Inspection on 16/07/08 for The Leys

This inspection was carried out on 16th July 2008.

CSCI found this care home to be providing an Good 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

The Leys 26/06/09

The Leys 06/02/08

The Leys 28/09/07

The Leys 06/11/06

The Leys 31/01/06

The Leys 15/02/05

The Leys 12/08/04

The Leys 26/02/04

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 63 Booth Rise Boothville Northampton Northants NN3 6HP Lead Inspector Thea Richards Unannounced Inspection 16th July 2008 09:30 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 DS0000012843.V368608.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 DS0000012843.V368608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Leys Address 63 Booth Rise Boothville Northampton Northants NN3 6HP 01604 642030 01604 670028 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) Mrs Sheila Samuels Manager post vacant Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18), Physical disability over 65 years of age (2) of places The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. The home limits its services to the following Service User Categories No person falling within the category OP can be admitted where there are 18 persons of category OP already in the home. No person falling in the category PD (E) can be admitted where there are 2 persons of category PD (E) already in the home Total number of Service Users in the home must not exceed 18 To enable the home to admit persons who are in the category old age (OP) To limit the number of persons to be admitted under the category OP To limit the number of persons to be admitted under the category PD (E) To limit the number of persons accommodated in the home Date of last inspection 6th February 2008 Brief Description of the Service: The Leys is a converted and extended dormer bungalow providing care for 18 older people two of whom may have a physical disability. The Leys is situated on the outskirts of Northampton, close to local amenities and can be reached by both public and private transport. There is parking available at the front of the house. It has been owned by Mrs. Sheila Samuels for many years. The new acting manager Mrs. Maureen McDonagh, has been in post for seven weeks. There is a large lounge, and a bright dining room and conservatory on the ground floor and there are plans to update the kitchen. The home has bedrooms on the ground and first floors, each of which has ensuite facilities; three of these include a bath. Stairs or a stair-lift access the two bedrooms on the first floor. There is a large, pleasant, well -maintained garden with a small patio area that has tables and chairs. This is accessible for the residents to enjoy. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 5 The home can be contacted by telephone or fax. The monthly fees are up to £1600.00. There are additional costs for hairdressing, dry cleaning, chiropody and toiletries. The registration certificate from the Commission for Social Care Inspection, an up to date certificate of insurance and the latest inspection report are available in the reception area. The Leys DS0000012843.V368608.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 2 Star. This means that the people who use this service experience good quality outcomes. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection), spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 6th February 2008. The visit took place on the 16th of July 2008 and lasted six hours. During the visit we checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that we looked at the care provided to three of the residents. To achieve this we spoke with the staff supporting their care and looked at the records relating to their health and welfare. We spoke with the residents and their families. With their permission the residents’ bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them was looked at. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. We read the survey forms that had been returned to us from the residents and the staff. We had four returned from the residents and four from the staff. During the visit we spoke with the homes’ owner, the acting manager, the staff and families and visitors to the home. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? Care plans have improved to make sure that they have enough detail for the staff to look after the residents properly, although further improvements are needed. The activities programme has improved and now includes the residents’ interests. The cleaning in the home has improved and we found it clean and welcoming. The recruitment process was found to be thorough and included all the required checks. The new manager has developed a thorough training programme for the staff to make sure that they have enough knowledge to care for the residents. The manager and the owner are now having regular meetings to make sure that there is good communication between them and to decide whose role and responsibility for different areas. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 8 ‘ This is the best place I have ever been, the food is excellent, there are good activities, the staff are very good and always happy and will do anything for me’ ‘They look after me well’ What they could do better: The Statement of Purpose should be updated to include the new contact details for the Commission for the Social Care Inspection (CSCI) Consideration could be made to include the results of the annual quality assurance audit into the Statement of Purpose. With their permission, photographs of the residents should be put on the front of the care plans and the medicine sheets to make sure that the staff know which resident they are treating. The risk assessments should describe how the staff should cope with a risk that has been identified. The care plans could have more space to allow adequate entries for reviews and for the resident and/or the families agreement to the care plan. The night medication that is being used in the home should be treated as a controlled drug to make that it is being used correctly. The complaints book should have space to record the dates and signatures of when and who dealt with a complaint and when and how it was resolved. The complaints policy should be updated to include the contact details for Social Services and CSCI. The hot water temperatures should be tested regularly to make sure that they are safe for the residents. Consideration should be made to employ a dedicated cleaner in the home to reduce the risk of cross-infection for the residents. Consideration should be made to redesign the staff application form to give more space for the candidates’ previous employment dates. The health and safety requirements made by the fire officer should be complied with. The provider should complete the documentation required by the national minimum standards, monthly, when she completes a statutory visit. