Inspection on 10/12/07 for The Lawns

This inspection was carried out on 10th December 2007.

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

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

Other inspections for this house

The Lawns 23/09/09

The Lawns 02/12/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Lawns The Lawns 1A Knighton Rise Oadby Leicestershire LE2 2RF Lead Inspector Mrs Carole Burgess Unannounced Inspection 10th December 2007 10:00 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 Lawns DS0000070277.V355288.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 Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lawns Address The Lawns 1A Knighton Rise Oadby Leicestershire LE2 2RF 0116 244 8864 0116 244 8864 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) FSHC NEWCO Ltd Mrs Linda Thorpe Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (4) of places The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following categories of service only:Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories:Old age, not falling within any other category - Code OP Physical disability - Code PD 2. The maximum number of service users who can be accommodated is 41. New Service Date of last inspection Brief Description of the Service: The Lawns is a purpose built home and provides care for up to for up to fortyone older people and older people with a physical disability. This is a spacious, well-appointed home set in well-kept gardens. There is a TV lounge and quiet sitting room and separate dining room. All rooms have en suite facilities and there are additional toilets and assisted bathing facilities. The home is situated in the pleasant area of Stoneygate and is close to local shops and the nearby village of Oadby. It is close to the A6 where there is a regular bus service into Leicester. The Statement of Purpose, Service Users Guide & Inspection Report are available in the reception hall of the home and on request (these provide information on how the home is organised and what services they provide). The Statement of Purpose and Service Users Guide are provided for all new residents. At the time of the inspection, fees ranged from £520 to £630 per week. Extras include: Hairdressing, newspapers and dry cleaning. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This was the first key inspection for the home as a new service, having been recently purchased by FSHC NEWCO Ltd. The home can achieve no more than an overall rating of good at the first key inspection, which is undertaken within in the first six months following purchase. The site visit was unannounced and took place over five hours. The Inspector selected three residents and tracked the care they receive through a review of their records, discussion with them, other residents, the care staff, and observation of care practices. The Inspector spoke with staff members regarding training and support. Planning for the Inspection included assessing notifications of significant events sent to the CSCI by the home and the home’s Annual Quality Assurance Assessment (AQAA). There have been no complaints received by the CSCI regarding the home. Registered Manager (a person registered with the CSCI), and other staff spoken with were positive and helpful during the inspection. What the service does well: The Lawns provides an excellent standard of care within a bright, spacious, and homely environment. The home and the attractive gardens are well maintained and provide a safe environment in which residents can be supported to maintain as much independence as possible. The home maintains a very high standard of décor and cleanliness throughout. Food is nutritious and well-presented, individual diets and preferences are catered for, and the chef and staff are very flexible to ensure that residents’ requests are accommodated. Visitors are made very welcome and are able to dine with their relatives. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 6 Levels of staffing ensure that the residents’ health and welfare needs are fully met. Six residents, spoken with during the inspection, said that they were very well looked after and that staff were kind, caring and respectful. They said that the home was always maintained to a high standard, the food was very good and well presented and that there were sufficient activities which they could take part in if they chose. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with detailed information about the home, and have their health, welfare and social care needs assessed, so that they can be fully met once they move into the home. EVIDENCE: The home provides prospective residents and their relatives with a Statement of Purpose and Service Users Guide (both give information about the home) to help them decide if the home is the right one for them. Prospective residents are encouraged to visit the home, where possible, to help them decide if the home is the right one for them. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 9 Residents spoken with confirmed that they had received detailed information and contracts (terms & conditions) when they moved into the home. The three residents’ care plans reviewed contained a detailed pre-admission assessment to show that the home could meet their specific health, welfare, and social care needs. It included personal details, relative and GP contact numbers, past and present medical history, current health care requirements and medications, personal preferences, social interests and hobbies to ensure that the home could meet all of a prospective resident’s needs. The home does not provide intermediate care. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are well looked after in respect of their health, personal and social care needs. EVIDENCE: The home is currently implementing new care plans inline with FSHC NEWCO Ltd policies and procedures and all care plans are being reviewed during this process to ensure that they are current and meet the needs of the residents. Residents’ care plans are detailed and give carers thorough information about the health, personal and social care needs of the residents. Residents The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 11 confirmed that they were aware of their plan of care and fully involved in any reviews or changes to it. Contact with healthcare professionals such as GP’s, District Nurses, hospitals, and Chiropodists were recorded to ensure that healthcare needs and treatments were addressed. Medication policies and procedures were sound. A significant number of residents manage their own medication. This is closely monitored by the Registered Manager who signs the prescription sheet to say that she has assessed that the resident is competent to do so. All residents have a lockable facility in their rooms to keep medicines safely new risk assessment form is to be implemented and kept in the resident’s care plan to show that a formal assessment has been undertaken and that the resident is able to self medicate safely. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. Staff spoke to residents and visitors in a respectful, friendly, quiet and supportive way. Six residents, spoken with during the inspection, said that they were very well looked after and that staff were kind, caring and respectful and they. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 staff work hard to ensure that residents experience a safe and homely life style. EVIDENCE: The home has appointed an activities organiser who is due to start in the next week or so. The home has a monthly entertainment programme and residents are provided with information, in large print, on the residents’ notice board and in their own room and can choose which events they wish to attend. There is a full programme of activities arranged for December and the Christmas period including a visit from the Lord Mayor and a Christmas party for residents to enjoy. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 13 The home has its own pool car and shopping trips are arranged for small groups of residents. (The use of the car is included in the fees). There is a hairdressing salon and there are regular visits from the hairdresser, chiropodist and reflexologist; residents can also take part in music and movement once a week to enable residents to maintain their appearance and wellbeing. Birthdays and festive days are celebrated and religious and spiritual needs are supported. There is Church of England Holy Communion in the home once a month, and some residents go to church with their families. Residents are able to have their own television and telephone in their room should they choose to do so. Residents said that they are able to have visitors at any time and a number of people came to visit during the course of the inspection. Staff support residents with making choices in their everyday life. All residents spoken with said they got up and went to bed when they wished, are able to choose what they wanted for their meals, breakfast in their rooms if they wished, and are well supported by very caring staff. All meals are prepared in the home’s kitchen by the chef. A cooked breakfast is available every day, if required, and there are choices at all main meal times. Drinks are available throughout the day. Residents have a pre-lunch sherry and wine with their evening meal. There are homemade biscuits and coffee in the morning and homemade cakes and tea in the afternoon. Special diets such as diabetic are catered for. The Registered Manager is to implement a nutritional assessment for all residents to ensure that their dietary needs are fully met. Residents said that food was very good and that there were always choices. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are sound resulting in satisfactory protection of residents’ rights. EVIDENCE: Residents and staff comments showed that people feel at ease discussing any concerns with the staff. Information regarding advocacy services is available if residents require independent support and advice. Age Concern visited the home during the inspection to speak with one of the residents and provide assistance with a personal matter. Neither the home nor the CSCI have received any complaints about the home. The home’s complaints process reflects the Safeguarding Adults policies and procedures and staff were clear how to protect residents from harm. However, staff have not received training for some time (approximately two years or so). It is recommended that all staff, including ancillary staff, are provided with appropriate training as soon as possible to enable them to demonstrate the most current local procedures for safeguarding residents. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 15 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 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A comfortable, clean, safe and high standard of accommodation is provided for the residents. EVIDENCE: The home is clean, safe and well maintained and decorated and furnished to a high standard that creates a comfortable, light, spacious but homely environment. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 16 All residents’ rooms have en suite facilities and all have a ‘nurse call’, and were clean and well decorated. Residents are able to bring items of their own furniture and possessions with them to personalise their rooms. Residents’ rooms were highly personalised with some of the resident’s home furnishings. Residents also have access to attractive, safe gardens. There are sufficient additional toilets, bathing and assisted bathing facilities. The home’s health and safety arrangements such as regular maintenance and servicing of equipment, regular fire drills and monitoring heat control valves on hot water taps throughout the home show that the Registered Provider (owner) and Registered Manager are mindful of their responsibilities to make sure that residents live in a safe environment. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Staff at the home are trained and sufficient in number to meet the residents’ needs. EVIDENCE: There were thirty-seven residents at the time of the inspection. Staffing levels, at the point of inspection, were in line with those suggested by the Department of Health Residential Forum Guidelines and were sufficient to meet the residents’ needs. During the morning there are six carers, early afternoon four carers; and six carers in the evening and two carers at night. In addition, during the day, there are chefs, cleaners, kitchen and laundry staff and an administrative assistant and maintenance staff. Residents said that there always seemed sufficient staff on duty. The Registered Manager and her deputy are supernumerary. This ensures that care staff are able to concentrate on caring for the residents. Three staff files were checked during the inspection and showed that there is a satisfactory recruitment process to ensure that residents are well protected. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 18 New care staff complete an induction programme and have training updates. Staff undertake training in specific areas such as fire training, first aid and moving and handling. The new owners have introduced a training matrix to identify what training has been undertaken and where training is required. Some shortfalls have been identified such as safeguarding adults training and this is to be addressed in the near future. The Registered Manager said that about 50 of care staff had completed an National Vocational Qualification (NVQ) in Care. This ensures that staff have the necessary skills to give safe care to the residents. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 19 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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager provides supportive leadership to staff, ensuring that residents receive a high standard of care. EVIDENCE: The Registered Manager is an experienced carer and works in a supervisory and management role in addition to the care staff numbers. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 20 Excellent interaction between staff, residents and residents’ relatives ensures that there is a culture of openness and friendliness in the home. The home has regular residents and staff meetings - four times a year, which are minuted with feedback and action plans. The home is to implement a yearly quality audit (satisfaction survey) for residents to complete. The results are to be collated and actioned and written feedback provided so that the comments from residents and visitors help to improve the service. Most of the residents manage their own finances. The home keeps small amounts of money on behalf of a few residents. Accurate records are maintained and all deposits and withdrawals are signed by the resident and a member of staff. Staff are well supervised by the Registered Manager in performing their care tasks. Staff receive recorded supervision (regular review of staff’s personal and training needs in relation to their work) and appraisals to ensure that they have the necessary skills to provide a good service for the residents. However, the Registered Manager said that they were a little behind with these but she is in the process of making appointments with staff for their next session. These need to be done regularly to ensure that staff have the necessary skills to continue to provide a good service for the residents. There is a programme of maintenance and refurbishment. The home has recently had a new bath downstairs and a new bath hoist in the first floor bathroom. They have purchased new kitchen and household equipment and all residents’ rooms, when vacated, are redecorated and re-carpeted to ensure that the home maintains its high standard of décor. Health and Safety Policy and Procedures, such as regular recorded fire drills, fire alarm and hot water tests are completed, to ensure the health and safety of the residents and staff. The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 21 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 “ ” 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 4 X 4 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 The Lawns DS0000070277.V355288.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations It is recommended that all staff, including ancillary staff, undertake safeguarding adults training as soon as possible to ensure that they have up-to-date information to enable them protect residents from harm and abuse. 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