Inspection on 11/06/08 for The Leys

This inspection was carried out on 11th June 2008.

CSCI found this care home to be providing an Adequate service.

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 Leys 20/06/07

The Leys 03/05/06

The Leys 24/10/05

The Leys 16/05/05

The Leys 13/10/04

The Leys 02/06/04

The Leys 10/11/03

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Leys The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT Lead Inspector Jill Wells Unannounced Inspection 09:30 11th June 2008 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 Leys DS0000036269.V365643.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 Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Leys Address The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT 01335 233100 01335 238019 terjeevanbajwa@derbyshire.gov.uk www.derbyshire.gov.uk Derbyshire County Council 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) Terjeevan Kaur Bajwa Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2007 Brief Description of the Service: The Leys Residential Care Home is located on the southern edge of Ashbourne. It provides care for 36 residents, who are all aged at least 65 years or older. The home is purpose built and all facilities are on one level. All residents are provided with their own bedroom, although none of these have en-suite facilities. The Home has four lounges and three dining rooms and front and rear gardens, which are well maintained. Information about the service is provided through the Statement of Purpose and Service User Guide, both of which are made available to residents. The previous inspection report is located in the reception area. Fees for the home were £381.84. Items not included in this fee are hairdresssing, toiletries and newspapers. The Leys DS0000036269.V365643.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 the service is one star. This means the people who use the service experience adequate quality outcomes. The inspection visit was unannounced and took place over 7.5 hours. There were 35 people living at the home on the day of the inspection. 7 residents, 5 staff, 2 visitors, and the manager were spoken with during the visit. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. We also looked at all the information that we have received, or asked for, since the last key inspection on the 20th June 2007. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. • The previous key inspection report Completed surveys from people living at the home, staff, relatives and professionals that visit. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. What the service does well: There is a very dedicated team of care staff working at the home. They often do things over and above their job description including fundraising and sponsored walks in order to benefit people living at the home. Comments from people living at the home include, staff are wonderful, they are like friends and they will do anything for you. The management team are knowledgeable and experienced, working well together and have very organised systems and procedures in place to ensure the smooth running of the service. The medication is managed very well with excellent systems in place to ensure that people are provided with medication in a safe way. The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 6 The home is clean, comfortable and well maintained. The small lounge areas give the place a homely feel. The manager has introduced some good ideas to help people living at the home, including colour co-ordinated doors to help people find their way around. Excellent training is provided for staff. This includes very thorough induction programme for new staff and ongoing training for existing staff. The home is well above the required 50 care staff with National Vocational Qualification 2 Care, which should be commended. The manager ensures that visitors and people living at the home have the opportunity to voice any suggestions, concerns of complaints that they may have. One person living at the home said that, Ive made several suggestions and they listen. 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 Leys DS0000036269.V365643.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 Leys DS0000036269.V365643.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): 1,3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. EVIDENCE: The statement of purpose and service user guide were available for prospective people wishing to live at the home. They were also in peoples bedrooms. People were asked to sign that they had received a copy and had the information explained to them if necessary. These documents provided most of the information that was necessary to inform people about the service provided, although the new contact details of the Commission for Social Care Inspection (CSCI) and information concerning fees needed to be added. We were told that the manager could visit prospective residents at their home or in hospital as part of the assessment process. Prospective residents were The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 9 encouraged to come for a short stay prior to making a decision about whether the home will meet their needs. A person recently admitted to the home for respite care was spoken with and said that, it has been a very nice stay, I will come again if I need to . Copies of assessments carried out by Social Services care managers were seen on peoples records. These were detailed and included information concerning each persons health and personal care needs, social interests, relevant history and family involvement. This gave staff basic knowledge about each person, and helped them with a personal service plan. However information on one was out of date and was clearly an assessment for day care rather than a care home. The home does not provide formal intermediate care and therefore standard 6 was not assessed. The Leys DS0000036269.V365643.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 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The lack of some personal service plans and health assessments did not support staff to meet peoples needs, however medication was well managed. EVIDENCE: The care records of three people living at the home were seen. One file included individuals needs, preferences, information about their health as well as daily records. Individual’s records also included a moving and handling plan, nutritional assessment and tissue viability risk trigger tool. Personal service plans had been reviewed monthly and updated on a regular basis. They were available for care staff to read to ensure that they were aware of each persons needs. They were written in plain language, and were easy to understand. A questionnaire was completed with each person concerning choice. Information included the need for an advocate, preferred title, additional furniture and sockets in bedrooms. This showed that the home was keen to The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 11 provide individualised care. Two files were seen for people