. It was noted that she followed the homes’ procedures and good, safe practice was seen. Throughout the day, the interaction between staff and residents was observed and without exception this was respectful and based upon friendship and trust. This is a view borne out by the comments received from relatives and visitors who made comments such as: “I rate this home very highly”; “…staff, without exception, always treat him with love and respect”; “I have noticed all the little things they [staff] did to make special moments for the residents…”. It was noted that no member of staff walked past a resident without speaking to them. The staff are commended. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Residents enjoy a lifestyle that reflects their preferences and expectations. Residents are enabled to maintain contact with their relatives and friends. Residents are supported and guided to make appropriate choices about their day-to-day lives. Residents receive a well-balanced and nutritious diet. EVIDENCE: Activities were seen throughout the day that was meaningful to each resident. Whilst group activities were in evidence (craft in the morning and video in the afternoon), individual activity was also taking place with the support of staff as needed. Staff spoken to stated that they felt there was generally sufficient staff on duty to allow “quality time” with residents during the day. One member of staff stated that residents are encouraged to make choices and these are respected. Three visitors to the home were seen and spoken to during this inspection. In all cases, the visitors felt welcomed by the staff and confirmed they were always offered refreshment on arrival. One visitor stated that the home was St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 12 “always the same” in that there were never any odours he was aware of and that staff were “always about” and were “very caring”. Staff were observed supporting residents to make choices about activity and daily living. Lunch was eaten with residents and the way residents were offered a choice was noted. One resident was unable to understand the options offered and the member of staff showed them to the resident to assist him to make his choice. As previously stated, lunch was eaten with residents in the dining room. The meal was ready so that residents did not become distracted or restless. The food was well presented and clearly enjoyed by the residents. Fresh fruit and vegetables are delivered to the home daily to ensure produce is as fresh as possible. Plenty of staff were on hand to offer discreet assistance to the residents. Where support with eating was needed, this was given appropriately with the member of staff sitting next to the resident and talking to them socially. It was particularly pleasing to hear a member of staff discussing with the resident what was on her plate and describing what she was eating at each mouthful. Mrs Nelson described the current consideration about providing more finger foods for 1 resident. The mealtime was clearly an enjoyable and social event for the residents. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The homes’ complaints procedure is well known by relatives. Residents are protected from abuse by a well-trained and knowledgeable staff group and robust practices. EVIDENCE: The homes’ complaints procedure is well known by relatives and visitors to the home. Only 1 of the returned questionnaires stated that the person did not know the homes’ complaints procedure, however they described the action they would take that suggested they had confidence in Mrs Nelson to deal with their concerns. No complaints have been received by the Commission in the last 12-months about this service and there have been no complaints made to the home. During discussions with staff, their knowledge and understanding of adult protection matters was explored. This revealed that staff have very sound understanding of adult protection and the relevant training they have attended was described. Refresher training is undertaken every year. The home has good recruitment practices that include all new staff having Criminal Records Bureau and Protection of Vulnerable Adults (CRB/POVA) checks prior to commencement of duties. Overseas staff are subject to relevant checks are required to have up to date work permits. All the current documents were seen during this inspection and were in order. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26 The home is safe and well-maintained. Residents have access to indoor and outdoor communal space. Residents bedrooms are clean and comfortable and have their own possessions in them. The home is clean, tidy and there were no unpleasant odours detected. EVIDENCE: A brief tour of the building took place. Work has been done to refurbish some of the bedrooms to a good standard. The lounge was also in the process of being redecorated. Maintenance records were seen for electrical equipment such as the lift, hoists and assisted bath. One of the fire exit routes was being used to store 2 radiator covers whilst the lounge was being decorated. They were not blocking the escape route but were cluttering the area and it was suggested they be moved; this was done straight away. