CARE HOMES FOR OLDER PEOPLE
The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT Lead Inspector
Vanessa Davies Unannounced 24 October 2005 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 V248791 241005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Thy Leys Address Old Derby Road Ashbourne Derbyshire DE6 1BT 01335 238011 01335 238019 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) Mr Kieran Anthony Hickey Derbyshire County Council Terjeevan Kaur Bajwa Care Home with Personal Care 36 places Category(ies) of 36 OP Older People registration, with number of places The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 16.05.05 Brief Description of the Service: The Leys Residential Care Home is located on the southern edge of Ashbourne. It provides care for 36 residents, who are all aged at least 65 years or older. The home was purpose built in a very pleasant area, on one floor, and there are no steps within the building. All residents 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 V248791 241005 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced. Information for this report was gathered by speaking with residents, the deputy manager, the manager and reading documentation kept by the home. What the service does well: What has improved since the last inspection?
The home has improved a great deal since the last inspection. Residents files have been developed and it is now clear that residents are involved with their care planning. Any limitations or restrictions are now agreed with residents and evidence available within their care files. The manager evidenced a refurbishment plan for the home, covering all aspects. Issues highlighted at the previous inspection regarding the environment have already been addressed.
The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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 V248791 241005 Stage 4.doc Version 1.40 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) 3,4,5,6 Detailed assessments, care plans and risk assessments provide staff with information necessary to meet the needs of the residents and support them to lead as independent a life as possible. EVIDENCE: Standards 1 – 4 were assessed at the previous inspection and requirements made have been addressed. The inspector examined 2 of the residents files, the manager and staff have clearly worked hard to improve them. Both had detailed assessments of need, regularly reviewed with evidence of input from the residents. Each file had care plans and risk assessments to meet the needs of the residents and to support them to remain as independent as possible. The manager goes out to visit potential residents and completes a preassessment; residents are invited to visit the home prior to any move. On admission residents are informed that the home is able to meet their needs. The home does not offer intermediate care. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 9 The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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) 7,9,11 Detailed information within the files ensures that residents wishes are addressed and met. EVIDENCE: Standards 7,8,10,11 were assessed at the previous inspection and the manager has addressed requirements made. Each file had detailed information to address all of the needs of the residents. All staff administering medication have received training to do so. Medication is stored, recorded and administered appropriately. Documentation was available within residents files to detail their agreement for staff to administer medication or to self administer and store their own medication in a locked cupboard in their bedroom. The manager has detailed information within files about residents wishes in the event of terminal illness and death. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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) 14 Supporting residents to exercise choice ensures their continued independence. EVIDENCE: Standards 12,13,15 were assessed at the previous inspection and requirements have been addressed. It was evident when speaking with residents and reading their files that they are supported to exercise choice and control over their lives. Residents bedrooms were personalised and staff keep clear records of financial transactions. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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) EVIDENCE: The key standards were assessed and met at the previous inspection, therefore they were not assessed on this occasion. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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) 22,23,24,25,26 A clean, pleasant and homely environment ensures that residents feel as comfortable as possible and settle into the home as quickly as possible. EVIDENCE: Standards 19,20,21 were assessed and met at the previous inspection. The home provides specialist equipment as required, each of the toilets has grab rails, baths have hoists, there are portable hoists available and call bells throughout the home. Each of the bedrooms seen were personalised and residents spoken with stated that they had what they needed and were made to feel more comfortable with their own possessions around them. The surroundings are clean and comfortable. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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) 27 Staff training and suitable staffing numbers ensure that the needs of the residents are met and independence is promoted. EVIDENCE: Standards 28,29,30 were assessed at the previous inspection, the requirement left has since been met. Residents spoken with stated that there was always enough staff on duty, this was evident on the day of inspection. The manager ensures that the skill mix on duty each day meets the needs of the residents. Staff on duty on the day of inspection worked well with residents and clearly had good positive relationships. The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 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) 32,36 An experienced manager who provides clear leadership manages the home, ensuring that staff develop professionally and residents benefit from this development. EVIDENCE: The keys standards 33, 35, 38 & 31 were assessed at the previous inspection and were all met, the inspector briefly looked at the standards again and the manager continues to meet them. The manager and staff team have clearly worked hard to meet the requirements made at the previous inspection. Residents records have been greatly improved and residents have been involved with their records. It was evident on the day of inspection that the manager provides clear leadership and supports the staff team. Staffing records were examined and the manager meets the National Minimum Standards of providing supervision at least 6 times per year.
The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 16 The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 17 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 x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x
COMPLAINTS AND PROTECTION x x x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x x 3 x x The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 18 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Leys C52 C02 S36269 The Leys V248791 241005 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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