recently admitted to the home, one for respite care. Neither was fully complete, even though one person had been at the home for four weeks. There were no photographs of these two people, no health assessments or personal service plan and no questionnaire completed concerning choice. Therefore care staff did not have adequate information in order to meet these peoples needs. On admission people received a letter, which stated that, after you have been with us for a few days we will work with you to develop your own personal service plan but this was not being done. A care worker was spoken with who said that staff were expected to read peoples plan of care as soon as they were admitted to the home. Record showed that people were encouraged to be involved with their care plans, read them and sign them if they were able. Records, staff and people living at the home all confirmed that GPs and other health professionals were contacted and visited when required. One person said that, all you do is ask for a doctor and one comes . A district nurse visited the home during the inspection visit. She said that there is good communication between the home and the district nurses. Medication in the home was stored securely. Either the manager or a deputy manager administered medication. All had received medication training. The medication administration records were seen and were correctly completed. Although there were no controlled drugs being used at the time of the inspection visit, there was a safe system for storing and recording them. There was a locked fridge for medication that required refrigeration. Records showed that individuals had been assessed or asked if they wished to self medicate. One person had chosen to do so. The good management of medication systems meant that people received medication safely and when required. People spoken with said that were treated with respect by staff. One person said that, staff are very good, although they are always very busy, which can make them rush me, especially in the morning . Staff spoken with were aware of the importance of retaining a persons privacy and dignity for example giving help in intimate situations as discreetly as possible. The staff were observed seeming a little sharp at times with people, for example at lunch time, as they were so busy and clearly felt torn between different peoples needs and wishes. The Leys DS0000036269.V365643.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 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The standard of meals offered was good, but activities were reduced when there were staffing shortages, which limited stimulation provided for people. EVIDENCE: Planned activities were displayed on notice boards. On the day of the inspection visit the activities on the board were the hairdresser visiting and the local newspaper. Other activities planned for the week included floor dominos, quoits, bingo, skittles, listening to music and sport on SKY tv. Records were kept of activities offered, including names of people taking part. This record often had gaps of several days where no activities were recorded. The manager was spoken with about this and explained that sometimes activities were cancelled due to staff shortages, and sometimes staff forgot to record that an activity had taken place. It was difficult to know which activities had been cancelled, or taken place but not recorded. People were encouraged to go out to the local church hall on a monthly basis for lunch with support provided. A member of staff said that, we try to do activities but there is often not enough time. Most people living at the home wrote in our survey that there were usually activities arranged, although some The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 13 said that they were not interested in the activities that were offered. The manager told us that people were encouraged to suggest new actvities. A relative commented in our survey that, ‘ Varying activities are provided but need proper organising/supervising, staff do their best’. There was not a dedicated activities co-ordinator at the home. A Church of England service was held on a monthly basis. Several people said that they enjoyed watching ‘Songs of Praise’ on Sunday evening. Residents meetings were held on a 3 monthly basis. Minutes of these meetings showed that people were well consulted concerning the service for example trips out, entertainment and meals. There were several concerns expressed at the last meeting in January about food provided. Several people were asked about this during the inspection visit. Due to lack of cooks working at the home, frozen meals had to be provided on a temporary basis at that time. Everyone said that meals had improved since then. Staff and people living at the home told us that people could go to bed and get up when they wished to do so. One resident said that, most people are ready to get up, but anyone can stay in bed if they wanted to . People were encouraged to bring their own personal possessions with them and bedrooms that were seen were comfortable and had been personalised. There was a choice of food at mealtimes. Staff spoke with people each morning to ask which choice they preferred. Menus were displayed on tables, although one table had the wrong day’s menu. The cook had changed the dessert from what the table menus had said. On the day of the inspection the main option was cheese pastie, which was not popular with people. The cook was told about this and she explained that menus were due to be revised after the next residents meeting. All the people that were spoken with said that the food was usually of a good standard. One person said that, food is pretty good. There is an odd thing that is not cooked well but everybody has an off day. Information provided was that all care and catering staff had received training in safe food handling. Staff spoken with confirmed this. A monthly newsletter was produced at the request of people living at the home. This included birthdays, recent entertainment including an organist, a singer, a special St. Georges Day lunch and an outside organisation called, First Taste doing music and crafts with people. The newsletter also included poems and praise for staff from residents. Several people spoken with said that they were very pleased with the newsletter. The Leys DS0000036269.V365643.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 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and are protected from abuse. EVIDENCE: There were 5 complaints recorded at the home since the last inspection visit. These were mainly during a time when the home was closed due to a virus and relatives and professionals were frustrated as they felt that there had been a lack of communication by the home. Records showed that these were investigated and taken seriously. The complaints procedure was displayed around the home and in the service user guide. The address and telephone number of the Commission for Social Care Inspection (CSCI) had not been revised. People said that they would talk to staff or the manager if they had a complaint. One person said that, ‘there is nothing to complain about’. Training records showed that care staff had attended training in safeguarding vulnerable adults and care staff confirmed that they had attended this training and were aware what to do if they suspected abuse of a vulnerable adult. The Leys DS0000036269.V365643.