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Inspection on 09/06/08 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 9th June 2008.

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

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

Relatives stated that they could visit at a time that suited them, therefore residents were always able to maintain contact with their family and friends. Money, which is held on behalf of residents by the home, was accounted for and there were good systems in place to ensure residents` finances were respected and protected. Information provided to prospective residents on the whole is good. The Foundation of Lady Katherine Leveson includes a school and a church and these are involved from time to time with the lives of the residents. Residents are happy with the care they receive saying "staff couldn`t fault great" "staff care for me in some many ways" and "they are good and caring here". Residents thought the food on the whole 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 environment of the home is good providing residents in their flats a degree of independence in safe surroundings. Residents have good access to external health professionals.

What has improved since the last inspection?

There have been a number of areas in the home that have been redecorated and refurnished, making the environment pleasant and homely.

What the care home could do better:

Care planning and record keeping must improve to ensure all residents` needs are identified, planned for and met. Plans were not being updated quickly enough when a residents needs changed so that all changing and developing needs are fully met. The medicine management must improve to a correct and safe level so the clinical needs of residents are met. A compliance check was made by theCommissions Pharmacy inspector post inspection in relation to medication management and this had improved significantly. Staff need training in the new Mental Capacity Act to ensure that the rights and any risks for residents are identified, maintained and promoted. The home has systems in place to deal with complaints, concerns and allegations but these are not always being systematically dealt with according to policies and procedures in place therefore cannot be guaranteed that issues raised will be appropriately dealt with. Staff recruitment is not robust and does not guarantee residents are safeguarded. The home must improve the way in which it notifies the CSCI of incidents that affect the well being of its residents to ensure their welfare is protected. Residential agreements/contracts are needed for all residents living at the home to ensure they are fully aware of their rights and obligations.

CARE HOMES FOR OLDER PEOPLE The Foundation of Lady Katherine Leveson Temple Balsall Solihull West Midlands B93 0AL Lead Inspector Karen Thompson Key Unannounced Inspection 9th June 2008 08:40 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.V366504.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. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.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.V366504.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 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. There are a number of suites comprising of 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. Fees vary and are dependent on the needs of the service users. Items not covered by the fees include toiletries, private treatments such as physiotherapy and chiropody, hairdressings and newspapers. The home’s ranges of fees are between £432 and £485 per week. For up to date fee information the public are advised to contact the home. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use this service experience poor quality outcomes. This was an unannounced inspection, which was carried out over a two day period. Another inspector accompanied the lead inspector for the first day of the inspection. The focus of inspection undertaken by us is about outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirement, minimum standards of practice and focuses on aspects of service provision that need further development. The inspection commenced at 8:40am on the first day and the home/provider did not know that we were coming. The manager was present for the duration of the inspection. Information used in the report was gathered from a number of sources: a questionnaire (AQAA Annual Quality Assurance Assessment) was completed before the inspection by the management team of the home. During the inspection a tour of the building was undertaken, records and documents were examined about the management of the home, conversation with managerial and care staff plus visitors and a number residents took place. Direct and indirect observation was also used to inform the inspection process. Three residents who live in the home were ‘case tracked’ which involves establishing individuals experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on the outcomes of their lives including their health. Tracking people’s care helps us understand the experience of people who use the service. Questionnaires were forwarded to a randomly selected number of residents, relatives and health professionals prior to the inspection. Comments from residents and relatives spoken to during the inspection have been incorporated into the report, along with comments from staff working at the home. The inspectors would like to thank the residents, relatives, management and staff for their hospitality throughout this inspection. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care planning and record keeping must improve to ensure all residents’ needs are identified, planned for and met. Plans were not being updated quickly enough when a residents needs changed so that all changing and developing needs are fully met. The medicine management must improve to a correct and safe level so the clinical needs of residents are met. A compliance check was made by the The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 7 Commissions Pharmacy inspector post inspection in relation to medication management and this had improved significantly. Staff need training in the new Mental Capacity Act to ensure that the rights and any risks for residents are identified, maintained and promoted. The home has systems in place to deal with complaints, concerns and allegations but these are not always being systematically dealt with according to policies and procedures in place therefore cannot be guaranteed that issues raised will be appropriately dealt with. Staff recruitment is not robust and does not guarantee residents are safeguarded. The home must improve the way in which it notifies the CSCI of incidents that affect the well being of its residents to ensure their welfare is protected. Residential agreements/contracts are needed for all residents living at the home to ensure they are fully aware of their rights and obligations. 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. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.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.V366504.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2.3.5 Quality in this outcome area is adequate Information about the service or facilities is available to residents and or their representatives to enable them to make an informed choice about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the residents handbook (Service Users Guide) was given to the inspectors at the time of the visit. The manager stated that these are given to all residents on admission to the home. All residents spoken to confirmed they had a received copy of the residents’ handbook. Although the residents’ handbook is a comprehensive document, it will need to include the range of fees the home charge in order to meet the current legalisation. Prospective residents do however receive a detailed letter confirming that the home can meet their needs and within this are included details of the weekly fee. Within The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 10 this letter it states that the first four weeks are a trial period and at the third week a formal review will take place to ascertain whether the needs of the resident can be meet by the home or whether the resident feels that this is the home for them. A resident stated, “It lives well up to the information” The organisation has its own website where the Statement of Purpose for the home is available. This gives an accurate description with photographs of what the public might expect regarding the environment, services and limitations, options, processes, ethos and values. The Statement of Purpose generally reflects the current staffing make-up but could be updated, for example says that CSCI determines staffing levels. Staffing levels are not set by CSCI but are determined by the needs of the residents as informed by the National Minimum standards, which the home must assess and these are monitored by CSCI. This was discussed with the Care Manager at the time of the inspection. Not all residents have a formal contract with the home, the inspector was shown a pro-forma for a potential residents contract that the home was in the process of considering giving to residents. The home has accepted residents who are outside their registration category. This was discussed with the management team at the time of the inspection. The home will need to consider submitting a variation to their registration and demonstrate to the Commission they are able to care for people outside their current category. The manager confirmed that following an initial enquiry by a potential resident or their representative the home at that stages ascertains whether they can meet the needs of the prospective residents. Information is then sent out to the enquirer. This can lead on to a pre-admission assessment being carried out where the Care Manager or deputy manager will visit potential residents prior to admission at their home or in hospital. Relatives and or potential residents are asked to visit the home during this period. Whilst at the home if a room is vacant the visitors will be shown this. Three pre-admission assessments were reviewed, one was found to be detailed and comprehensive the others were basic in detail. There was evidence of recording of individual preferences but this was not being consistently recorded. A good preadmission assessment is crucial to ascertaining whether a potential resident needs can be meet. Residents’ confirmed that they and or their relative had been invited to visit the home prior to deciding to live there. One resident spoken to stated, “my daughter found the home… it was too far for me to travel to visit, but I am very satisfied.” The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9 Quality in this outcome area is poor Whilst residents expressed a high level of satisfaction with care delivered inconsistencies in care planning and monitoring could lead to residents’ needs are not being fully met. Medication management is poor and is placing residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of three of the people living at the home were looked at in detail and other records were sampled. Care plans are based on the assessment that is completed before the person moves into the home. The care planning documentation was not comprehensive although risk assessments were in place for moving and handling, environment and fire. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 12 Residents did not however have assessments for mental health, skin integrity, challenging behaviour nutrition or bedrails. Care planning instructions were not always being followed or recorded as taking place . One resident required weekly testing of blood sugar levels for monitoring of their diabetic condition. There was only one blood sugar level recording found for a six-week period. Staff were not recording when residents had a bath or a shower, despite the recording system in place allowing for this to happen with ease. There is no tissue viability risk assessments taking place despite, having a skin inspection checking system. These checks are important and are indicators of potential concerns that need to be monitored. The records for one resident were found to be confusing and were not leading to the development of a plan of care to demonstrate that care delivery was being dealt with appropriately. On a number of occasions the record of daily events simply stated that the resident was “fine”. This is insufficient detail and improvements need to be made to ascertain what sort of day the resident had and who and what this involved. Residents admitted with dementia had no assessment of extent, orientation or mental capacity. Recordings need to include assessment of capacity, significant best interest decisions and processes of consultation that afford least restrictive alternatives of rights including privacy and evidence of how the views of the person concerned are considered. Incidents of challenging behaviour were not always being recorded so that triggers or trends could be established. Residents on the whole expressed a high level of satisfaction with the care given. The home has a good system in place for recording health professional visits but this was not being used. A health professional was seen visiting the home on the day of the inspection and residents informed the inspectors of visits from health professionals. One health professional commented that they felt the home had “personalised care offered rather than a system of care”. Medication management was poor, systems for checking, administering and recording were not robust. Staff were not adhering to the home medication policy and procedure, therefore placing residents at risk. There were a number of examples found of poor practice which included signing for medication that had not been given, signing by staff to say medication had been given but had never been received into the home, non adherence to checking of the controlled drugs policy and procedure and dispensing medication several hours prior to distributing to residents. Residents can self administer their own medication, which is good practice but systems to ensure residents are safely The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 13 doing this, were not being adhered to. An immediate requirement was left on the first day of the inspection. On returning to the home for the second day, the inspector was informed that an audit of all residents’ medication had been carried out by the management team and the findings were poor. The Care Manager had contacted their pharmacist who would be updating all staff who dispense medication on good practice. A letter was sent to the providers representative post inspection detailing what was required on the home to ensure residents safe and well being. Due to the severity of the concerns the Commissions Pharmacy inspector will check compliances with these requirements. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this outcome area is good. There were no rigid routines and visitors could visit at times that suited them enabling residents to maintain contact with them. The home is good at providing residents with a stimulating and purposeful life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to on the whole were happy with the activities provided. Residents each week receive a sheet listing all the activities, which are taking, place within the home. The home has the use of a minibus to take residents out and about. The home was in the process of recruiting new staff members of whom they hoped one would be able to drive a mini bus so that residents with limited mobility could get out and about more. One resident commented, “they do take me shopping which I enjoy”. One relative commented, “It would be good perhaps to see additional activities - perhaps a card/games session, The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 15 craft sessions or few more outings. There are practical limitations, but I think it would help residents to relate more”. Another resident commented, “These include some delightful “outings which included a pleasant trip on the canal in a narrow boat. Strawberry tea, BBQ and much happy entertainment at Christmas”. The home has an activities co-ordinator and has recently conducted a survey of activity provision within the home to ensure that this is meeting the needs of residents. Relatives are encouraged to visit and take residents out. Relatives were happy with the care the home provided making comments such as “excellent, gold star”. The home has a relative association who have hosted a number of events within the home for residents. They were due to host a Strawberry tea event at the home at the weekend. Residents’ bedrooms/flats were personalised with their own possessions so providing a more comfortable and homely environment. Residents confirmed that there were no restrictions on getting up or going to bed The weather on the day one of the inspection was very hot. Residents were observed sitting outside in the courtyard under a canope, which provided shade. The staff demonstrated vigilance on ensuring residents received fluids thorough out the day to ensure they did not dehydrate. One staff member commented, “ checked every