CARE HOMES FOR OLDER PEOPLE
ST LEONARDS COURT 6 St Leonards Street Mundford Thetford IP26 5HG Lead Inspector
Geraldine Allen Announced 19 May 2005 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. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service St Leonards Court Address 6 St Leonards Street, Mundford, Thetford, Norfolk, IP26 5HG. 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) 01842 878225 01842 878238 Manorcourt Care (Norfolk) Ltd Mrs Annette Nelson Care Home 25 Category(ies) of DE/E Dementia registration, with number of places ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 25 Older people of either sex who have dementia may be accommodated. 2 Maximum number of 25 may be accommodated. Date of last inspection 25 October 2004 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 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 v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning of 20 May 2005. The focus of the inspection was to look at some residents’ care plans, discuss the care and other needs of residents with the staff of duty and to observe the activities of the residents and staff during the visit. A tour of the communal parts of the home and also the enclosed garden also took place. All care staff on duty were spoken to and residents were seen and spoken to as part of the inspection process. Time was spent, sitting in on a staff daily report meeting and time was also spent with the manager. Part of the discussions with the manager included considering the questions that follow below. What the service does well: What has improved since the last inspection?
The manager has needed to deal with some staffing matters during the last 12 months, but she has done this well and has been able to learn much from her experiences that have helped her in her good practice. As a result, it was clear that the staff team is working very well together. Staff communication has improved; with staff understanding better the approach to care the manager intends to have at this home. The approach she wants throughout the home is recognised as best practice. Staff and residents are more relaxed as a result of this.
ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 6 Staff at the home appear to have a better understanding of the roles of the manager and senior staff and what support they can expect from them. 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 v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 & 6 The home provides information to residents and their representatives to ensure they are able to make an informed choice when entering the home. All residents receive a statement of terms of residence. All admissions to the home are subject to a full needs assessment. This home does not provide intermediate care. EVIDENCE: A copy of the home’s brochure was provided. The brochure contains information about ManorCourt Care and the home specifically. The brochure is written in accessible language and sets out precisely what the resident may expect from the home. A blank copy of the statement of terms of residence is included within the brochure pack. As a result, the resident and their representative are able to make an informed choice to live at the home. The manager is continuing to develop the very good care planning processes at this home. Pre-admission assessments have been part of this development process and the most recent assessments were seen. Evidence was obtained
ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 9 that demonstrated an excellent process for gathering relevant and timely information to ensure care is provided appropriately from the day of admission. Relatives and health care professionals are fully involved in this process and the result is an abundance of relevant information about the person entering the home. The home is commended. This home does not provide intermediate care. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 9 Each resident has a care plan that sets out clearly how his or her needs are to be met. The home uses safe medicine control, administration and recording procedures. EVIDENCE: As previously stated, care plans are continuing to be developed with good results seen at this inspection. The care plan is informed by the pre-admission assessment and is based on a strengths analysis. There is also a daily record for each resident. This record was seen and needs to be developed further. Some entries were very brief and did not include details of activities enjoyed by the resident through the day. Subsequent to this inspection, evidence was received that showed the manager had discussed these issues with staff and a plan to include more holistic information about the residents’ day had been agreed. The opportunity was taken to sit in on a staff handover meeting. The exchange of information about each resident was comprehensive and covered
ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 11 all aspects of their physical, emotional and healthcare needs. The daily record for the morning was completed at this meeting. The arrangement for the control, administration and recording of medicines was observed. The member of staff followed the home’s procedures and good practice was seen. The manager provided a copy of the medicine audit undertaken to ensure continuing competence of staff. The audit covers all aspects of safe medicine control, administration and recording and provides a good record of competence. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 14 Residents are able to spend the day in activity and with whom they wish. Staff assisted residents to make choices about their daily living based on a sound knowledge of their preferences, likes, dislikes and personal histories. EVIDENCE: Opportunity was taken to observe interaction between staff and residents. It was noted that residents were encouraged to make choices with staff support, for example about having a bath, where to sit and also activity. Staff demonstrated a good knowledge of residents’ individual preferences regarding how they spent their day and with whom. Staff were observed meeting these preferences and supporting residents’ as necessary wherever possible. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 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 standard(s) 16 & 17 The home responds positively to all comments and complaints made by residents and their representatives. The residents’ legal rights are protected. EVIDENCE: The manager responds positively to any comments or expressions of concern as soon as they are received. Care plans demonstrated appropriate responses being made to comments received from a relative. Comments are also regularly sought through the quality assurance audits and any suggestions are considered and implemented if possible. As a result of this approach, this home has a very low complaint activity. Efforts are made to ensure residents’ legal rights are protected and guidance about independent support and advice available to residents can be found within the home’s brochure. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 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 standard(s) 19, 20 & 26 The home is well maintained and safe. All areas are decorated to a good standard. There is a good range of communal space in and outside of the building that is safely accessible to residents. All areas of the home are clean and free of unpleasant odours. EVIDENCE: Those areas of the home seen on the day of inspection were in a good state of repair, decorated to a good standard and were clean. Since the last inspection, substantial progress has been made to the enclosed garden to very good effect. This area has level access from several points, including residents’ bedrooms. The garden has been designed to provide a sensory experience for residents, with a safe water feature, wind chimes, herbs and scented planting. There is also a gazebo and plenty of seating along pathways and under trees. The garden is still very young but should mature into a particularly pleasing and popular area. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 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) 30 Staff are appropriately trained to meet the needs of the residents. EVIDENCE: This home continues to provide very good staff training and development. A copy of the home’s annual training programme for 2005 was seen and showed that, in addition to statutory training (manual handling, first aid, fire safety, etc.), the home is also providing induction, foundation training, NVQ at levels 2 & 3, Diabetes & diet, Dementia and Managing Challenging Behaviour. The manager described other training also provided recently and relevant to the client group that included Constipation, Continence and Stoma Care. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 16 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) 32, 33 & 37 The ethos and leadership qualities of the owners and manager provide an environment for residents that is supportive and inclusive. The home is run in the best interests of the residents and the views of residents, relatives and visitors are sought and acted upon. Not all records were up to date or properly maintained. EVIDENCE: The interactions between the manager, staff and residents were observed. Each resident was treated as an individual, with staff demonstrating a very good knowledge of the person and their history. Interactions were meaningful to the residents and were not patronising or demeaning. A copy of the summary of the Quality Assurance questionnaires, conducted in September 2004, was provided. The questions asked were relevant and covered topics such as care, food, staff and responses to concerns. Many comments were included within the summary from relatives and visiting
ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 17 professionals. All were positive and reflect the standards of care to be expected from this home. The accident records were seen as part of the case-tracking process. No entry could be found referring to an accident that occurred to 1 resident on 10th May 2005. There was evidence that suggested staff were unclear how to complete the new accident records and in what order. The result was a chaotic record that was not completed in date order. Subsequent to the inspection, written evidence has been received from the home to show that the manager has dealt with this concern in a timely and appropriate manner. Staff have received instruction about how to correctly complete accident records. Because of this, no requirement has been made. No risk assessments had been completed for 1 resident although they had experienced 2 falls recently. Other care plans were seen to include risk assessments. As stated previously, the manager has provided evidence that shows this matter has been properly dealt with. Because of this, no requirement has been made. ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x
COMPLAINTS AND PROTECTION 3 3 x x x x x 3 STAFFING Standard No Score 27 x 28 x 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 3 x x 4 3 x x x 2 x ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations ST LEONARDS COURT v228990 i55 s27456 st leonards v228990 190505 stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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
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