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 9 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 DS0000012843.V368608.R01.S.doc Version 5.2 Page 10 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 DS0000012843.V368608.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are always assessed before moving into the home and they have good information to help them make an informed choice about the home. EVIDENCE: All of the residents who were ‘case tracked’ had been given a Statement of Purpose and terms and conditions. The Statement of Purpose and Service Users’ Guide gives people the information that they need to know about to help them make a decision about the home. The Statement of Purpose should be updated to include the new address and telephone number for the Commission for Social Care Inspection. Consideration should be made to include the results of the homes’ annual The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 12 quality audit. This will give the prospectiv resident and their family a view on what people who use the service think about it. Providing a comprehensive Statement of Purpose & Service Users’ Guide results in good information for the residents, making sure that they they can get the most suitable care. The acting manager always visits prospective residents before they are admitted to the home and there is a thorough pre admission assessment form in place. This was seen in the care plans looked at and confirmed by the residents and the families spoken with. This makes sure that that the manager and the staff in the home have the the right information before the resident is admitted, so that they can get the best care. It makes sure that the home can meet the residents’ needs and that the resident meets someone from the home who they can recognise. This makes the move into care easier to manage for them. The families spoken with confirmed that they were given the opportunity to visit the home before their relative came in. Members of the staff spoken with said that they always knew what the residents’ needs were before they moved in. The suveys that were returned to us from the residents told us that they had good information before they were admitted to the home. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home with a copy of the latest report from the CSCI. An up to date insurance certificate was displayed in the entrance hall. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. The staff meet the care needs of the residents as identified in the care plans with privacy, dignity and respect. EVIDENCE: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents and reflected the care that the residents needed. The residents and the families spoken with told us about the care that they needed and that they were happy that they received it. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in the care plans, showing that thorough health care is being provided for the residents. The residents and their families spoken with said that they could see the doctor The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 14 and other health professionals when they needed to. There was some evidence that the care plans had been reviewed but the care plan paperwork did not give a lot of space for this or for the resident and/or their family to sign to say that they had seen the care plan and agreed with it. Signing the careplans would make sure that the resident and/or their families were aware of the care to be given and that they were happy with it. The residents and the families spoken with were happy with the care being provided and were happy not to sign the careplans. Where this is the case, their decision should be written in the care-plan. The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. The entries in the daily record did not describe the residents day or activities fully and staff are going to have more training to help them make meaningful entries. We saw residents being treated with dignity and respect when staff spoke with them and undertook their care. The staff sat down with the residents and spoke with them giving reassurance by touching their hands and talking directly to them. Staff seen giving care did so in the right way, giving the residents privacy where needed, particularly when moving them. There are records of the residents’ weight, which makes sure that they are not losing or gaining large amounts of weight. The staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. This information was confirmed in the surveys that were returned to us. There were risk assessments in place to cover all the identified risks for the residents, however, it was not always clear how the staff would manage those risks. The staff and the resident may be put at risk if the right instructions were not given, particularly in areas involving moving and handling. Although this was not documented, the staff spoken with and seen, did move people safely and were aware of the possible risks. This will make sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had training to give medicines. We were shown the training package that the staff were given and it was very thorough and covered all the areas that were needed. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 15 We saw that the medicines were administered individually and the residents were seen to be taking them. The medicines are packaged by the chemist into a ‘monitored dosage system’ where each tablet is in a separate pop out card. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The manager carries out a monthly written audit of the medicines and the medicine sheets to make sure that they are correct. A nightime medicine that should have been being treated as a controlled (dangerous) drug to be checked, counted and signed by two people was being treated as a normal medicine. When this was shown to the acting manager she said that she would change the practice immediately. There was a self-medicating policy in place but there were no residents looking after their own medicines at that time. The care plans or the medication records did not have photographs of the residents on them, which would make them more easily identifiable for the staff when giving treatment and care. The manager told us that these were going to be completed and that they had bought a camera to do this. The Leys DS0000012843.V368608.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): 12, 13, 14, 15. Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. The residents have their social, spiritual and nutritional needs met. very well. EVIDENCE: The staff were seen to be spending individual time with the residents. A resident told us that ‘I have good conversations with the staff ’ The T.V was on in the lounge, for part of the visit, which the residents were enjoying. During the day the staff had a sing-a-long with the residents and a quiz and counting game. Most of the residents joined in and enjoyed the activities. The staff, the residents and the activities programme confirmed that there were regular activities such as, bingo, quizzes, sing-a-longs and barbecues. Special days such as American Independence day had been celebrated and there was to be a strawberry tea on the day following the visit. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 17 The residents spoken with were happy with the level of activities and said that they had plenty to do. The families spoken with felt that there were enough activities for the residents to do. There was evidence in the daily records and in the care plans about the activities that the residents take part in. Cooking, art, exercise, clothes party, craft, shopping and fairs were described in addition to the previous activities. All the families spoken with said that they were made very welcome in the home, which we saw whilst we were there. The residents spoken with said that the food was good and that they had a choice of what they had. The menus were varied and were discussed with the residents individually. We spent time talking with the residents at lunch- time. The meal looked plentiful and well presented and the residents were enjoying it. We were told that the meat and vegetables were always fresh and the owner uses the local farm shop to buy them. Comments made by the residents, to us and through the surveys included: ‘ This is the best place I have ever been, the food is excellent, there are good activities, the staff are very good and always happy and will do anything for me’ ‘They look after me well’ ‘ The food very much improved since the arrival of the new cook’ ‘I am very happy and content living at the Leys’ The residents have a hairdresser arranged for them when they want it. The religious needs of the residents are met individually as requested, with the residents either going out to services or the clergy visiting the home. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 18 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, 17, 18. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to in the home if they needed to. The details for Social Services are not in the policy and the deatails for the Commission for Social Care Inspection are out of date. This can be made available in a large print, which makes sure that as many people as possible can read it. The home had received nine complaints since the last inspection on 6th February 2008. These were in the form of concerns raised by the staff and had increased since the new acting manager had been in post, as she is encouraging concerns to be noted. The Commission for Social Care Inspection has not received any complaints in this period, but has received two letters supporting and complimenting the home. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 19 The complaints book should include the dates that the complaint was resolved and by whom. This will give the home an audit trail of what has happened and how they dealt with it. The residents and the families spoken with were aware of the policy, of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. The staff spoken with were able to describe how they would deal with an allegation of abuse, knew the areas where abuse could happen and could describe the process that they would go through if they suspected any abuse. They confirmed that they had had training in safeguarding adults and whistle blowing and the acting manager and the records seen supported this. Most of the staff have either got an NVQ at level 2 or have started the award, during which they receive training in safeguarding as well as the training given in the home. They were confident that the management would handle any issues correctly. We looked at the accident book, which had been completed correctly. These practices make sure that the residents are safe from any abuse and that any concerns are handled correctly. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 20 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, 23, 24, 26. Quality in this outcome group is good This judgement has been made using available evidence including a visit to the service. The residents are protected by the policies and procedures in the home to provide a safe environment. EVIDENCE: The Leys is an extended and converted dormer bungalow on the outskirts of Northampton. There is a large lounge, conservatory and dining room on the ground floor with bedrooms on both floors, all of which have en-suite facilities. The stairs or a stair lift can reach the two bedrooms on the first floor. The home was clean and welcoming on our arrival. The reception area was a little dark and could cause difficulty for a resident with poor sight. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 21 The lounge was clean, but a little dark and the decoration could be updated. The dining room and the conservatory were clean and bright and very pleasant places to sit. The bedrooms seen had been personalised and were found to be clean and well decorated. The residents spoken with were happy with their rooms and said that they were able to bring their own belongings in with them. The use of a shared room is discussed and agreed with the residents before they are admitted to the home and their privacy is maintained by the use of curtains and each resident has their own storage for their belongings. The kitchen was clean and we were told that it was about to be refurbished and updated. The bathrooms were clean, well planned and clear of any items that could cause a hazard for the residents. There is a lovely garden with a small patio area that is accessible to the residents and makes a pleasant place to sit. The residents and the families spoken with were happy with the cleanliness of the home. The care staff complete the cleaning in the home and they have had training in health and safety. The cleaning products are stored in a locked cupboard. Consideration should be made to have staff that only do the cleaning to make sure that there is no risk of cross-infection with the staff cleaning and then looking after the residents. There are separate staff employed who do the cooking. The staff spoken with, the records seen and seen on the visit confirmed that this was the case. There was no record that the hot water temperatures had been checked recently. The residents could be at risk of being scalded if temperatures were above the advised level. Fire alarm testing and the fire drills were up to date. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 22 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 group is good. This judgement is made using the available evidence including a visit to the service. The residents’ needs are met and the recruitment policy and the training protect their safety. EVIDENCE: The duty rota reflected the number of staff on duty on the day of the visit and all the shifts covered by the four weeks seen had enough staff. The residents, staff and families spoken with felt that there were enough numbers of staff on duty to look after their needs. We looked at two staff files and the required information was complete in one them. This included evidence of identification, adequately completed application forms, two written references, a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults check. There was a reference missing from one of the files for a member of staff employed before the new acting manager started and she told us that she would obtain one immediately. The application form did not have enough space on it to give details of previous employment. This is necessary to make sure that prospective staff The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 23 have the right experience and that any reasons for gaps in employment can be explained. The acting manager makes sure that all the required documentation is in place before an employee starts work. This was confirmed by the staff spoken with and in the surveys returned to us, which told us that they could not start until they had all the paperwork in place. There was evidence of staff training, including induction and the staff spoken with confirmed that they had received recent training in moving and handling, medication, safeguarding and first aid. The acting manager has reorganised the training to use one training college and is committed to providing a thorough training for the staff in all the mandatory areas and for others that are related to the care of the residents. The residents and the families spoken with felt that the staff were well trained to do their job. A new member of staff told us ‘ I am really enjoying the work and the home’ All of the staff either hold a National Vocational Qualification (NVQ) at least at level 2 or are in the process of completing it. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 24 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, 36, 37, 38. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents benefit from management that is committed to their safety, care and needs. EVIDENCE: The acting manager, who came in for the visit, although she was on annual leave, has been in post for seven weeks. She is completing the registered managers’ award and will make an application to the Commission for Social Care Inspection to be the registered manager. The residents are seen regularly on an individual basis as are the families and discussions are held on how the home is meeting their needs. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 25 The owner of the home visits regularly and talks with the residents and the staff but does not complete a monitoring form that is required once a month. There is an annual quality questionnaire sent to the residents and their families and the questionnaires that we saw on the visit confirmed this. We received positive comments from the residents and the families amongst which were that there was good communication with the home and that the staff were very supportive of them and their relative. The acting manager had arranged for health and safety checks to be completed when she started working. These included a visit from the fire officer, who identified several areas that needed attention. Some of these have been completed and the provider must make sure that the remainder are complied with as soon as possible. The residents’ accounts were seen and all in order with two signatures on entries and receipts obtained for purchases. There was evidence in the records and from staff spoken with that formal staff supervision is taking place at the required frequency. Formal supervision of the staff gives them and their ‘line manager’ the opportunity to discuss work and training issues and needs. There are regular staff meetings held, confirmed by records held and by the staff. The acting manager and the provider have regular meetings when the home is discussed and these are helpful in improving the home and identifying the areas that each is responsible for. The acting manager and the provider confirmed that these took place and were positive. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 26 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 X4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES3 Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X 3 3 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 X 3 3 2 1 The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP9 OP19 Regulation 13 (2) 23 (2)(j) Requirement That the identified night medication is treated as a controlled drug. That the hot water temperatures are tested every month from all the outlets that the residents have access to and the results are recorded. That the health and safety requirements made by the fire officer are complied with. Timescale for action 17/07/08 30/07/08 3. OP38 23(4) 30/09/08 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. 2. 3. Refer to Standard OP1 OP1 OP7 Good Practice Recommendations The Statement of Purpose should be updated to reflect the new contact details for the Commission for Social Care Inspection. The Statement of Purpose could include the results of the annual quality audit undertaken by the home. With their permission, photographs of the residents should be put on the front of the care plans and medicine sheets. DS0000012843.V368608.R01.S.doc Version 5.2 Page 28 The Leys 4. 5. 6. 7. 8. 9. 10. 11. 12. OP7 OP7 OP7 OP9 OP16 OP16 OP26 OP29 OP37 Risk assessments should describe how the staff should cope with a risk that has been identified. The care plans could be redesigned to allow space for the reviews to be documented and for the resident and/or their families’ signature to agree to he care plan. The care staff should have further training to help them make meaningful entries into the daily record of care. The night medication that is in use in the home should be treated as a controlled drug. The complaints book should have space to include dates and signatures to create an audit trail. The complaints policy should be updated to include the contact details for Social Services and the commission for Social care Inspection. Consideration could be made to employ a dedicated cleaner in the home. Consideration could be made to redesign the staff application form to allow more space for dates of employment. The registered provider should complete a regulation 26 form when she has undertaken her monthly statutory visit. The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI The Leys DS0000012843.V368608.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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