Inspection on 13/10/08 for The Leys

This inspection was carried out on 13th October 2008.

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

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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE The Leys Old Birmingham Road Alvechurch Birmingham West Midlands B48 7TQ Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 13th October 2008 09:15 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 DS0000071685.V371939.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. DS0000071685.V371939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Leys Address Old Birmingham Road Alvechurch Birmingham West Midlands B48 7TQ 0121 445 5587 0121 445 5587 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) Crystal Nursing Services Ltd Mrs Jeannette Westwood Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (20), Physical disability over 65 years of age (20) DS0000071685.V371939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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: Dementia over 65 years of age (DE)(E) 20 Mental Disorder over 65 years of age (MD)(E) 20 Physical Disability over 65 years of age (PD) (E) 20 Old age not falling within any other category (OP) 20 2. The maximum number of service users to be accommodated is 20. Date of last inspection New Registration Brief Description of the Service: The Leys is registered to provide residential care for up to twenty older people. The Leys is a large Victorian house, which has been upgraded and adapted for its present purpose. The premise is located just outside the village of Alvechurch, along a country lane close to the Birmingham to Redditch Road. The home is easily assessable from the M42 and has parking to the front of the building The home has 16 single and 2 double bedrooms. Eight of the single and both double bedrooms have en-suite facilities. The home is situated in approximately 2 ½ acres of ground, with pleasant gardens, which are well kept and accessible to people using the service. The accommodation provided for people using the service is comfortable and well maintained. The Service Users Guide states that The Leys aims to provide a warm, homely, safe and supportive environment to help you make the most of your time here. DS0000071685.V371939.R01.S.doc Version 5.2 Page 5 The Statement of Purpose states: The aim of The Leys is to continue to provide a happy and stimulating stable and suitable environment for its dependent residents, with the objective of sustaining the quality of care while responding to the statutory requirements of new legislation and regulations concerning the provision The most recent Service Users Guide states that fees depend upon the care needed and accommodation provided. It continues saying that fees start at £430.00 per week depending upon the care needed and accommodation. For the most up to date information regarding fees charged the reader should contact the service directly. DS0000071685.V371939.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We, the Commission, carried out this key inspection without any prior notice. A key inspection is one in which we look at all the aspects of the service that are most important to people using it. This key inspection took place during October 2008 involving one regulation inspector. At the time of the inspection the home was accommodating 16 people. Prior to this inspection the registered manager completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. The AQAA was completed on time. We sent to the service a number of questionnaires for both people using the service to complete and members of staff. We received 6 questionnaires back from people using the service. In addition we received 7 questionnaires back completed by members of staff. During the inspection, discussions were held with the registered provider, the registered manager, a number of staff members, some people using the service, and some visitors including relatives and a minister. We had a look around the home and the grounds. We also observed what was happening in the home. In addition, we viewed the care documents regarding some people using the service such as care plans, risk assessments and daily records. We also viewed medication records and some staff records. This inspection takes into account information we have received since the home changed registration to a new provider during April 2008. What the service does well: An assessment takes place prior to a new admission taking place to ensure that identified care needs are able to be met. Pre admission visits are encouraged so that people have an initial awareness of the service provided. One person using the service stated Couldnt be in a better place than this one. People we consulted were complimentary about the food provided within the home. DS0000071685.V371939.R01.S.doc Version 5.2 Page 7 People are aware of how to make a complaint and staff have sufficient knowledge in relation to safeguarding people against abuse. Refurbishments to the home are attractive. People living in the home are able to personalise their own bedrooms. Staff and visitors spoke with enthusiasm about the registered manager. Throughout this inspection, whenever we brought matters to the attention of the registered manager, suitable action was taken to respond to our immediate concerns. What has improved since the last inspection? What they could do better: Information currently in draft needs to be readily available within the home to ensure that people using the service are aware of the service and facilities they can expect. Written records and risk assessments about people using the service do not always collate and give staff conflicting information. This could potentially result in people