Inspection on 21/02/07 for St Leonards Court

This inspection was carried out on 21st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Leonards Court 03/03/09

St Leonards Court 01/11/05

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 Maggie Prettyman Unannounced Inspection 21st February 2007 09:45 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.V331304.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. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Leonards Court Address 6 St Leonards Street Mundford Thetford Norfolk IP26 5HG 01842 878225 01842 878238 stleonardscourt@manorcourtcare.co.uk www.manorcourtcare.co.uk Manorcourt Care (Norfolk) Ltd 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) 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.V331304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 25 Elderly people of either sex may be accommodated 25 people of either sex who have dementia may be accommodated Maximum number of 25 may be accommodated Date of last inspection 1st November 2005 Brief Description of the Service: St Leonard’s Court is a care home providing personal care and accommodation for up to 25 older people who have a dementia. St Leonard’s 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 Leonard’s 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. The current range of weekly fees is £410 - £450 St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. What the service does well: What has improved since the last inspection? The system of medication in the home has been improved. A new laundry area and treatment room have been built. A quality audit has been undertaken and falls are now being recorded and audited. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Leonards Court DS0000027456.V331304.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 St Leonards Court DS0000027456.V331304.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): Standards 2, 3 and 6 Service users have written contracts with the home. No Service user moves in to the home without having their needs assessed. Short stays are not routinely offered by the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence of contracts was seen in service user files. Some extra charges are not noted in pre admission information. It is recommended that all extra charges are included in the homes’ information. Evidence of detailed needs assessment made by the manager with the service users and their families was seen. Families usually visit prior to people coming to the home. Where possible short day care visits are used to acquaint the St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 9 service user to the home prior to their admission. Service users families commented that the needs assessment process is helpful, informative and supportive. The nature of the home means that short stays are rarely accommodated. St Leonards Court DS0000027456.V331304.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): Standards 7, 8, 9 and 10 An individual plan of care is in place for each service user. Service users health care needs are fully met. The homes procedures for medication administration protect service users from harm Service users are treated with dignity and respect The home supports service users at the end of their lives with care and compassion. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual service users care plans were found to be comprehensive and strengths led. Risk assessments were in place. Detailed life stories were found in many files. Records were up to date and reviewed. A handover book was found to contain information, which had not been transferred to care notes. It St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 11 is recommended that duplicate notes are not kept. Summary communication notes are displayed on the office wall. It is recommended that communication notes displayed use only the initials of service users. Evidence from service user records, observation of service users and discussion with the manager demonstrated that service users health care needs are fully met. Evidence of good relationships with the district nursing team was seen. Concern over a service users’ health and prompt action taken was seen during the inspection. Pressure area risk assessments are taken. Evidence of continence support was seen. The manager described the use of touch and music therapies. Evidence of specific dementia care support was seen throughout the day. The manager has arranged for medication to be provided by a more local supplier since the last inspection. The medication system was examined and found to be well managed. Photographic identification is being put on all medical records. Feedback from service user and relative questionnaires as well as observation of care practice throughout the inspection demonstrated that the home continues to maintain excellent standards in respecting the privacy and dignity of service users. Evidence that the home is now using the Liverpool Care Pathway to support end of life care was seen. Many letters of thanks from relatives of service users who have passed away were found in the homes’ file of compliments. These factors suggest that excellent standards of palliative care and family support are offered by the home. St Leonards Court DS0000027456.V331304.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): Standards 12, 13, 14 and 15 The lifestyle of the home matches the needs of its service users. Service users maintain contact with their family and friends. Service users are helped to exercise choice and control in their lives. Service users have a wholesome and appealing diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence from life story information and needs assessments about service user likes and dislikes is used to generate a range of activities in the home. Discussion with the manager and observation on the day of inspection showed that these activities are age and culturally appropriate. Service users were seen to choose rising times. A variety of activities are provided and recorded by an activities co-ordinator. It is recommended that a regular and one off activities be displayed so that service users and their relatives can anticipate upcoming events. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 13 The manager described a wide range of community groups that are involved in the home. Service users are involved as far as possible in village events. On the day of inspection one service user was seen enjoying lunch at the local pub with her family. Person centred care planning driven by a good needs assessment means that service users likes and dislikes are incorporated into their daily routines. Staff demonstrated good knowledge of individual wishes of service users. Rooms were seen to contain personal possessions. Information about advocacy is displayed in the home. Toiletries in shared rooms were not always personally identified. It is recommended that individual storage facilities for toiletries in shared rooms are clearly identified. An informed and professional team of catering staff were seen working in the kitchen. Freshly cooked appetising food was seen being prepared from fresh ingredients. Finger food is provided for a service user with particular needs. Discussion with the catering team demonstrated a good knowledge of service user needs and wishes. The nature of the service user group makes individual choice more difficult to assess. It is recommended that the detailed information about food likes and dislikes in care plans is provided to the kitchen team to facilitate further menu development and service user choice. St Leonards Court DS0000027456.V331304.