Inspection on 28/09/07 for The Leys

This inspection was carried out on 28th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 16/07/08

The Leys 06/02/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Leys 63 Booth Rise Boothville Northampton Northants NN3 6HP Lead Inspector Helen Abel Key Unannounced Inspection 28th September 2007 09:50 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.V349816.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.V349816.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 Mrs Carolyn Melva Shiers 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.V349816.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 November 2006 Brief Description of the Service: The Leys is situated on the outskirts of Northampton, with good road access. The home offers single and shared room accommodation to 18 service users. The home has a large lounge and dining room, and a conservatory area. Two single bedrooms are situated on the first floor, accessed by stairs or a stair lift. The home has a large garden, which is accessible to residents. The weekly fees are up to £425pw. There are additional costs for individual expenditure such as hairdressing and private chiropody. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The home’s Registered Manager arrived shortly after the Inspector and assisted with the inspection process. Planning for the Inspection included assessing the service history of the home including the reporting of significant events. The Commission for Social Care Inspection have not received the Annual Quality Assurance Assessment. The Inspection took place between at 9.50 until 2.40 and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspectors spoke with three residents and three members of staff and the registered manager. What the service does well: Residents are enabled to have a good lifestyle in the home and receive varied and nutritious meals. Residents can take part in cooking sessions each Wednesday and generally make small and large cakes and pies. Cakes are stored and served at mealtimes. There was an abundance of fruit trees in the homes garden and staff pick the fruit and make dishes together with the residents. Stewed plums and apple pies were reported favourites. Some salad ingredients and vegetables were also grown such as carrots and lettuce. Resident’s benefit from a comfortable living environment. There is a light bright airy dinning area and the lounge faces the back garden with good views. Resident’s benefit from positive recruitment processes and staff receive some good training including National Vocational Qualifications. The Inspector observed positive interactions between staff residents and their relatives and visitors. Residents were spoken to kindly and with concern and respect. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 6 A resident told the Inspector, “The girls are great here. When I was very sick once they gave me perfect attention. They got stuck in and looked after me. The home is kept clean and they are hardworking staff.” What has improved since the last inspection? What they could do better: A Statement of Purpose and Service User Guide to be drawn up and made available to current and prospective residents. This should include arrangements for dealing with complaints. The assessment format to be reviewed to ensure it meets the National Minimum Standards and includes more detail for individuals. All care plans to be completely reviewed and updated and ensure they hold the relevant information including aspects around cultural needs and preferences. The Mediation policy to be updated and shared with staff to ensure safe dispensing of medicines. Staff training to be obtained around the administration of medication, vulnerable adult issues and First Aid to keep residents safe. Lounge chairs to be replaced with chairs that are easy to keep clean and hygienic. Record keeping to be improved to ensure individual records and home records are kept secure and in good order. The staff rota format to be developed to record all staff on duty and in what capacity they hold. This would ensure the daily skill mix of staff on duty meets resident’s needs. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 7 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.V349816.R01.S.doc Version 5.2 Page 8 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.V349816.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive adequate admission procedure to the home with some written information about the accommodation and services. EVIDENCE: Prospective residents are given a colour brochure upon inquiring or joining the home and some supporting information. However this information is limited and does not include the required information people need to make an informed choice about the home. The registered manager agreed and is currently considering purchasing a Statement of Purpose and a Service Users Guide to the home for current and prospective residents. This will give prospective residents full information about The Leys Residential Home. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 10 An assessment was examined for a new resident into the home but was basic and lacked detail. The assessment process should be reviewed to ensure it includes all the key information about a new person entering the home to ensue his/her needs be properly met. Residents are invited in for a day before they decide to stay at the home at no cost. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 11 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 poor This judgement has been made using available evidence including a visit to this service. There is insufficient attention given to meeting people’s health and care needs of residents in order to ensure residents are well looked after. EVIDENCE: A resident case tracked had little written information around nutritionally screening and pressure sores intervention recorded on their care plan although they required a lot of care around these issues. The same resident was found not to have had any medication recorded as administered for the last two days. Staff confirmed they had tried to administer some medicines but had not recorded this on medication sheets, which left the identified residents health needs unmet. The registered manager confirmed medication errors would be investigated on the same day of the inspection visit and action taken. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 12 Another resident case tracked had not been risk assessed to self-administer medication. This had resulted in medication not being administered appropriately and the service user not being safeguarded. The registered manager agreed to complete the risk assessment for the identified resident to self-administer medication immediately following on the inspection. The medicine policy was examined and needs updating and was also raised at the last inspection. The registered manager confirmed all care staff have received medication training. Issues around the around cultural preferences were not recorded in care plans or met for a resident case tracked. Some daily records were completed others were not. The registered manager confirmed there was an ongoing transfer of care plan information from the old to the new care plans, and some key information had not been fully transferred. This left care staff unsure of resident’s individual cares needs and resident’s needs not being fully met. The Inspector observed positive interactions between staff residents and their relatives/visitors. Residents were spoken to kindly and with concern and respect. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 13 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 area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to have a good lifestyle in the home and receive varied and nutrioutious meals. EVIDENCE: Staff spoke of holding regular quizzes and going shopping with residents. Recently all the residents went to the theatre to see Dads Army. Residents can take part in cooking sessions each Wednesday and generally make small and large cakes and pies. A lemon meringue was made by the residents the previous day and eaten for desert on the day of inspection. Various small cakes have been made by residents and stored ready for tea and snacks. There was an abundance of fruit trees in the homes garden and staff pick the fruit and make dishes together with the residents. Stewed plums and apple pies were reported favourites. Some salad ingredients and vegetables were also grown such as carrots and lettuce. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 14 One resident case tracked had special dietary needs. Records were not available to confirm this but there were stocks of special foodstuffs available for them. Processed baby food in jars was identified for the same resident. It was agreed by the registered manager these would no longer be administered to the resident and to consult with health care and dietetic staff. Ensuring appropriate cultural food is available for the identified resident should be considered and recorded on the care plan. Residents told the Inspector, “It’s not the best food and sometimes the roast meat isn’t carved well. Its too thick” (The registered manager agreed to look onto ensuring the Sunday joint is carved appropriately). “The meals are alright. They bake beautiful cakes, tarts and apple pie. If I don’t like something on the menu they will cook me something else.” “ We are given a choice of food to eat.” The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are mostly protected by procedures around complaints. EVIDENCE: Written information about the home does not include information on how to contact the local office for the Commission for Social Care Inspection (CSCSI). The Registered manager confirmed the complaints procedure is going to be updated. A resident said, “ Yes, I do complain if I am not happy.” A visitor said, “ Staff listen to me if I have a concern, they will do as I ask. They are very good.” Staff case tracked has not received any training around protecting adults from abuse. Staff were unsure of procedures to follow if there were any concerns about harm to residents. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a comfortable living environment. EVIDENCE: The premises throughout were homely and comfortable. All three residents case tracked had their bedrooms viewed by the Inspector. They were personalised with their possessions and were clean and tidy. It was noted that easy chairs in the lounge were stained and worn. Staff confirmed they were difficult to clean, as any liquid spilt would absorb deep into the foam chairs. These chairs should be replaced and alternative chairs provided that can be kept clean and hygienic. Parts of the lounge overlook the mature garden area outside and residents were seen looking outside at the views. There is a The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 17 spacious hallway with a resident’s information board. This included details of events, menus and a copy of the last inspection report. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 18 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 area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from positive recruitment processes. EVIDENCE: When the Inspector first arrived at the home there was a shortage of staff but shortly after staff came into cover. The staff rota did not properly reflect the deployment of staff or in what capacity staff held. For example the registered manager was not on the rota despite working all week. The Inspector tracked two staff and found their recruitment files to be in order with ongoing improvements since the last requirement drive. Both staff are working towards National Vocational qualifications as were all the staff team including the cook. The most recent training to staff was infection control and manual handling. There is currently only one qualified First Aider available. The Inspector suggested other senior staff covering shifts also received this training to ensure staff are trained and competent and residents are safe guarded. A resident told the Inspector, The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 19 “The girls are great here. When I was very sick once they gave me perfect attention. They got stuck in and looked after me. The home is kept clean and they are hardworking staff.” The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Record keeping procedures do not safe guard resident’s best interests. EVIDENCE: Care plans were held in an unlocked kitchen cupboard with the kitchen door left open. Lists of resident’s and their doctors contact details were found on the kitchen notice board. A private letter to a resident’s family from the registered manager was found open and attached to the doorframe of a resident’s room. Individual records and home records must be kept secure and in good order. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 21 Following on a recent fire officers visit the registered manager is reviewing the homes fire risk assessment and will be making some changes around kitchen fire doors and residents bedroom doors being left open. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 22 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 2 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 3 x x 3 x x 2 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 x x x x x x 2 2 The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 23 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. Standard OP1 Regulation 4 Requirement A Statement of Purpose and Service User Guide to be drawn up and made available to residents and their families. This will inform prospective residents and their families about the latest aims, objectives and philosophy of the home, about its services, facilities, current staffing. The registered manager must ensure the assessment information plan is reviewed and developed to meet the National Minimum Standards. This must be fully detailed and completed prior to resident taking up residence in the home. Residents would be assured the home is able to meet their needs. Review and update all care plans to ensure they are sufficiently detailed to enable staff to fully care for individual residents personal, cultural, health and social care needs. The medication policy to be reviewed and shared with staff periodically. This would ensure DS0000012843.V349816.R01.S.doc Timescale for action 28/11/07 2. OP3 14 31/10/07 3. OP7 12 28/09/07 4. OP9 13 12/10/07 The Leys Version 5.2 Page 24 5. OP18 18 6 OP20 23 7 OP37 17 staff were given information to enable safe dispensing and administration of medication to residents in the home. To ensure staff receive training on vulnerable adult issues. This would ensure staff have full knowledge of adult protection issues. The lounge chairs should be replaced and alternative chairs provided that can be kept clean and hygienic. This would ensure a clean and comfortable environment for residents to enjoy. Individual records and home records must be kept secure and in good order. These would safe guard resident’s interests and maintain their confidentiality. 30/11/07 30/11/07 05/10/07 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 OP9 Good Practice Recommendations Review all staff responsible for administering medication and arrange additional training and support to ensure staff are competent and can follow written policy and procedure. This will ensure residents are protected around administration of their medication. Ensure special diets are provided when advised by health care and dietetic staff; In addition all religious or cultural dietary needs are catered for and recorded on residents care plans. This would ensure appropriate balanced diets for individual residents. To update the homes complaints procedure and include the name and address and telephone number of the Commissions for Social Care Inspection. A summary of the arrangements made for dealing with complaints should be included in the Statement of Purpose. This would DS0000012843.V349816.R01.S.doc Version 5.2 Page 25 2. OP15 3. OP16 The Leys 4. OP27 5. OP30 ensure anyone wishing to complain has the correct information to do so. The staff rota should include all staff on duty during the day and night and in what capacity they hold. This would help towards confirming resident’s needs are met and the skill mix of staff on duty each day. Provide First Aid training to key staff to ensure staff are trained and competent and residents remain safeguarded. The Leys DS0000012843.V349816.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V349816.R01.S.doc Version 5.2 Page 27 - 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. 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