not having their needs met or in unsafe practices taking place. There need to be improvements in the recording, ordering, administration and management of medication. As a result of our concerns we left an immediate requirement at the time of the inspection. We asked the registered persons to respond in writing upon the action they intended to take. The registered persons acted quickly and responded with an action plan to put this failure right. A review of the current arrangements in order to provide meaningful activities and leisure should to take place. Some parts of the home are in need of refurbishment especially some window frames and the communal bathing areas. Some management procedures need to be reviewed or improved to ensure that a suitable quality assurance system is in place and to ensure that people are kept safe while having their needs meet. DS0000071685.V371939.R01.S.doc Version 5.2 Page 8 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. DS0000071685.V371939.R01.S.doc Version 5.2 Page 9 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 DS0000071685.V371939.R01.S.doc Version 5.2 Page 10 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): Standards 1, 3 and 5. Standard 6 is not applicable. Quality in this outcome area is adequate Information about the home needs to be available to help people make a choice about whether they would like to live there. Peoples needs are assessed before they move in to ensure that the home can meet their individual care needs which helps to establish an initial care plan. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prior to this inspection we were sent a copy of the home’s Statement of Purpose and Service Users Guide. We briefly discussed these documents as part of our visit to the home. We were told that the documents were in draft format only. Once the documents are finalised and printed the Service Users Guide needs to be readily available to people currently living at The Leys as well as people who may potentially move into the home in the future. We were informed that a brochure is also to be printed to provide additional DS0000071685.V371939.R01.S.doc Version 5.2 Page 11 information about the home. The availability of information may assist people make a decision regarding whether The Leys is able to meet their care needs. We asked in our survey whether people had received enough information before admission into the home. One relative wrote ‘We looked at many homes. This one seemed the best and ** has proved to be happy here’. Both the Statement of Purpose and the AQAA state that the manager and the deputy manager carry out an assessment of potential users of the service to ensure that care needs can be met. People are invited to visit the home prior to their admission. The Statement of Purpose states that on admission people are offered a fortnight trial period. The AQAA and the draft Service Users Guide states that the people are initially admitted on a four week trial. The information within these documents therefore needs to be clarified. During our visit we confirmed that an assessment of care needs is carried out by either the registered manager or the deputy manager prior to an admission. The registered provider views each assessment to assess the fee to be charged. We viewed an assessment carried out in relation to a recently admitted person. The assessment contained sufficient information in order to devise a care plan. We also saw on file an assessment compiled by a social worker from the funding local authority. We were told that visits to the home by relatives seeking a suitable home for somebody are encouraged. People who may use the service are also encouraged to visit to see the home and stay for a meal. The Leys does not take people on an emergency basis. We are not aware of any plans to provide intermediate care at The Leys in the future. DS0000071685.V371939.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate People’s care needs are written down but records are not always consistent. People are generally treated by staff with respect for their privacy, dignity and self worth. Medications are not always recorded or administered as prescribed and as safely as they should be. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person residing at The Leys had a written care plan. This is a written document designed to guide staff about the level of care required by each individual to ensure that identified needs are meet and people receive the support they require. We viewed a number of care plans, risk assessments and other associated documents such as daily records. DS0000071685.V371939.R01.S.doc Version 5.2 Page 13 Care plans were comprehensive and covered many aspects of care in relation to daily living. The care plans evidenced that people have access to health care services within the home and in the community. Some information on care plans and risk assessments was however conflicting. For example one care plan stated that somebody was self caring and would ask for assistance as needed but the risk assessment highlighted that it was a hazard for the person to use the stairs on her own and needed staff to assist. On another risk assessment, reference was made to a wheelchair but this was not mentioned in the care plan. On another risk assessment, the use of a handling belt and wheelchair was mentioned but no further details were recorded, such as the number of staff required to undertake this task. On one person’s documentation it was evident that the person was considered to be at risk of pressure sores. Although we were told that the community nurse would arrange for a pressure reliving mattress were one required and that the person refuses to use a cushion, this information was not recorded. Although