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): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The Leys is a purpose-built single storey building providing 36 places. 3 places are used for short-term care. They also accept up to 4 people per day for day care. All bedrooms are for single occupancy, all with a wash hand basin. No bedrooms have en suite facilities. Bedrooms that were seen were comfortable and homely. Matching curtains and bed covers had recently been purchased. People had personalised their own room. One person said that, I dont spend much time in my room, but I do like it . Lockable storage was provided. The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 16 Records showed that people were offered a key on arrival. Additional furniture, a table and second chair were also offered. One bedroom has a fire exit within the room. This room is used for respite care, and the manager explained that the person is told in advance that this door cannot be locked. There are four lounges with televisions and music systems. The main lounge has a large screen TV. There are two toilets in each corridor, 2 shower rooms and 3 bathrooms, all with adequate aids to promote independent living. Additional moving and handling equipment had recently been provided. Bathroom doors had been painted yellow, toilet doors red and blue doors for staff only (e.g. sluice room) in order to help people to orientate around the home. One person spoken with found this very useful. There is a kitchenette area that has been recently refurbished for the use of visitors and people living at the home, if they wish to make their own drinks and snacks. There is a wheelchair bay for storage of wheelchairs. A tour of the building showed that the home was clean and well maintained. People spoken with said that they were happy with the level of cleanliness at the home. Information from the service was that they were planning to improve the outside area by creating a sensory garden and erecting new fencing. Staff spoken with said that they had done sponsored events to help raise money for this project. New garden furniture had recently been purchased. A relative commented in our survey that, ‘it is a comfortable place to live’, and someone living at the home wrote, ‘ it is a nice clean place’. There was a small hairdressing room, and the hairdresser visited weekly. There is also a beautician that visits when requested. The entrance to the home and outside paths had been widened to allow easier access. The Leys DS0000036269.V365643.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 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The recruitment practices and staff training programme were good and ensured that people were protected by competent, well-trained staff. There were not always sufficient numbers of staff to support the people who use the service. EVIDENCE: The last inspection visit report 20 June 2007 said that, The number of staff on duty on the day of the inspection was not consistent with the numbers identified on the planned staffing rota, due to ongoing staffing shortages. A requirement was made at the time stating that, The staffing levels must be reviewed to ensure they are in accordance with the dependency needs of the residents. This was to be met by 1st September 2007. This requirement has not been met. The manager said that there should be 4 care staff on duty in the morning and 3 in the afternoon as well as a manager or deputy manager. On the day of the inspection visit there was only 3 care staff until 12 noon, later reducing to 2 then 1 carer due to sickness. The manager was assisting and in the afternoon the deputy manager was working as a care assistant. The home was almost full with only one vacancy, and also had people for day care. There should The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 18 have been two domestic staff on duty but there was none that day, adding to the pressure on care staff. The staff rota showed that this was not a one-off occurrence. The manager said that there were 10 people with high needs, 7 with medium needs and 18 with low needs. The manager was not using dependency levels of people living at the home in order to calculate the correct numbers of staff that should be on duty The home’s statement of purpose said that there should be a total of 519 care hours per week but the home was not working to this. There were many comments made during the inspection visit concerning the impact of reduced staffing at the home. These included people living at the home saying, there is not the staff to help like they used to be, I can see staff getting downcast because they are so busy and tired, and, there used to be more activities but since the staffing shortages activities are not as often. Comments from staff included, staffing has been bad for the last three weeks and, all the managers help but it is not enough, 4 people need a hoist for moving and there just arent enough of us. One staff member said that there is regularly only one manager and two care staff on duty. Several comments in surveys also reflected concerns regarding the staffing levels including, it is sometimes difficult for staff to be available when you need them but they come when they can and from staff the stress is high just now but with more staff it will get better. There were also incidents observed which indicated that peoples needs were not being met. This included several people calling for assistance, one person was in distress, and no one being available as care staff were assisting someone in a hoist elsewhere. There were insufficient staff to help people that may need assistance at mealtimes. The manager explained that activities and supervision were often cancelled or postponed due to staffing problems. She also believed that the lack of personal service plans for new people was due to managers needing to undertake excessive care duties. One person spoken with was very distressed that they had not had a bath for two weeks as their key worker had been off sick and they had been told that everyone else was too busy. The manager was told about this and promised the person a bath the next day. The district nurse was at the home during the inspection visit. She said that staff are very helpful, good with residents and treat them with respect. One person wrote on our survey, ‘we are well looked after’. A visitor spoken with said that staff are very busy but they do everything they can. A member of staff said that, “ we work well as a team and try to support each other ”. It was evident from discussions and observation that all staff put residents first and worked very well as a team. Previous inspections had showed a safe