hour, especially today when it’s so hot….we top up their water”. Relatives were also observed being offered drinks when visiting which a nice friendly personalized welcome to the home for visitors. The mealtime experience was observed to be unhurried and staggered so that all residents could eat their meal at a pace that suited them. One resident was observed to be assisted by a volunteer, this was discussed with the management team post inspection as a risk assessment needs to be in place to ensure the resident is not placed at any risk. There was a high degree of satisfaction with the meals expressed by the residents, however one comment received back from a relative stated “the evening meal is very early - about 5.00pm, but I am sure this is to do with staff shifts and I think is common in residential homes.” Two residents commented to the inspector that they felt there was lack of choice in relation to breakfasts. The Manager stated they were experimenting with breakfast, they have trialled a hot breakfast which is likely to become a regular feature and breakfasts are now being served in both the dining room and residents bedrooms. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is adequate Systems for picking up and recognising complaints are not robust. Not all residents are safeguarded appropriately and this can affect their health and well-being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has written policies and procedures for complaints that meet the standard. There have been three formal complaints logged by the home since the previous inspection. A number of untoward incidents had been recorded. The audit trail to demonstrate what the outcomes of these were was not fully recorded. Complaints and incident records were found in disarray and were kept in many locations. This indicates that the systems in recording and reporting and procedures are not fully understood by staff. Systems need to be reviewed and staff made aware of these to ensure that concerns, allegations and incidents are dealt with appropriately to ensure residents are fully protected. All residents spoken to and those returning surveys felt happy to raise concerns with staff. One resident stated “I always am happy but if I have a problem it is soon sorted out” Also one relative commented “ I was impressed The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 17 at my ……recent assessment, at which I was present, that they made sure that my ….understood how …could make a complaint if necessary.” The home has the local safeguarding policy and procedure although the Commission was aware of one occasion where this was not followed in between key inspections. Staff knowledge about safeguarding issues was weak in a number of areas. Whilst staff demonstrated zero tolerance to any form of abuse they did not however always appreciate the principles of the reporting structure to Social Services. Staff need to be re-familiarised with the procedure via a number of methods, briefing, supervision and training. The Administrator for the home has been on a training day for Mental Capacity Act awareness. All staff need to receive training in this area. The management team had drawn up a summary sheet for staff on the Mental Capacity Act but some of the information on this sheet was incorrect. This was discussed with the management team at the time of the inspection. The management team were able to demonstrate however an acceptance of diversity. The home appears to achieve meeting peoples rights well, but needs to improve their systems and daily practice of obtaining consent for accommodation, care and treatment decisions in line with the Mental Capacity Act Code of Practice. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 18 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): 19.22.24.26 Quality in this outcome area is good The home’s environment enables independence and is in safe and comfortable surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the premises sampled areas of the home. It was evident that a programme of redecoration and refurbishment had taken place recently. One of the doors leading out into the court was observed to have been fitted with a sensory device, which meant the door opened automatically. This means residents and staff are not hindered in accessing or leaving the building. The The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 19 management team stated that sensory devices alerting staff to movement could be fitted to residents’ bedroom/flat doors with theirs and or their relatives’ permission so that the well being and safety of residents could be monitored. Residents were observed sitting out in the courtyard area under a canope for shade. The grounds around the home are well kept and ensure residents have a pleasant outside area to sit in and relax. Call points are situated around the home for residents to call for help or assistance. Residents are also issued with a pendant which can be used anywhere in the home to call for help. There was no evidence to suggest a key was offered to residents for their room with the accompanying risk assessment. One resident stated they had “not been offered a key, but then I have not asked for one”. Comments received from residents and relatives raised no concerns about the environment. The management team have reviewed the number of cleaning staff since the previous key inspection. One resident commented “delightful cleaning staff”. Areas visited were clean. The laundry area was clean and had the appropriate equipment. The laundry has its own staff during the week but over the weekend care staff man the laundry. The home has a policy that laundry will be returned to residents with in forty-eight hours of receipt. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 20 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): 27.28.29.30 Quality in this outcome area is adequate Staffing levels are currently satisfactory but will need to be monitored and adapted with changing resident dependency. Staff recruitment was not consistently robust therefore potentially placing residents at risk. Whilst there have been improvements made in the training given to staff to ensure they have the skills and knowledge to meet residents needs there is still some shortfalls which will need to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were thirty residents living at the home in receipt of care. The Care Manager stated they aimed to have five carers per shift on duty. The home also employs ancillary staff for duties such as cleaning, catering and laundry. One resident stated, “staff answer the buzzer promptly but now and then they may be delayed”. A relative commented that “staff are cheerful and demonstrate a caring attitude towards my…. This has helped to settle into …new home”. Approximately 67 of care staff have the NVQ2 in care. Senior care staff either have an NVQ3 or are in the process of obtaining one. The training The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 21 programme showed that staff are being developed for their roles and that the home was creating learning opportunities of various kinds to meet the needs of residents. Not all staff working at the home had a Criminal Records Bureau check carried out prior to commencing work at the home. An immediate requirement was left at the home requiring the organization to carry this out. In order to be absolutely certain of compliance with the regulations in future they were advised in writing following the inspection to consult the CSCI website (www.csci.org.uk) for the “Policy and Guidance” (for service providers and CSCI staff) on CRB checks. All other documentation in relation to staff recruitment was found in the staff files with the exception of one file contain only one reference. It is crucial that each step of the recruitment process is adhered to protect residents living at the home The deputy manager whose role involves training staff has qualifications in training. It was clear that staff were receiving training. The home keeps a matrix of staff training but this hadn’t been updated at the point of inspection 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. Care staff have not had training in the Mental Capacity Act 2005 however a training package has been obtained by the home. Staff need to receive this training so they are clear of their roles and responsibilities. Residents commented that they felt the staff were well trained. An induction training programme was in place in the home. Care staff confirmed that induction training had taken place and that they work with a senior carer initially when they start working at the home. An induction booklet shown to the inspectors had not got start or finish date however the inspectors were informed that the home aims to carry out this induction programme over a 14-week period. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 22 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): 31.32.33.35.38 Quality in this outcome area is adequate The home has good systems in place to support the management and running of the home however these are not always adhered to which places residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has worked for many years in the care profession. A deputy manager supports the manager in her work. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 23 Staff spoken to during the inspection spoke positively about management support and their role within the team “I can always talk to management, give ideas have. …supervision” The home manages generally small amounts of money for residents that need assistance with their personal allowances. Very little cash is kept in the home as most money managed is for services such as hairdressing, which is deducted from the residents account. The home retains a small amount in an overall resident’s 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 resident’s accounts and for these transactions a receipt book is recommended. On relative commented, “I think it is a wonderful place and everyone seems very happy. My ….has a very independent nature and they have gone to great trouble to encourage this. I like the way they knock on my … door before entering - They don’t just barge in. This is a good feeling of community” Concerns identified in the section on complaints and protection, health and personal care and staffing need to be addressed swiftly by the management team. These concerns have been highlighted in previous inspection reports and it is concerning that the management team are not consistently maintaining good practice to protect and promote the well being of residents. The home has a number of systems in place to assess the quality of the care it provides, these include for example surveys sent out to residents, audits in place to monitor the running of the home, regular visits by the providers representatives and a relatives association. Records in relation to fire, water, electrics and gas were sampled in respect of maintenance and servicing of equipment. These records demonstrated that maintenance and servicing of equipment was taking place on a routine basis promoting the well being of residents. The home has recently employed an independent consultant to carry out a fire risk assessment and a number of recommendations for action had been identified. The home was aware that it was due a visit from the West Midlands Fire Service in the near future to ensure the safety and well being of residents and staff were being promoted. Water temperatures in a number of bedrooms were observed to be in excess of 44c. Pressure relieving mattress servicing was taking place but his had not occurred for two years this needs to be reviewed. The accident records were reviewed and the Commission had not received notification of these events. Notification is required so that the Commission can monitor the home in between inspections. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 24 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 2 2 2 X 3 X 3 X X 3 X 2 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 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 2 17 X 18 1 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP4 Regulation NCSC Registrati on Regulation s 12 Requirement An application for a variation must be submitted for those residents that the home wishes to care for outside their current registration category. This will ensure that the Commission and the public can be confident that the home can meet the needs of people they are caring for. A photocopy of the original prescription (FP10) must be used to check all current medication being received into the home to ensure that residents receive their medication as prescribed by their doctor. Staff must adhere to the homely remedies approved list and any medication for homely remedies use not on this list must be disposed of appropriately this will ensure residents do not receive any medication that could possibly be undermine their current medication regime. The Controlled drugs and The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 26 Timescale for action 30/06/08 2 OP9 13(2) 26/06/08 register must be audited and appropriate action taken from these findings. Staff must also receive briefing, supervision and training of the administration of controlled drugs to ensure their practice safe guards the well being of residents. Staff practice of placing medication in a medication pot several hours before giving the medication to the resident must cease as this places residents at risk. Residents who self medicate must have a record of a risk assessment completed along with regular compliancy checks. This is to protect and promote the well being of residents who wish to administer their own medication. All medication must be recorded on the medication administration record (MAR) chart as the prescriber requests to ensure that the residents receive the correct medication as prescribed at all times to ensure that residents receive the correct levels of medication. A quality assurance system must be installed to ensure that regular medication audits must be carried out and records kept to demonstrate findings and any issues identified and how they were dealt with to ensure that residents receive medication as prescribed to promote and The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 27 protect their well being. 3 OP18 13 (6) The home must adhere to the Safeguarding procedures for its area to ensure that residents are protected. Staff must also receive briefings, supervision and training in safeguarding procedures to ensure they have a comprehensive understanding of their role in protecting vulnerable adults. The home must carry out its own Criminal Records Bureau check (CRB) prior to staff commencing employment at the home to ensure that a robust recruitment procedure is carried out to safeguard residents safety and wellbeing Hot water temperatures must be within the recommended range of 43 c minus or plus one degree to ensure residents are not placed at risk of scalding themselves. 26/06/08 4 OP29 19 4 (1)(b) 26/06/08 5 OP38 13 (4) 30/06/08 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 OP2 Good Practice Recommendations All residents must have a contract so they are aware of DS0000004517.V366504.R01.S.doc Version 5.2 Page 28 The Foundation of Lady Katherine Leveson 2 3 OP3 OP8 4 OP7 5 OP15 6 7 OP8 OP16 8 9 10 OP18 OP35 OP38 their rights and obligations. All pre-admission assessments carried out must be comprehensive so the home can ascertain fully whether they can meet residents’ needs. Risk assessments for skin integrity, mental health, nutrition, bedrails (when in use) must take place for each resident so a comprehensive plan of care can be drawn up the appropriate advise sort to meet these needs if required. Care plan documentation must include identified needs, these needs must have a plan of care and be evaluated regular. If needs change then the documentation must reflect the change in needs so that residents well being can be monitored and assessed appropriately. Residents who are assisted with personal tasks by volunteers must have a risk assessment in place to demonstrate any risks have been identified and strategies put in to reduce them, so therefore not exposing anyone to unnecessary concern. Diabetic residents must have their blood sugars monitored as their care plan dictates to ensure their well being is being monitored and maintained. Document management in relation to complaints and incidents should be reviewed to ensure these are retrievable and can be audited easily for trends and patterns. This will allow for better management of such issues identified. It is recommended that all staff at the home are familized with the “Mental Capacity Act 2005 and are aware of there roles and responsibilities It is recommended that the home have a receipt book for transactions with residents’ money. The Commission must be notified of incidents affecting the health and well being of residents so that the home can monitor between inspection visits. The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI The Foundation of Lady Katherine Leveson DS0000004517.V366504.R01.S.doc Version 5.2 Page 30 - 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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