improvements in the formal care planning and risk assessment process are needed we were nevertheless informed by one relative that she had recently seen the care plan appertaining to her relative and was happy with it. Furthermore, despite the gaps in records, staff were generally able to describe the level of care needed for each individual. We were informed that staff were due to attend some training on care planning however this was cancelled by the trainer. As part of this inspection we assessed the management and administration of medication. The trolley used for storing medication was, when not in use, suitably secured. When we looked inside the trolley we found the shelves to be very sticky, it would appear that liquid medication had run down the sides of bottles and was not cleared up. The majority of medication held within the original box had the date of opening recorded upon it. We viewed the current month’s Medication Administration Record (MAR) sheets and found a number of serious concerns. One course of antibiotics had too many signatures for the number of tablets originally prescribed. On a different MAR sheet for another person residing at the home we saw evidence that, although there were no gaps in the records, a course of antibiotics had run out too soon. The MAR sheet stated completed course after only 9 tablets were dispensed out of a course of 10. We noted occasions when staff had signed for medication as administered (therefore stating that the person had taken the medication) and then signed over the top of that signature with a code indicating that the item was not required or the person was asleep. DS0000071685.V371939.R01.S.doc Version 5.2 Page 14 On one MAR sheet it was unclear what dose staff had been administered to the person living at the home. We found evidence of an occasion when one person’s medication had run out. After a period of three days without a particular drug a further supply was obtained. We audited the new supply of medication and found that the home had 2 too many tablets remaining but it was also evident that the home was then about to run out again. The MAR sheet for one individual stated that medication was prescribed at night. The label on the container stated the same. However staff were signing for this medication in the morning. The registered manager was unable to account for why the above errors had happened. As a result of these errors we issued an immediate requirement at the time of the inspection and held a discussion with the registered manager and the registered provider the following day. We also audited 2 items stored within the controlled drugs cupboard. The number of drugs held balanced correctly with the records that the home had maintained. Following the concerns highlighted above we viewed the home’s medication policy which was last reviewed prior to the current provider taking over the home. It was evident that staff were not working in line with this document. For example, it stated that medication is to be signed for after dispensing and that medication to be destroyed must be put into a bottle labelled To Be Returned to Pharmacy. We could not find a procedure regarding the ordering of medication. During a later visit to the home we observed a member of staff administering some medication. It was of some concern that for a period of time the trolley was left unattended and unlocked with medication out on the top of it. We also observed the member of staff administering medication without referring to the MAR sheets. These concerns were brought to the attention of the registered persons. The registered manager and provider took our concerns seriously and devised action plans to address the shortfalls without delay. The AQAA stated that medication was administered by trained staff and it was evident during our visit that staff had received training during August 2008. It was however evident that further training and monitoring systems were needed and these were included within the action plan. DS0000071685.V371939.R01.S.doc Version 5.2 Page 15 People using the service told us that staff are respectful towards them and that issues around privacy and dignity are addressed. People told us that they are able to go to bed at a time suitable to them and that they can get up when they choose. We did comment to the manager that some information on display regarding toileting regimes could be an infringement on peoples right to privacy. The registered manager acknowledged this and under took to take appropriate action. We saw two cards complimenting the service provided at the home. These stated: Please let all the staff know how thankful I am for all the wonderful care you have given ** over her years at The Leys. Saw ** at weekend she seems much more settled and surprisingly happy. Thanks for all your support. We became aware that some members of staff were referring to one person using the service by a different name to the one the person gave to us. This matter was brought to the attention of the registered manager who informed us that the person concerned had previously indicated that she had no particular preference. DS0000071685.V371939.R01.S.doc Version 5.2 Page 16 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): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate People using the service are able to keep in touch with family and friends. Limited activities are provided by care staff working in the home. People are able to enjoy a variety of food that is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The draft Statement of Purpose stated: The programme of activities is coordinated by the Manager. This includes indoor games such as board games, indoor skittles, music, singing and dancing, outdoor activities such as