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Inspection on 18/11/05 for The Foundation of Lady Katherine Leveson

Also see our care home review for The Foundation of Lady Katherine Leveson for more information

This inspection was carried out on 18th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents appeared well cared with their personal hygiene needs met. Residents spoke of the kindness of the staff and the lovely environment in which they lived. Residents valued their contact with the school on the site and said that they had enough activities. The food was well prepared on the day and residents said the food was generally satisfactory. One resident said the laundry service was excellent. The homes induction of new staff was excellent it covered such areas of practice as adult protection and good skin care for residents. The home has good financial procedures. The accounts for the previous year showed the home to be viable. The records for the money managed on behalf residents were well managed.

What has improved since the last inspection?

The care planning in the home was more accessible than at the last inspection and the home had a system of showing the residents that had a high level of care need. The home had clear records of health professionals visits and this made it easier to see the progress of residents` health conditions.The arrangements for cleaning residents` flats had improved recently and residents were pleased with this.

CARE HOMES FOR OLDER PEOPLE The Foundation of Lady Katherine Leveson Temple Balsall Solihull West Midlands B93 0AL Lead Inspector Jill Brown Unannounced Inspection 18th November 2005 10:20 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 The Foundation of Lady Katherine Leveson DS0000004517.V267661.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. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Foundation of Lady Katherine Leveson Address Temple Balsall Solihull West Midlands B93 0AL 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) 01564 772850 01564 778432 www.leveson.org.uk The Foundation of Lady Katherine Leveson Miss Anne Atkinson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: The Foundation of Lady Katherine Leveson was founded in 1674 to provide almshouses for women in need. It now provides sheltered and residential care accommodation for older men and women. The foundation, which is a charity, offers accommodation for 30 residential service users and 15-sheltered accommodation places. The Court of Lady Katherine Leveson is situated in Temple Balsall, lying between Knowle and Balsall Common. It is a listed building and the majority of service users live in self-contained accommodation in the Court Yard where they have views of the mature gardens and a secure and pleasant place to walk and sit. The accommodation is mixed, all have en-suite toilet facilities, and some have a bath or shower. A number of rooms have a bedroom, small lounge, kitchen and bathroom. The Court of Lady Katherine Leveson has a Christian ethos, and although they will consider non-Christians, it is required that the service users are sympathetic to the Christian ethos. There is also a 14th Century Templar Church on the premises and service users are invited to attend the service on Sundays and other Christian celebrations. The registered provider is referred to as the Master and is an Anglican priest. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 5 and half hours on a day in November. Two service user files were looked at in depth. Staff employment files, records of money held on behalf of residents and the home’s accounts for the last year were looked at. The inspector spoke with 6 residents. The unannounced inspection does not cover all the standards and is best read in conjunction with the announced inspection that took place in June this year. A number of previous requirements were not looked at on this inspection and have been brought forward to the next inspection. These requirements are about medication administration, environment and quality assurance. What the service does well: What has improved since the last inspection? The care planning in the home was more accessible than at the last inspection and the home had a system of showing the residents that had a high level of care need. The home had clear records of health professionals visits and this made it easier to see the progress of residents’ health conditions. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 6 The arrangements for cleaning residents’ flats had improved recently and residents were pleased with this. 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 Foundation of Lady Katherine Leveson DS0000004517.V267661.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 The Foundation of Lady Katherine Leveson DS0000004517.V267661.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): EVIDENCE: These standards were not assessed on this occasion. The inspector was informed that no new residents had been admitted since the last inspection. The Foundation of Lady Katherine Leveson DS0000004517.V267661.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): 7, 8 The arrangements for care planning and recording were improving but still did not always reflect the good care residents were receiving or the outcomes for health issues raised. EVIDENCE: The home was changing its systems of recording to a new care plan and this has not had time to get fully set up in the home. The records were clearer than previously, had a good system of indicating which residents had a high level of need or risk. However a number of areas of the new paperwork had to be completed leaving gaps. The records on how personal care was to be delivered were not consistently in enough detail to assist new staff to deliver the care. For example one care plan stated that 2 carers were needed to assist the resident but not how this was to be achieved. A resident was noted to have wandering behaviour but a risk assessment with actions for staff was not in place. It was clear however that staff had a plan of management that they adhered to but it was not written down anywhere. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 10 The home had a clear record of health professionals visits and this was an improvement on the previous inspection. GPs, District Nurses, and opticians and so on saw residents when needed. A number of issues raised in records about the health of residents did not have an outcome recorded so it was difficult to see what action the home had taken. These issues included a bruise on a resident and weight loss on another, which were noted. A number of residents require turning as part of the pressure area care, turning charts should be used to show that turns have been done or have been refused, and the position that residents have been turned to. Residents at the home had their personal hygiene needs attended to. Residents said they were happy with the care the home provided and spoke of the kindness and willingness of the staff. The medication administration was not inspected on this occasion and some requirements were brought forward. A number of prescribed creams were found that had been opened longer than the 28 days recommended and a system of monitoring creams is to be put in place. The Foundation of Lady Katherine Leveson DS0000004517.V267661.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, 15 Arrangements for meals and activities suited residents spoken to. EVIDENCE: Residents spoken to on this occasion felt that they had enough activities and chose what they attended. Residents spoke fondly of their relationship with the school on the site and being invited to attend their Carol Services and so on. The inspector joined residents for a meal the residents said they enjoyed the food, which was either fish in sauce or smoked mackerel with vegetables. A full inspection of these areas was not carried out on this occasion. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 12 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): The home’s arrangements for adult protection were robust and this protects residents. EVIDENCE: The home has copies of the appropriate adult protection policy and procedures. Staff have been put on an Adult Protection course but unfortunately the course provider cancelled this. The course has been rebooked and the inspector is confident that this will be achieved shortly. The home’s staff induction pack includes a comprehensive section for adult protection. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 13 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): 26 The home was clean and fresh. Recent arrangements for cleaning had improved the environment for residents. EVIDENCE: A tour of the buildings was not undertaken on this inspection. However the inspector noted that the covering of the pipe work needed in a number of flats had been achieved. A number of other requirements made at the last inspection were brought forward for the next inspection. These included the risk assessment for the use of shale on one of the pathways, redecoration of flats, one bath water outlet that was running hotter than 43 degrees. The home was no longer using the small bedroom for a long stay resident and was reconsidering its use. One resident stated that the laundry service provided by the home was excellent. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 14 The flats seen were cleaner than on previous inspection as the home had managed to employ some cleaning staff. Residents were pleased about this and hoped the new staff would stay. The home generally was clean and fresh. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 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 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 & 30 The arrangements for employment and deployment of staff were variable and a more robust approach was needed to ensure the safety of residents. The induction and training of staff had improved and this ensures that staff have the skills to meet the needs of residents. EVIDENCE: Staff turnover at the home is high, despite incentives, due to the home being sited away from any settlement and infrequent public transport. The home has made all reasonable efforts and thought flexibly about how staff can be encouraged to work at the home and stay. This has the potential to cause difficulties at the home although the home uses agency staff when all other avenues fail. Rotas show that staff are available to provide care. The home has employed staff prior to the required Criminal Records Bureau checks have been undertaken. Staff files do not always have the required level of proof of identity and this must be remedied. Where staff are needed prior to these checks being in a place a risk assessment must be undertaken to ensure the safety of residents. The home has excellent induction procedures that not only show that staff have been taken through areas of work practice but also have to demonstrate competence. The procedures cover such things as communication with residents, acceptable behaviour, adult protection and skin care. New staff at the home undertake training that cover four of the mandatory training courses. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 16 The update training for existing staff have improved and there a clear system to audit these. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 17 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, 34, 35 and 36 Arrangements for the management of the home and finances were good and protected residents. A quality assurance system would ensure that the home continues to improve year on year. EVIDENCE: The Registered Manager was off work due to ill health at the time of the inspection however has many years experience in managing care. The Deputy Manager came into the home to facilitate the inspection and has taken over the duties in the Registered Managers absence. It was clear from the inspector’s discussions that the deputy manager was keen to ensure that the home provided a good service. The home has yet to have a formal audit completed and the requirement for a quality assurance system was brought forward. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 18 The home supplied a copy of accounts for the financial year 2004 to 2005. This showed that the site was viable. The accounts were inclusive of the sheltered housing income and costs. The home managed expenditure under clear budget heads that included housing costs and items such as training and medical costs. Resident’s finances looked after by administrator of the home had a clear financial process. The inspector discussed issues for residents that may become confused about signing for money and in this instance an additional signature from a member of staff would be required. New staff were receiving supervision in the form of their induction process other staff were receiving supervision but not at the frequency required by the standard. The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 19 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X 3 3 2 X X The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement The care plan must record in detail how care is to be delivered. (This requirement remained outstanding since 31/07/05) Risk assessments must be in place for residents setting out actions staff must take to minimise risks. Health issues raised must be investigated and have an outcome recorded. Monitoring charts must be used for health conditions such as turning, fluid balance and so on. Any service user wishing to selfadminister their own medication must be risk assessed as able and compliance checks undertaken on a regular basis. (This requirement was not assessed on this occasion and was brought forward) Staff must return all unwanted medicines to the pharmacy for destruction. (This requirement was not DS0000004517.V267661.R01.S.doc Timescale for action 31/01/06 2. OP7 13(4)(c) 31/12/05 3 4 .5 OP8 OP8 OP9 12(1)(a) 12(1)(a) 13(2) 15/01/06 15/01/06 31/12/05 6 OP9 13(2) 31/12/05 The Foundation of Lady Katherine Leveson Version 5.0 Page 21 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 OP19 13(6) 12 OP19 DDA 13 OP24 23(2)(d) 14 OP25 13(6) assessed on this occasion and was brought forward) Staff must refer to the Medicines Administration Record (MAR) chart prior to administration and record directly after the transaction has taken place in all instances. (This requirement was not assessed on this occasion and was brought forward) Any secondary dispensing must be against a policy and correctly labelled and checked by a second member of staff for accuracy. (This requirement was not assessed on this occasion and was brought forward) The homely remedy policy must reflect medicines purchased. (This requirement was not assessed on this occasion and was brought forward) Medicinal creams must be discarded 28 days after opening to prevent the spread of micro bacterial infection. Areas of shale used, as a surface must be risk assessed for residents with poor mobility. (This requirement was not assessed on this occasion and was brought forward) The home must consider the car parking needs for disabled visitors to the home. (This requirement was not assessed on this occasion and was brought forward) Residents flats must be audited for redecoration and a schedule produced a copy must be sent to the Commission. (This requirement was not assessed on this occasion and was brought forward) The bath hot water outlet that DS0000004517.V267661.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/01/06 31/03/06 31/01/06 31/12/05 Page 22 The Foundation of Lady Katherine Leveson Version 5.0 15. OP29 17(2) Sch 4 (6) 19 Sch 2 (7) 16 OP29 17. OP33 24 registers a hot water temperature above 43 degrees centigrade must have its thermostat adjusted to comply. (This requirement was not assessed on this occasion and was brought forward) Proof of identity including photograph of staff must be retained on file. (Outstanding since 31/08/05) All staff must have a valid Criminal Records bureau check prior to commencing work in the home. (Outstanding since 31/08/05) A quality assurance system must be set up in the home. (This requirement was not assessed on this occasion and was brought forward) 31/01/06 31/01/06 30/09/05 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 OP3 Good Practice Recommendations It is recommended that the place and time of the assessment be recorded. (This recommendation was not assessed and was brought forward) It is recommended that the photocopied prescription be kept alongside the Medicine Administration Record (MAR) chart for the relevant 28-day cycle for reference. (This recommendation was not assessed and was brought forward) It is recommended that the home review its information and contract to ensure that limits to the amount of furniture in residents accommodation are clearly stated to prevent health and safety risks. (This recommendation was not assessed and was brought forward) DS0000004517.V267661.R01.S.doc Version 5.0 Page 23 2. OP9 3. OP23 The Foundation of Lady Katherine Leveson 4. OP28 5. 6. OP36 OP37 It is recommended that the future training of staff include NVQ2 to ensure that the standard is met. (This recommendation was not assessed and was brought forward) It is recommended that recorded supervision occur no less often than 6 times a year. It is recommended that further administration support be given to effect the requirements made at this inspection. (This recommendation was not assessed and was brought forward) The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 The Foundation of Lady Katherine Leveson DS0000004517.V267661.R01.S.doc Version 5.0 Page 25 - 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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