recruitment procedure. Application forms were being completed. The manager confirmed that references and The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 19 criminal record bureau (CRB) checks were being done, although these were stored at the human resources office. The manager and staff were concerned that the time it took to recruit staff meant that new people had often found another job. There was an induction programme in place that met the Skills for Care standards and included first aid, food hygiene, moving and handling, hoist training, dementia care, safeguarding adults and bereavement. Training had been requested from the district nurse for catheter care and diabetes. The manager described a well-developed training programme, with training records to support this. Care staff had achieved above the minimum requirement of 50 care staff with National Vocational Qualification(NVQ)2, having reached 80 with NVQ. 3 domestic staff were also doing a relevant NVQ qualification. All new staff received training in equality and diversity, and staff spoken with had an understanding of this subject. The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed, with effective quality assurance systems, ensuring that people living at the home and staff are listened to. EVIDENCE: The manager had completed the Registered Managers Award (RMA). It was evident from discussions and observation that the manager is organised, dedicated and a good team leader. It was also evident that the deputy managers were very skilled and knowledgeable. A staff member said that, the manager tries to be fair and all of the managers will always help out . The managers had undertaken relevant training to increase their skills The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 21 including health and safety for managers, risk management and supervision skills. There were a number of ways that the manager ensures that people were given an opportunity to comment on the service. This includes an annual quality assurance survey. The results were compiled together and action taken to address any issues or suggestions. The results of the most recent survey showed that people living at the home scored the service excellent/good for how trustworthy and respectful staff were, the welcome visitors received, the quality of care given and the laundry service. Relatives surveys scored high in the areas of cleanliness, the welcome received, privacy provided when wanted, respect and cheerfulness of staff. The manager had written an action plan in response to the results of the questionnaire. This included involving people more in menu planning, more one-to-one time and to ensure that library books were renewed more regularly. Residents meetings were held to discuss how the home should be run, menus, outings, activities and entertainment. There is a suggestion box in the reception area. Relatives meetings were also regularly organised, although there had been a poor attendance recently. Regular staff meetings were held to ensure good communication between the management team and staff, and to give staff the opportunity to make suggestions about improving the service. The service manager responsible for the home was expected to visit unannounced minimum monthly and write a report of their findings. There had been almost a year where this had not been done, however a new service manager had started to visit and write these reports. The aim was to have a representative of the provider to monitor the way that the service was providing care. Several issues had been highlighted in these reports and action taken to improve care, however no action had been taken concerning staffing levels. The managers undertook supervision for all staff, which was clearly recorded. One staff member said that supervision was a useful time to talk about concerns. Information provided was that regular health and safety checks were being done. This included testing water temperatures, call systems and fire equipment. A recent virus that had affected staff and people living at the home . The situation had been well managed. The service had isolated itself until the virus was over. After this incident the manager had sent questionnaires out to people living at the home to ask them how they thought the situation had been managed and whether it could have been done better. Residents responded very positively to the way staff had coped. The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 22 Accident forms were completed and included action to be taken to reduce risk of further accidents including falls by residents. Chemicals were securely stored and staff spoken with were aware of relevant health and safety issues. Staff were observed using gloves and aprons where appropriate. Information received from the service was that all policies and procedures were in place and had been reviewed. The Leys DS0000036269.V365643.R01.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 3 X 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 3 The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 (1) (a) Requirement The care staff hours must be reviewed. This review needs to take into account the number of people living at the home and their dependency levels, respite and day-care, time for activities as well as the number of hours care staff undertake domestic duties. This is to ensure that people’s needs are being met at all times. Completed personal service plans, health assessments and a photograph must be in place for everyone living at the home, including new people and people staying for respite care. This is to ensure that staff are aware of peoples needs and wishes in order to provide good quality care. Timescale for action 11/09/08 2. OP7 15(1) Schedule 3 (2) 11/09/08 The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 25 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 OP1 Good Practice Recommendations The statement of purpose and service user guides should be amended to include fees and the up-to-date address and telephone number of CSCI so that people have the correct information. The complaints procedure displayed at the home should include the up-to-date address and telephone number of CSCI to make sure that people can contact us if they wish to. The activities record should include when a planned activity has been cancelled, and the reason for this, so that the record reflects whether people are offered adequate stimulation to meet their needs. The menus displayed on dining tables should reflect the meals that are being offered so that people have accurate information about the food to be served. Everyone living at the home should have the opportunity to bathe as often as they would like in order to promote their own wishes and freedom of choice. There should be sufficient domestic staff on duty so that care staff are able to focus on the care provided to people living at the home. 2. OP16 3. OP12 4. 5. OP15 OP8 OP27 6. The Leys DS0000036269.V365643.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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