Inspection on 06/07/06 for The Foundation of Lady Katherine Leveson

This inspection was carried out on 6th July 2006.

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.

Other inspections for this house

The Foundation of Lady Katherine... 12/05/09

The Foundation of Lady Katherine... 03/03/09

The Foundation of Lady Katherine... 09/06/08

The Foundation of Lady Katherine... 18/11/05

The Foundation of Lady Katherine... 10/06/05

The Foundation of Lady Katherine... 19/01/05

The Foundation of Lady Katherine... 14/07/04

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

CARE HOMES FOR OLDER PEOPLE The Foundation of Lady Katherine Leveson Temple Balsall Solihull West Midlands B93 0AL Lead Inspector Jill Brown Unannounced Inspection 6th July 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.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. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 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.V302675.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 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 home’s range of fees are between £356 and £400 per week. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited the home unannounced on a day in July. During this visit five resident care files were looked at three staff employment files. One of the inspectors looked around parts of the home looking at the kitchen laundry dining area and lounge and visited a number of residents in their flats or rooms. Records of maintenance and inspection of services such as gas, electric, lifting equipment and fire safety were seen. Prior to the inspection the home sent a pre-inspection questionnaire, menus, staff rotas and the home’s five year business plan to the Commission. The Commission received 18 resident comment cards and 17 relative and 3 health professional comment cards. Five residents and two care staff were spoken with on the day of the inspection as well as the manager and the deputy manager. What the service does well: The home provides prospective residents with good information and ensures that residents have the protection of a contract. They undertake good assessments before residents are admitted including visits to the home. They are clear about the service they provide and make residents aware of the distance between the home and the nearest village. The Foundation of Lady Katharine Leveson includes a school and a church and theses are involved from time to time with the lives of residents. Residents’ health and personal care needs were met. Residents had good access to medical professionals. Medical professionals thought the home were giving good care, one thought that the increasing complex needs of residents were concerning. Residents were very happy with the care they received saying ‘the best home in the borough’ ‘ I can recommend anyone seeking care and attention and peace of mind’ ‘I feel safe here but also independent’ ‘I enjoy being at the home’ ‘It is staffed by considerate people and I consider myself lucky to be here’ and ‘if you can’t be at home you can’t find a better place.’ The home checks on falls and injuries to residents and this means they can put in place measures to lessen these. Residents though they had enough activities provided or that they preferred to stay in their flats reading watching television and so on. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 6 Residents thought the food was good and relatives were happy with their treatment by the home. The home consults residents about the service they provide by questionnaires and meetings. The manager is looking at the role of the key workers in this consultation. The home manages complaints well and has appropriate procedures in place to protect residents. The home must remember to inform the Commission of any event that affects the life of a resident. The environment of the home is good providing residents in the flats a degree of independence in safe surroundings. There were no issues of decoration or repair raised at this inspection. The communal areas of the home were clean and fresh. A resident described the laundry service as excellent. The management of the home is good. There is an experienced qualified manager and deputy that wish the home to continually improve. The home has meetings with residents and also sends out questionnaires about parts of their service. The home manages residents’ money appropriately. The home has good records of maintenance, inspection and checks of fire, electrical and gas safety. What has improved since the last inspection? What they could do better: Care plans needed to be more consistent in the information they provided. A number of care plans had gaps in the management of issues such as behaviour, falls and nutrition. Plans were sometimes not updated quickly enough when a resident’s need changed. Medication systems were generally in place but a number of practices were seen that needed improvement such as not signing for medication straight after administering it and not watching a resident taking medication could cause difficulties for the resident. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 7 The levels of staffing were an issue for a number of residents and relatives. Some residents felt that they had to wait for care and cleaning in the flats was not as residents would wish. The home had a systematic approach to training but had yet to meet the target of 50 staff trained to NVQ2 currently the home has 35 . A number of staff had not had all the update training required in a timely way. The home needed to ensure that a risk assessment is completed for any member of staff with a medical issue. 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.V302675.R02.S.doc Version 5.2 Page 8 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.V302675.R02.S.doc Version 5.2 Page 9 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): 2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information to residents and collects information that is useful in providing care in the way residents wish. The home is aware that there are elements of their service that does not suit everyone and they are clear about explaining this and this ensures that the home can meet residents needs. EVIDENCE: All but one resident stated they had received a contract the other was unsure. The contract gave details on trial periods, how to pay and which flat the resident was to occupy. The contract also listed the details of services included in the fees and other services, which can be arranged for individual residents. All residents received information before deciding to come to the home. Residents visited the home before deciding to stay. One resident said that she had two visits before making this decision. One relative comment card stated ‘the home was very helpful when my parents moved in.’ The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 10 A pre admission assessment was very detailed containing information about the residents daily routine for example ‘likes a calming non hectic lifestyle,’ as well as medical conditions and personal care needs. These preadmission assessments would be enhanced by a discussion about diet before admission so appropriate food can be arranged. Assessments are thoroughly completed and where appropriate residents sign in agreement. Residents’ flats or rooms are risked assessed on admission to ensure residents safety and this is good practice. Assessments contain information about residents hobbies and life history which can be useful in assisting residents to settle at the home. The home is clear about which residents they can and cannot meet the needs of. The home discusses with the resident the relative isolation of the home, which means that it does not suit everybody. The home has excellent links with the school and church that are part of the Foundation of Lady Katharine Leveson but other supports are at best 3 miles away in Knowle. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home attends to residents needs well and there is a high level of resident satisfaction inconsistencies in the care planning and medication administration could mean residents needs are not met. EVIDENCE: The home has care plans in place for all residents and these are improving but still have some gaps. For example for one resident that was at high risk nutritionally did not have a nutritional plan, sizes of pads to be used were sometimes not recorded, strategies for managing confused behaviour, falls and pain were sometimes not developed. The plans do not always reflect changes in a resident’s condition quickly enough. The development of key worker system may assist in this. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 12 The home keeps monitoring charts in residents’ rooms or flats and this is good practice. Summaries of care contained good information and bring information closer to the resident requiring care. Residents receive visits from their GP when required. One resident wanted to know when the GP was visiting the home. There was a high satisfaction level with the medical service residents received. It was clear that residents were referred to opticians, dentists, chiropodists and so on when they needed. Residents that had chronic conditions were kept in touch with their GP. Medical professionals that completed comment cards said ‘one of the best homes around’ and ‘ exceptionally high quality.’ One raised a concern about the complexity of resident needs the home were managing and that the home may become a mini hospital. The home records daily events these could be improved to reflect the resident’s day more than stating the resident is fine which appeared a number of times. The home keeps good accident records recording both falls that result in injury and near misses. Two residents that were falling a lot have been referred for more specialist care; another is receiving extra care within the home. The manager reviews the falls on a regular basis to check for changes in individual resident’s health and trends that may need action. The home had a good system of checking medication coming into the home and being administered. The count of medication against the medication administration record was correct for the medications sampled. Residents that self medicate did not always have an assessment in place to ensure that they could administer the medication appropriately. However the residents with these assessments in place were reviewed appropriately. A medication was left with a resident and a member of staff did not watch it being taken, another medication was given and not signed for immediately after as required and second signatures were not always being obtained when controlled drugs were administered; these failures were the subject of immediate requirements. A GP had signed for a list of homely medications these need to be individual to the resident to ensure that none of the homely medications react with the tablets the resident is on. All of the residents that completed resident comment cards thought that staff listened to them. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 13 Residents thought the staff were kind and attentive. Comments from relatives and residents were ‘the best home in the borough.’ ‘ I can recommend anyone seeking care and attention and peace of mind’ ‘I feel safe here but also independent.’ ‘I enjoy being at the home.’ The residents on the whole have their own flats and residents in the main house have their own room. Staff appeared to be aware of how to maintain the privacy and dignity of residents. One resident said ‘It is staffed by considerate people and I consider myself lucky to be here’ another ‘if you can’t be at home you can’t find a better place’. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements the home has for activities, relatives visiting, choice and meals were good and this enhances residents’ lives. EVIDENCE: Residents in the home said they had enough activities and these included going to concerts and outings, involvement with the church and the school. A number of residents attended the keep fit session in the home. A number of residents stated they preferred to spend time reading in their flat to organised activities. Residents’ interests and hobbies were recorded in their assessments. Residents that received care in their room had music playing or other stimulus. The home has put a number of resident accessible computers in an upstairs lounge. Relatives were encouraged to visit and take the resident out. Relatives were happy with the care the home provided with comments such as ‘I looked at 30 homes before Lady Katharine Leveson, I didn’t find anywhere to compare with the sense of well-being.’ Residents felt there were no restrictions to relatives visiting. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 15 The home does not unduly restrict residents and residents are able to choose when they get up and go to bed. Residents have choices whether they join in the activities provided. Where a restriction has occurred it has been a result of a risk assessment and other options have been explored. There was a high degree of satisfaction with the meals. Residents stated in the comment cards ‘excellent meals’ ‘best sponge pudding ever’ and ‘meals cannot be bettered there are always alternatives.’ However there were a couple of comments ‘plenty of vegetables but rather repetitive main courses,’ ‘ variation in the teas in the flats would be appreciated. The home had just issued its questionnaire on meals and these comments may well be picked up by this survey. The home menus showed that there was a planned lunchtime meal but there were other options available. Residents were given a list of meals for the week and care staff assisted residents to choose what they wanted to eat. Specialized diets for diabetics, pureed food and vegetarians were available and although the home has no residents requiring Halal food the cook on duty was confident they would be able to source this if needed. The kitchen showed that the home kept good stocks of fresh vegetables as well frozen vegetables and meals. The provision of hot breakfasts and teas to flats was raised especially in winter and this could bear further investigation to solve some of the problems. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that residents are kept as safe as possible and their concerns are listened to. EVIDENCE: The Commission has received no complaints about the conduct of the home since the last inspection. Residents stated in the comment cards received that they knew who to speak to if they were unhappy and were able to make complaints. One resident card stated we have meetings in the lounge with Anne Atkinson who is always ready to listen. The home has had no complaints referred to them. The home discussed with inspector differing ways to capture comments of residents so that they can continue to improve. The home has a good complaint procedure but must ensure the shortened version is consistent with that procedure. The home had an adult protection issue this year this was not reported to the Commission in a timely way however the home did work with the police very effectively to gain a good outcome. Adult protection procedures are in place and training about adult abuse and the protection of residents are part of the home’s induction programme. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 17 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): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment enables independence and is in safe and comfortable surroundings. EVIDENCE: The home has a clear plan of upgrading flats in facilities and decoration. The Commission is kept informed of the programme by the five-year business plan of the home and by the home’s monthly visit from a representative of the Master of the home. The garden areas were not inspected on this visit. The tour of the premises sampled areas of the home. This tour raised no concerns in matters of decoration or repair. The home has not been able to provide a disabled car parking facility for the home but was making some progress towards this by gaining approval for access to the site from another road. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 18 The home has invested in a new assisted bathing facility on the ground floor of the main house since the last inspection and this should be more comfortable for the residents that need this. Aids were available where needed and district nurses assisted in getting specialised aids for individuals where needed. Whilst the majority of comment cards raised no concerns about the environment, access to cleaning services was raised on a number of comment cards. While the residents thought the home was generally clean the access to cleaners for their flats varied. Two relatives thought this could be improved upon one specifically mentioning toilets and bathrooms. During the inspection one raised toilet seat needed a clean. Communal areas and the kitchen were clean. The kitchen staff were aware of the ways to keep food fresh and minimise any contamination. The laundry had the appropriate equipment, one dryer was not working on the day of the inspection but a call had been made for repair. One resident stated that the laundry service was excellent. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the staffing levels meet the recommended amount the home must ensure that it is enough to provide a consistent service. The staff files had improved and thorough checks were being undertaken and this protects residents. Training was not quite meeting the requirements and this does not ensure that staff are skilled at providing care. EVIDENCE: Staffing levels appear to have varied since the last inspection. Residents thought that staff did try to get to them as quick as possible but that there was sometimes a delay. Residents state that there is a delay in response time to call bells comments such as: - ‘ aware of staff shortages at times and ….is understanding about delays,’’ ‘ biggest bugbear is getting assistance to the toilet,’ ‘ there is a problem of availability of staff due to illness’ another said that ‘on occasions information is not handed over to the staff coming on duty.’ Some agency staff has been used to cover shortfalls. The home reviews staff it needs by use of the staffing formula however if residents are very dependent then this will need to be reviewed. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 20 Approximately 35 of care staff have the NVQ 2 in care a number of staff have left and this has affected this figure. The home has a rolling programme of training and a number of staff are currently on the NVQ 2 in care course. Staff employed by the home have appropriate checks undertaken before starting. These checks include, references, a health declaration, a criminal records bureau (CRB) checks and a protection of vulnerable adults check (PoVA). At the last inspection the inspector viewed all staff CRBs at this inspection due to contrary advice from CRB the new ones had been destroyed too. Staff complete an application form and have an interview and responses to the questions asked at interview are recorded. One staff that disclosed a health condition requires a risk assessment and this should be placed on their file. Staff have induction and this is structured and the tests the knowledge of the staff member before they move forward. The induction format needs to be checked against the latest guidance from Skills for Care. It was clear that staff were receiving training. The home keep a matrix of staff training this hadn’t been updated at the point of the inspection but it was clear that there was a systemised approach to training some of the key mandatory training or update training was outstanding for some staff. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Qualified and motivated people provide the management of the home with an interest in continually improving the service for residents. The home has clear procedures for management of resident money and for arranging the maintenance and inspection of services. EVIDENCE: The manager of the home has worked for many years in the care profession and has appropriate qualifications to undertake this role. The home is well managed and the staff are well respected. Comments made were ‘The head of care is always available, the staff are willing to do anything,’ ‘the management have the finger on the pulse,’ ‘professionally administered’ and ‘staff are The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 22 fantastic.’ The management of the home have had significant challenges since the last inspection but have continued to ensure the home continues to improve. The home has just achieved the investors in people award. This means that the home and its staff understand the business they are in and maintain good professional working relationships. It looks at the training development and supervision of staff group. In addition to this the Manager ensures quality audits of meals, activities, accidents and so on are undertaken with all residents. The home holds resident meetings but some discussion was had about residents also meeting with the residents they are responsible for. The home reports to the Committee regularly and a business plan is produced. The home manages generally small amounts of money for residents that need assistance with their personal allowance. Very little cash is kept in the home as most of the money managed is for services such as hairdressing, which can be deducted from the residents account. The home retains a small amount in a overall residents bank account and this ensures that transactions do not put residents at risk. Relatives occasionally bring in money for residents and money is given from residents’ accounts and for these transactions a receipt book is recommended. The home has a good system of fire safety all the equipment maintenance, drills, and checks are undertaken appropriately. Gas and electric services are routinely inspected. A sample of individual flats showed that 5 year wiring certificates were in place and tests of small electrical equipment done. The home ensures that appropriate maintenance of the lifting equipment including the passenger lift. A yearly inspection of the lift was required. At the time of this report the inspection had been completed ad the home were awaiting a copy of this certificate. The home ensured that all wheelchairs, special mattresses and hoists were checked. A number of products that are regulated by Control of Substances Hazardous to Health(CoSHH) regulations were unlocked in the laundry and a risk assessment must be completed. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 23 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 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 24 Yes 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 OP7 Regulation 15(1)(2) Requirement A care plan must be in place for every need or risk identified. Care plans must respond as quickly to changes in need. The home must ensure that daily records more fully reflect residents’ lives. Any service user wishing to selfadminister their own medication must be risk assessed as able. (This remained oustanding since 31/12/05). The homely remedy list must be individual to the resident. Timescale for action 31/08/06 2. 3. OP8 OP9 17(2) 13(2) 31/08/06 15/08/06 The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 25 4 OP9 13(2) Staff must record on the 07/07/06 Medication Administration Record (MAR) directly after the transaction has taken place in all instances. Medication must not be left unattended staff must see residents take them if administering them. All administrations of controlled drugs must have 2 signatures to confirm that these have been administered correctly. The home must inform the Commission of any event that affects a resident’s life. 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. (Outstanding since 31/03/06) The home must have enough staff to consistently provide for cleaning in flats and care within a reasonable time frame. The home must ensure that 50 of care staff achieve the NVQ 2 in care. All care staff with a health condition must have a risk assessment evident on file. All care staff must have valid mandatory training. A updated version of the matrix of training must be sent to the Commission. A risk assessment of CoSHH products in the laundry must be undertaken. DS0000004517.V302675.R02.S.doc 5. 6. OP18 OP19 37 13(6) 31/07/06 30/09/06 7. OP19 DDA 31/12/06 8. OP27 18(1)(a) 30/09/06 9. 10. 11. OP28 OP29 OP30 18(1)(c) (i) 19(4)(a) 18(1)(c) (i) 31/10/06 31/08/06 31/10/06 12. OP38 13(4)(c) 31/07/06 The Foundation of Lady Katherine Leveson Version 5.2 Page 26 13. OP38 23(2)(c) A copy of the LG1 lift certificate must be sent to the Commission. 15/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations It is recommended that the home have a receipt book for transactions with residents money. The Foundation of Lady Katherine Leveson DS0000004517.V302675.R02.S.doc Version 5.2 Page 27 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.V302675.R02.S.doc Version 5.2 Page 28 - 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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