bowls, entertainers and garden fetes. The home organizes outings such as shopping trips on a regular basis, and pub lunches, Christmas lunch outings, etc. DS0000071685.V371939.R01.S.doc Version 5.2 Page 17 The Service Users Guide listed a range of activities such as bingo, exercises to music, music evenings and sing along, board games and fetes as well as other events similar to those above. We noted a number of photographs that were on display from the fete in September. The Service Users Guide made reference to a local Rector from a Church of England visiting once every four weeks. The AQAA made reference to music and movement and hairdressing as well as the visits from the vicar. We spoke to a retired Vicar who was visiting the home. He felt that the religious / spiritual needs of people using the service were being met. The AQAA acknowledged that The Leys has no dedicated activities coordinator therefore activities are carried out by care staff. As a result the event may be subject to interruption if carers need to provide care elsewhere. A list of activities was on display. We were told that, despite not having a coordinator, staff are good at what they can do. We were told that music and movement happens fortnightly while staff manage to play some games with people using the service. We were told that parties happen to celebrate birthdays as well as certain times of the year such as Halloween. One relative mentioned some activities that have been seen taking place however the person believed that more activities are needed. One person commented on our questionnaire when asked what the home could do better more activities organised properly. We asked a number of staff members about activities. Some staff told us that activities tend to be spontaneous and limited due to time constraints. We were told that some time ago people did attend events outside of the home environment but that this tends not to be the case any longer. While at the home we saw a number of people visiting relatives or friends. Visitors were seen to be made welcome and they seemed to be at ease with staff. DS0000071685.V371939.R01.S.doc Version 5.2 Page 18 People using the service are able to bring in personal possessions to make their own room more homely. We asked people using the service in our questionnaire whether they like the meals provided. A total of 2 people responded always while another 2 responded usually A relative told us that the food is fantastic. We were told that their relative loves the food and complimented the steak and kidney pie. We were told that tables are nicely laid and that sandwiches look like a buffet spread. Another relative said that the food smells beautiful. The minutes from a residents meeting held in August 2008 stated that people had commented on the food within the home saying I like my meals please dont change I am happy with the food I like my meals and puddings. A certificate dated November 2007 was on display showing that the home was assessed as Very Good by Bromsgrove District Council in relation to food hygiene standards. DS0000071685.V371939.R01.S.doc Version 5.2 Page 19 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): Standards 16, 17 and 18. Quality in this outcome area is good People are aware of how they can make complaints and can be confident that these will be addressed. Staff have sufficient knowledge about safeguarding procedures to ensure that people are safe and protected from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw evidence of complaint procedures within the draft versions of the Statement of Purpose and the Service Users Guide. Furthermore we saw information displayed around the home. The information upon these documents was not consistent and not always in line with the National Minimum Standard in relation to the fact that people may refer any concerns or complaints to us at any stage and the address where we can be contacted. The registered manager informed us on the AQAA that the service had not received any complaints. We have not received any formal complaints regarding the service provided at The Leys. We asked people upon a questionnaire whether they knew who to contact in the event of them wishing DS0000071685.V371939.R01.S.doc Version 5.2 Page 20 to make a complaint. The vast majority of people indicated that they were aware of who to speak to. While at the home we asked people a similar question and people were confident that they could speak to the manager if they had concerns. People were also aware of us as the regulator of care services and of our role. During our visit the registered manager confirmed the statement within the AQAA stating that the appropriate arrangements were recently made in order to ensure that people using the service receive postal votes. The registered manager is aware of local advocacy services should such a service be required by anybody residing at the home. The registered manager was aware of local safeguarding procedures and has raised concerns with the necessary persons in the past. Staff members were consulted about the action they would take if they became aware of actual or potential abuse taking place. Staff responded appropriately to our questions on safeguarding and confirmed that they had received training on this matter. DS0000071685.V371939.R01.S.doc Version 5.2 Page 21 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): Standards 19, 20, 21, 23 and 26 Quality in this outcome area is good People live in a clean and pleasant home and the on-going improvements are enhancing the environment for their benefit. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has sixteen single and two double bedrooms. Eight of the single bedrooms and both of the double bedrooms have en-suite facilities. The home has two bathrooms, one on each floor, and three communal toilets on both floors. A passenger lift is provided to afford easy of access between the two floors in addition to a central staircase. The home is set in two and a half acres of garden which are well maintained. DS0000071685.V371939.R01.S.doc Version 5.2 Page 22 We were told by the registered persons and some visitors that a number of improvements to the environment have taken place since the new provider took ownership of the home. We were told that the carpet and chairs in the foyer area are new. This area was a pleasant seating area where a number of people seemed to enjoy watching the comings and goings of people and what was generally going on. The dining room has new flooring. The lighting and decoration in this area were good. The main lounge is well maintained, pleasant and warm. The current owner has changed the carpet and provided new chairs in this area. The lounge has a very large flat screen television. A conservatory leading off from the lounge provides an addition seating area which looks over the extensive garden. We viewed a number of bedrooms. It was evident that people living at The Leys are able to bring in personal items which are familiar to them. We were told that some new beds were recently purchased. Further improvements are needed as some windows either need attention or renewing. We noticed that the fire escape appeared green and therefore may need attention to ensure it is safe to use. Bathing facilities need to be improved to ensure they are suitable to meet the needs of people using the service. Furniture in many bedrooms is in need of replacement as much of it is damaged. Most areas of the home were clean and tidy. We did not detect any unpleasant odours while visiting the home. We were told that the laundry system in the home works well and that clothing is returned on hangers. DS0000071685.V371939.R01.S.doc Version 5.2 Page 23 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good There are sufficient staff on duty to ensure that people using the service have the appropriate level of support they need. Training is provided to ensure that staff are provided with the skills and knowledge needed to carry out their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We asked about staffing levels and were told that during the morning there would be 2 care assistants in addition to the manager / deputy manager or senior carer. Other staff would include a cook and on certain days a clerk and a handyperson. Between 4.00 and 10.00 pm 1 senior and 2 carers are on duty. The night shift is covered by 2 wakeful carers and a senior member of staff on call at home. To help cover the rota when permanent staff are off sick, on training or on holiday the home has 1 senior care and 1 care assistant who work on a relief basis. The registered manager told us that they had recently appointed another senior carer but the person had changed their mind therefore the home was short of senior staff at the time of this inspection and as a result staff had to continually cover. DS0000071685.V371939.R01.S.doc Version 5.2 Page 24 One relative commented on a survey that: Staff appear very helpful. From the surveys people using the service believe that staff listen and act upon what they are saying and that they are available when needed. We surveyed staff who generally felt that there are usually enough staff on duty to meet care needs. The AQAA stated that 8 out of 14 carers had completed a NVQ (National Vocational Qualification) level 2 or above. This figure was confirmed while we were undertaking the inspection. As a further 4 staff are either working towards or about to start a NVQ it is likely that The Leys will well exceed the National Minimum Standard in the near future. The draft Statement of Purpose stated that staff have attended courses in manual handling, food hygiene, fire, health and safety, infection control, first aid, protection of adult abuse and dementia care. When we surveyed staff they confirmed that they believed their training to be relevant and up to date. A list of training events was displayed near to the kitchen showing different training available to staff over the next few months. We viewed the documents regarding the recruitment of two members of staff. The file on one person, somebody not involve in direct care, was satisfactory. The other file was in relation to somebody appointed around about the same time as the current provider took over responsibility for the home. We had some concerns about this file and fed these back to the registered manager. A CRB (Criminal Records Bureau) disclosure had not been obtained by The Leys. The person had brought one with her from a previous employer. DS0000071685.V371939.R01.S.doc Version 5.2 Page 25 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): Standards 31, 33, 34, 35 and 38. Quality in this outcome area is good The home is being managed in a way which meets the needs of people using the service, involves people in their own care and seeks their views. There could be greater confidence in the service once some management systems are improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is experienced and has also achieved the Registered Manager’s Award (RMA) which is a level 4 NVQ (National Vocational Qualification). The manager told us of her desires to develop person centred approaches within the home. DS0000071685.V371939.R01.S.doc Version 5.2 Page 26 Members of staff made some positive comments about the manager and her deputy upon the surveys they completed and returned to us prior to our visit. Manager is always there to give full support and advice if needed The manager and deputy manager are very supportive of the staff who work at The Leys. They