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 15 Mrs Nelson and the maintenance worker have worked hard to provide a sensory garden at the home. This is now complete and provides an excellent outdoor area for residents to enjoy. All senses are catered for, with fruit plants, herbs, colourful scented plants, water feature and wind chimes being included. Seating is also available for residents to enjoy the experience in comfort. It was noted that the old lounge chairs were stored out of sight in the garden pending their removal scheduled for the day after the inspection. The refurbished bedrooms were seen during this inspection and they have been completed to a high standard. Each room has benefited from redecoration that has resulted in bright, fresh bedrooms that are very comfortable. Various personal items were seen in each of the bedrooms, including pictures, photographs and ornaments. One shared bedroom remains in need of refurbishment. This particular bedroom has suffered damage that will require a wall to be re-plastered due to a specialist bed being used. The bedroom is currently occupied and it was agreed that it would be inappropriate to move the residents to facilitate refurbishment. All areas of the home seen during this inspection were clean and tidy. No unpleasant odours were detected during this inspection. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 The number of staff on duty and the skill mix and competence of staff meet residents’ needs. The home operates robust recruitment procedures that ensure residents are protected. EVIDENCE: A copy of the homes’ staff rota was provided and this showed that, excluding Mrs Nelson, a minimum of 1 senior and 3 care assistants are on duty between 07:30 and 22:00. In addition, the home employs a member of staff who is not yet 18 years of age. Whilst she is studying her NVQ at level 2, she does not undertake any personal care. There are 2 waking night staff on duty each night. Three staff files were seen as part of this inspection. These demonstrated the recruitment process used at this home. All applicants are required to complete an application form and to make a declaration regarding any criminal record disclosures. Two references are requested in all instances and all staff are subject to CRB & POVA checks. Mrs Nelson stated that, on occasions, it is necessary to start new staff after the POVA 1st check has been successfully completed but before the full CRB disclosure has been received. In these circumstances, staff work supervised. A very recently recruited member of staff had commenced working supervised having had a full CRB & POVA disclosure but with 1 reference outstanding. This was discussed with Mrs Nelson, who confirmed that the reference was being pursued and the member St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 17 of staff would continue to work supervised and do her induction training in the interim. All interviews are conducted by Mrs Nelson and a senior member of staff. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 37 & 38 The home is run and managed by a person who is competent and fit to discharge her responsibilities. Residents’ benefit from the leadership and management at the home. The residents’ personal financial interests are safeguarded by good practice. The homes’ policies, procedures and standard of record keeping demonstrate that residents’ are safeguarded. The health, safety and welfare of residents, staff and visitors to the home are protected by good practice. EVIDENCE: Mrs Nelson has demonstrated through her leadership, knowledge and competence that she is fit to run and manage this home. There is evidence St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 19 that she keeps up to date with recognized best practice and strives to share her vision of quality dementia care with the staff team. Mrs Nelson understands the concept of “Person centred care” and works hard to ensure staff understand this approach and put it into practice. During this inspection there was some professional debate around the appropriate use and monitoring of some therapies used to care for people with dementia. Staff described how they feel included in professional debate and decision making within the home. Staff respect the skills and knowledge that Mrs Nelson offers and trust her judgement. Comments received from relatives and visitors support this. One relative described the staff as “a credit” to Mrs Nelson. Where relatives made additional comments, these were invariably positive and complimentary of the standard and appropriateness of the care provided. The home does not control or keep any money on behalf of residents. For normalization, some residents like to have a few coins in their purse or pocket but this is agreed through discussion with their next of kin and within a risk assessment framework. A variety of records were looked at during this inspection. It was seen that all records were well-maintained, up to date and legible. The contents were appropriate and relevant. Records had been completed in accordance with the homes’ policies and procedures. Various health and safety records were seen as part of this inspection. These included risk assessments, Control of substances hazardous to health and their relevant data sheets, maintenance records, electrical testing records, accident records and reporting under RIDDOR, water temperatures and fire safety records. All were up to date and demonstrated that the home operates in accordance with its policies and best practice. St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X 3 X 3 3 St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 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. 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. Refer to Standard Good Practice Recommendations St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 St Leonards Court DS0000027456.V249521.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!