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): Standards 16 and 18 Service users and their relatives complaints are listened to and acted upon. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received by the home since the last inspection. Feedback from relative and service user questionnaires demonstrated awareness how to make a complaint and confidence that staff would listen and take action. It is recommended that a record of minor complaints, comments and suggestions be kept and audited to identify patterns and trends and to further inform practice in the home. A file of compliments is kept. Evidence from staff records demonstrated that training in adult protection and in positive management of behaviour that challenges takes place. Evidence from a recent event showed that good communication takes place and that whistle blowing is responded to and supported. Issues about POVA reporting were discussed at length. It is recommended that the home reports all matters, even if considered minor, relating to POVA, to the relevant authorities for advice and guidance. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 15 St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20 and 26 Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated that it is safe, well maintained and fit for its purpose. All areas are accessible and it meets individual and collective needs in a comfortable and homely way. Two bathrooms were seen to contain items for storage elsewhere. It is recommended that the home remove St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 17 unnecessary equipment from bathing areas in order that they are homely and comfortable for people to use. The communal areas of the home are comfortable and homely. Of particular note are the sensory garden and front lounge, which are particularly supportive of the needs of people with dementia. The staff team is to be commended for its efforts in this area. The home is clean, hygienic and pleasant. Good laundry facilities are in place since this area has been extended. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30 The home is currently recruiting new staff to cover vacancies. Service users are in safe hands at all times. Service users are protected by the homes’ recruitment procedures. Staff are trained and competent to do their jobs Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a number of vacancies, which are causing current staff resources to be stretched at times. The manager is working towards more staff being available at peak times. Rotas are being covered by staff working overtime. New staff have been recruited and are in the process of being vetted and inducted. An excellent number of staff have achieved or are studying for NVQ qualifications. The staff team and the home are to be commended for this hard work and commitment. Examination of staff files demonstrated that on most occasions a good recruitment process is followed. Recent files were less well documented. It is recommended that good practice as outlined in “Safe and Sound” be St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 19 adopted by the home. A recent approach by a potential volunteer demonstrated that it would be sensible for the home to have a policy and procedure regarding the vetting and use of volunteers. It is recommended that the home develop a policy and procedure for the use of volunteers. Examination of staff training records demonstrated that excellent standards of staff induction and training are in place and are regularly updated. A staff member interviewed spoke positively about training received, and identified clear points of good practice that she had benefited from. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 20 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): Standards 31, 32, 33, 35, 36 and 38 The home is run by a kind, competent and caring manager. Service users benefit from the ethos and leadership of the home. The home is run in the best interests of service users. Service users financial interests are safeguarded. A system of staff supervision is not yet in place The health, safety and welfare of service users and staff are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager demonstrated herself to be professional, knowledgeable and caring. Vacancies in the senior staff team have caused some disruption to the normal smooth running of the home. New seniors are being recruited and it is hoped that this will soon resolve these problems. Observation of the home, the conduct of staff and the interaction of service users, as well as pre inspection questionnaires and internal quality audits, all demonstrate that the managers person centred and open approach is cascaded throughout the home. A quality assurance questionnaire has been developed, and responses detailed in a report, which is given to prospective service users. The manager is in the process of drawing up an annual development plan. No money is held on behalf of service users. Evidence of staff meetings was seen. A record of informal individual meetings with staff is kept. The manager is yet to put a system of individual planned supervision with staff in line with the standards. It is hoped to implement this when the new senior team is ion place. It is recommended that a system of supervision in line with the standards be put in place as soon as possible. A tour of the building and inspection of maintenance and water temperature records demonstrated that the home is run according to safe working practice. Mandatory training for staff is given and regularly updated. An accident book is maintained and a record of falls is being kept and audited. The upstairs laundry room was not secure. It is recommended that this room is kept secure as service users could access hazardous substances. St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 22 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 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 4 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 X X 3 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 4 3 X X 2 X 3 St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 23 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. 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 2 3 4 5 6 7 8 9 10 Refer to Standard OP2 OP7 OP7 OP12 OP14 OP15 OP16 OP18 OP19 OP29 Good Practice Recommendations Charges for services should be detailed in service user information Duplicate handover notes should not be kept Service user initials only should be used on communication notes. A board detailing activities should be provided. Individual named storage facilities should be provided for service user toiletries Information about service user food likes and dislikes should be given to the kitchen team to facilitate menu development Minor complaints and comments should be audited The home should report even minor POVA matters to the relevant authorities for advice and guidance Unnecessary equipment should be removed from bathrooms and appropriately stored The good practice guidelines outlined in “Safe and Sound” DS0000027456.V331304.R01.S.doc Version 5.2 Page 24 St Leonards Court 11 12 13 OP29 OP36 OP38 should be adopted A policy and procedure for the recruitment and supervision of volunteers should be adopted A planned and recorded system of supervision should be put in place The upper laundry room door should be secured St Leonards Court DS0000027456.V331304.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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