encourage all staff in their self development to achieve job satisfaction. The home has a quality assurance manual at its disposal. This manual has not as yet been used as a means to self-assess the quality of service provided. The Leys has, under previous management, carried out surveys and the results of the last survey were on display. The registered manager intends to carry out another survey in December 2008 and hopes to receive similar positive feedback as in the past. A comment card needs to be amended to show the details of the current provider if it is intended to be used in the future. During our visit to the home we spoke to two relatives and a local minister as well as people using the service all of whom were complimentary about the home and the improvements to the environment since the new provider took over. The registered provider visits the home on a regular basis and seemed to be well known to people using the home and visitors. Written reports are prepared on a monthly basis as required which were available for inspection. The reports were comprehensive although they did not evidence discussions with people using the service and the comments made by them. The draft Service Users Guide states that insurance is provided for personal effects within the home up to a limit of £1,000 per resident. People are however advised to check the exact cover provided as some individual items may not be covered and may therefore need to be insured by the individual personally. We enquired whether any money is held by the home on behalf of people residing in the home. The draft Service Users Guide stated that people using the service are encouraged not to keep large amounts of money in their own rooms and that it is possible for individuals to keep up to £50.00 in the home’s safe. It was evident that some money was being held in this way for safe keeping but no records are held and the storage arrangements were not ideal. In addition, a small number of valuables were also held but no records of these were maintained. Having no documentary evidence of incoming cash or expenditure could potentially place both people using the service and those managing the home at risk of allegations, misunderstandings or abuse. The necessary certificates of public liability and registration were on display. As indicated previously some policies and procedures need to be reviewed. The AQAA stated that they were last reviewed during November 2007. As this date DS0000071685.V371939.R01.S.doc Version 5.2 Page 27 was prior to the current provider becoming registered these documents need to be reviewed and up dated accordingly. Evidence was available to demonstrate that equipment is serviced appropriately by visiting contractors. The registered manager was aware that a routine service on a hoist was overdue as the contractor had postponed the visit. The registered manager believed that the servicing was in line with the Lifting Equipment Regulations although the documentation did not actually confirm this. The registered manager showed us a good evacuation plan for the home in the event of an emergency. Information readily available included details of staff members, of transport available and available accommodation in the event of The Leys becoming unsuitable. Information about people using the service included a copy of the current Medication Record. Also at hand was a supply of blankets and torch. We were informed that action had taken place to implement the recommendations made following the most recent visit undertaken by a fire safety officer. We viewed the window restrictor in one bedroom and were concerned regarding its ineffectiveness. The restrictor consisted of a chain and a wire which was rusty. We were able to fully open the window with ease. The registered manager took immediate action to reduce the risk within this bedroom and another with a similar devise fitted. DS0000071685.V371939.R01.S.doc Version 5.2 Page 28 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 X 3 X X 3 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 3 X 2 3 2 X X 2 DS0000071685.V371939.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? New service STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement Ensure that care plans are an accurate description of how service users needs are to be met and match associated risk assessments. This is to ensure that care is provided in a safe and consistent way. 2 OP9 13 (2) Ensure that the medication records are signed accurately following the administration of medication or alternately the correct code is used if medication is omitted. Ensure that MAR sheets have the correct information entered upon them regarding prescribed medication. Ensure that medication is available and administered as prescribed to people using the service. This is to ensure that medication is managed safely. DS0000071685.V371939.R01.S.doc Version 5.2 Page 30 Timescale for action 31/03/09 13/10/08 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 OP12 Good Practice Recommendations A review of how activities are provided should be undertaken to ensure that people have a meaningful leisure available to them. A review of the arrangements regarding the safe keeping of money and valuables of people using the service should take place to ensure that everybody is safeguarding against allegations or actual abuse. A full audit of window restrictors should be undertaken and any necessary action to ensure their suitability should be taken. 2 OP35 3 OP38 DS0000071685.V371939.R01.S.doc Version 5.2 Page 31 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 DS0000071685.V371939.R01.S.doc Version 5.2 Page 32 - 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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