Inspection on 16/05/05 for The Leys

This inspection was carried out on 16th May 2005.

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

The inspector 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 11/06/08

The Leys 20/06/07

The Leys 03/05/06

The Leys 24/10/05

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT Lead Inspector Vanessa Davies Unannounced 9:30am 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 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 C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Leys Address Old Derby Road, Ashbourne, Derby Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01335 238011 01335 238019 Derbyshire County Council Terjeevan Kaur Bajwa CRH 36 Category(ies) of Older People registration, with number of places The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13.10.04 Brief Description of the Service: The Leys Residential Care Home is located on the southern edge of Ashbourne. It provides care for 36 Service Users, who are all aged at least 65 years or older. The home was purpose built in a very pleasant area, on one floor, and there are no steps within the building. All Service Users are provided with their own bedroom, although none of these have ensuite facilities. The Home has four lounges and three dining rooms. Well-maintained gardens are provided, and staffing in the Home appeared to be relaxed and friendly. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out over 4 hours. 4 files were examined and 8 residents were spoken with. In addition to residents care files the inspector examined fire records, complaints records and staff files. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that completed assessments of need, care plans and risk assessments are on file for all residents. The manager and providers have a number of outstanding requirements from previous inspections which still need to be addressed within the timescale set, failure to address these requirements may lead to enforcement action being taken. The Registered Manager must ensure that suitable activities are offered taking into consideration past hobbies of residents. There are areas of the home which need to be up dated, these are detailed as requirements, some have been highlighted at previous inspections. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 6 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 Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 Files are incomplete and missing information results in service users needs not being met. EVIDENCE: The home has a detailed up to date Statement of Purpose and Service user guide and all residents have received a copy, signed documentation was available in files examined, to confirm this. There was an assessment in files examined, however 2 of the assessments were incomplete, and all provided very little information relating to meeting social needs. There was no evidence of an assessment completed by the manager. The assessment had highlighted some needs but these had not been addressed with a care plan or a risk assessment. There was evidence of risk assessments and care plans but no evidence of residents involvement or regular reviews. The Registered Manager did state that she was working with the 2 deputies with the intention of re-writing the care plans and involving the residents. Daily records are kept by staff, however they are difficult to follow, no time of writing and no area for signature. It is recommended that the daily The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 9 record is designed to ensure that a specific area is set aside for a signature and that staff document time of writing. The was evidence of contracts of Terms and Conditions in 3 of the 4 files examined, however only 1 was signed by the resident. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10,11 The manager and staff work well with the service users, in order to meet their needs, however there are areas, which must be addressed in order to fully meet their needs. EVIDENCE: The home keeps a record of medication received. Each file examined had a signed document authorising staff to administer medication; document signed by the resident. There was evidence of input from the GP and district nurses and residents spoken with confirmed that they saw health professionals as necessary. The manager has started to document residents wishes in the event of terminal illness and death, there was documentation in 2 of the 4 files examined. As stated in the previous section, there is little information relating to social needs, therefore the home do not meet everybody’s social needs. Residents confirmed that they are treated with respect and staff ask their preferred name. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Activities offered in this home are limited and therefore do not meet residents expectations or needs. The food choice is varied and appreciated by the residents. EVIDENCE: The residents spoken with stated that there were “activities to do but not as many as when Carol was here” The Manager stated that Carol was the Activity Coordinator but has since left and the post has not been filled. Some of the residents stated that their families visit regularly and are always made to feel welcome. The residents said that the food was very good and they always had a choice. The chef asks each resident what they would like to eat for the following day. All staff in the kitchen have a food hygiene certificate. There is a list of food preferences for all residents, kept in the kitchen for reference. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Adult Protection is given priority in this home to ensure that residents are protected from abuse. EVIDENCE: The home has a detailed Adult Protection policy, all staff completed Adult Protection training June, July, August 2004. The Manager keeps clear financial records for each resident, along with preparing a monthly expenditure statement, which is forwarded to relatives. All residents spoken with were aware of how to complain and who to complain to and were confident that it would be addressed. The manager has a complaints record, recording the complaint and the response. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21, This home is clean, comfortable and has sufficient facilities to meet the residents needs, however there are a number of outstanding issues that need to be addressed to ensure the safety of the residents. EVIDENCE: The Leys is a large purpose built building, there are 4 dining areas and 4 lounges. There are 6 toilets, 2 shower rooms and 2 bathrooms. Grab rails are situated throughout the halls and in the toilets. The home was very clean and free from offensive odours on the day of inspection. The home provides a smoke lounge, however the carpet is very badly damaged and must be replaced. The manager stated that this was due to be replaced. There are still a number of outstanding requirements from previous inspections, which need to be addressed. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29,30 There are clear procedures in place to ensure the safety of residents, however the staff team need further specific training in order to fully meet the needs of the residents. EVIDENCE: The inspector examined a number of staff files, all had proof of identification, 2 references and proof of CRB checks. All staff are offered a copy of the GSCC Code of Practice. All kitchen staff have completed Food Hygiene certificate. All staff have completed fire training. 2 files had evidence of medication training. All other training appeared to be out of date. The manager must ensure that all staff receive up to date training necessary to meet the needs of the residents. The home currently employs 17 members of staff, with 3 staff awaiting CRB checks before starting. Twelve staff have NVQ 2, One staff has NVQ 3 and 3 staff have NVQ 4 excluding the manager. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,38 This home is well managed by an experienced manager, systems are in place to monitor and review the quality of the service provided. EVIDENCE: The manager has 10 years experience working in care and has worked at the home since January 2004. She currently has NVQ 4 in Care & Management and has the Registered Managers Award, a Certificate in Management and a Registered Nursing qualification, although this is not currently kept up to date. The manager has a very good relationship with both the residents and staff. The manager keeps very clear up to date financial records for all monies kept on behalf of the residents. The manager completes Health & Safety audits, cleaning audits and fire audits. Regulation 26 visits are undertaken and reports left. Fire records were all up to date and checks carried out a relevant intervals. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 x x x x x STAFFING Standard No Score 27 x 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x x 3 The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 17 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 17.1 (a) sch 3 (3)(q) Requirement Each file must contain details of the limitations made by the home, and agreed by each service user or their representative, on the service users ability to make choices, freedom and ability to make decisions. (OUTSTANDING SINCE NOVEMBER 2003) The registered person must ensure that equipment provided by the home for the service user is maintained and in good working order.(not met 30.04.04) Each service users file must contain informtion from the Registered Providers to say that the services provided in the home are suitable to meet the service users assessed needs in respoect of their health and safety.(not met 31.01.05) The Registered Providers must ensure that the cold taps in bedrooms 1 & 8 can be easily turned off.(not met 30.11.04) The Registered Providers must ensure that suitable adaptations and appropriate equipment is provided. Timescale for action 31.07.05 2. 21 23.2 c 31.07.05 3. 7 14.1 (d) 31.07.05 4. 19 23.2 C 31.07.05 5. 19 23.2 (n) 31.07.05 The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 18 6. 37 7. 3 8. 3 9. 10. 11. 3 7, 12 11 12. 13. 19 30 The manager must ensure that when records are up dated at formal reviews and at the time of the monthly up date by care staff that service users are shown their file, given the opportunity to add to the file and are asked to sign to say they have seen it.(not met 31.01.05) 14.1, 14.2 The Registered Manager must ensure that a completed assessment of need is obtained for all service users and is regularly reviewed. 12.1 (a) The Registered Person must ensure that care plans and risk assessments are in place to address needs highlighted 15.2 The Registered Person must ensure that the service users plan is made available to them. 16.2 (m) The Registered Person must consult with service users about their social interests. 12.2 The Registered Person must take into account the wishes of the service users with regard to care. 23.2 (b) The Registered Person must replace the badly damaged carpet in the smoke room. 18.1 (a) The Registered Manager must ensure that staff receive suitable training in order to meet the needs of the service users. 15.2 31.07.05 31.07.05 31.07.05 31.07.05 31.08.05 31.08.05 31.08.05 31.08.05 14. 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. The Leys Refer to Standard 2 Good Practice Recommendations The Registered Person should ensure that all contracts of C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 19 2. 3. 4. 5. 3 3 3 12 terms and conditions are signed by the service users and or representatives. The Registered Person should develop an assessment of need in addition to the Community Care Assessment. The Registered Person should ensure that daily records are signed by staff and the time documented. The Registered Person should ensure that assessments of need include detailed information relating to social needs The Manager needs to gather further information about leisure activities for residents. The Leys C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 C52 C02 S36269 The Leys V226585 160505 Stage 4.doc Version 1.30 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!