Inspection on 03/05/06 for The Leys

This inspection was carried out on 3rd May 2006.

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 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 11/06/08

The Leys 20/06/07

The Leys 24/10/05

The Leys 16/05/05

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 The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT Lead Inspector Claire Williams Unannounced Inspection 3rd May 2006 08:45a 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 DS0000036269.V292931.R01.S.doc Version 5.1 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 DS0000036269.V292931.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Leys Address The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT 01335 238011 01335 238019 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) Derbyshire County Council Terjeevan Kaur Bajwa Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 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 is purpose built and all facilities are on one level. All residents are provided with their own bedroom, although none of these have ensuite facilities. The Home has four lounges and three dining rooms and front and rear gardens, which are well maintained. The fees for the home commence from £286.80 The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a seven hour period. The inspection involved assessing key areas as defined by the CSCI. The inspector spoke with 9 residents and examined four files using the Case tracking methodology. The inspector also spoke with two relatives. The inspector joined the residents for their lunchtime meal and a tour of the building was undertaken. Time was spent observing residents and staff interaction, and the inspector spoke with 5 staff members and examined four files. The manager of the home and the deputies assisted with the inspection. Following consultation with the people living at this home, it was agreed that they would be referred to as ‘residents’ for the purpose of this report. What the service does well: What has improved since the last inspection? What they could do better: The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 6 The home should ensure that all of the required information about residents is contained in their file in particular a photo, and their marital status. It should be clear in the files, which is the current care plan in order to avoid any confusion. The assessments completed to monitor residents moving and handling needs and any general risks identified should reflect the date and the outcome of the review undertaken. The Registered Manager should develop a medication competency assessment, which can be used to assess all staff that administers medication to ensure safe practices are used. The Registered Manager must ensure that they obtain an applicant full employment history to ensure that the recruitment of staff safeguard residents from risk. The Registered Manager must ensure that minimum staffing levels are always maintained to ensure residents needs are met. 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 DS0000036269.V292931.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection The Leys DS0000036269.V292931.R01.S.doc Version 5.1 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 the following standard(s): 1, 3, 4, and 5 (Standard 6 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 home provides information about the service to prospective residents and invites them to visit the home before admission. Residents are assessed prior to admission and the home can demonstrate that they can meet the needs identified. EVIDENCE: In the residents files examined there was a signed declaration confirming that a copy of the Service user guide had been received. Discussions with both residents and visitors also confirmed that they had received this document. Copies of the reference guide, which contain a copy of the Statement of purpose, are located in all of the lounges. There was evidence in the resident’s files to support that pre-admission assessments had been completed and a letter sent stating that the home is able to meet the needs identified. Residents spoken with confirmed that they were able to visit the home before admission, and some residents who were at the home for a short break, felt that it enabled them to “test drive” the home so that they could make an informed decision for when they may need to move in on a more permanent basis. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes care-planning system ensures that resident’s personal, health and social care needs are met. The medication practices safeguard resident’s welfare. EVIDENCE: Four residents’ files were examined in accordance with the case tracking methodology. All the files contained detailed care plans that covered all aspects of the resident’s health personal and social care needs. There was evidence to support that residents were consulted and involved in the development of their plan, and residents confirmed this during discussions with the inspector. All of the required risk assessments were completed, and majority of the assessments had evidence to support that they were regularly reviewed. However the inspector did note that there was a couple of assessments in particular moving and handling and the general risk assessments that did not reflect the date the assessment was reviewed and the outcome. There was evidence to support that files were reviewed and updated accordingly following the monthly and the main generic review of the residents needs. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 10 Both the residents and their relatives felt that the staff team had a good knowledge of their support needs. Comments received included “ the staff are brilliant” “they are a good team and are marvellous”, “I cannot fault the care here we are well looked after”. Residents felt that their dignity and privacy was upheld and residents confirmed, “the staff always knock the door first before coming into the bedroom”, and that personal care tasks were supported in a “respectful and sensitive manner”. Observations of the staff team interacting and supporting individuals confirmed these comments. The Medication storage and practices were examined and all were found to be satisfactory. The management team are responsible for administering medication and all had undertaken training in this area. A medication competency assessment has not yet been developed, which should be used to assess the staff member’s competency in administering medication. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents believe the home fulfils their expectations, and activities are provided which residents enjoy. Residents receive visitors without any restrictions, and felt that the food provided met their preferences. EVIDENCE: Residents were complimentary about the way they were supported in daily tasks and confirmed that they chose how they wished to spend there days. Residents felt the routines were flexible and that they had choice and control over their lives. A list of activities was displayed on the notice board and one resident had a copy of her own in her bedroom. The inspector was shown by a resident some of her recent craftwork, which included working with clay, she also commented how he enjoys the movement to music activity. The home does not have a dedicated activity co-ordinator therefore the care staff try to facilitate activities, which one staff member stated “can be difficulty if we are short staffed or have other tasks to do” A relative informed the inspector about the voluntary work undertaken at the home, and the garden group that has been developed, which maintains the garden areas in particular, the front garden. The inspector was informed of the trip that had been organised for the following day, which included a pub meal and the residents expressed how much they was looking forward to this. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 12 Residents stated how they enjoyed the meals provided and confirmed that “choices are always available”. The inspector was invited to have a meal with some of the residents and the mealtime was relaxed with residents chatting amongst themselves. A brief tour of the kitchen was undertaken and found to be generally satisfactory, although the walls and the fan in the kitchen were dirty and needed to be cleaned. The required records were maintained and the cook had a good knowledge of the resident’s preferences and dietary need’s, which were also recorded. The head cook had the required qualifications in food hygiene. The cook informed the inspector that she regularly consults the residents on their preferences of food and to obtain feedback about the quality of the food provided. The cook expressed her concerns over the reduction in catering hours in the kitchen and stated that she was short on the day of the inspection so the staff member who usually undertakes domestic duties was helping out. The inspector was informed that there was a vacancy for a kitchen assistant. The inspector gave the head cook a copy of the publication written by the CSCI on “improving meals for older people in care homes” which was devised following consultation with older people. The inspector was informed that the home recycles most of its waste products, however the staff have encountered problems as the bins provided are also used by the public, as the home is on a the list for recycling sites. This however is causing difficulties for the catering staff as the bins are not adequate enough to hold all of this waste, and the public are not using them appropriately resulting in the catering staff having to sort the waste, which on one occasion had maggots within the waste. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives felt that their complaints and concerns were listened to and acted upon. Staff had a good awareness of the safeguarding adult’s procedures and their associated responsibilities. EVIDENCE: Residents and their relatives confirmed that they knew how to complain, and felt that any concerns or complaints would be acted upon. Residents stated that they had no hesitation to raise any concerns and felt that both the management and staff team were all approachable. A complaints procedure is in place and is contained in the Service user guide, a recording format is also in place. The inspector was informed that the home had received 2 complaints since the last inspection, which have been responded to appropriately. In discussions with the staff team it was evident that they had a good knowledge of what to do if they ever witnessed an abusive situation. Staff confirmed that had received training in this area and a procedure was available in the home. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19, 20, 22, 23, 24, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is furnished and maintained to a satisfactory standard and offers homely and spacious facilities for residents to enjoy. EVIDENCE: Residents informed the inspector that the home was homely and “always well maintained and clean. A relative said, “it never smells here” and “is always clean and pleasant”. Although some of the bedrooms are below 12sqm residents felt that they had adequate space for all of their belongings. The inspector was given permission to enter some of the resident’s bedrooms, and they were personalised to suit individual preferences. Residents informed the inspector that they were given a choice of what colour they would like their bedroom, before and following their admission to the home. The front garden was well maintained by the garden group who had planted a lot of flowers and had developed a sensory garden. The garden at the rear of the home was a grassed area that required cutting. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 15 Although the environment was generally satisfactory there was areas that required redecoration. The inspector was informed that refurbishment plan has been devised and areas within this will be completed. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a trained and competent staff team. The home is operating with staff vacancies and the rostered numbers are not always being maintained. EVIDENCE: The inspector was informed by both the staff and management team of the recent problems encountered by the staff shortages at the home. This is a result of the home having three vacancies, which have been filled, but the manager is waiting for all of the recruitment checks to be completed, in particular the Criminal Records Bureau disclosure check (CRB) which is taking a long time to be returned. The Human resource department of the local authority does not undertake Povafirst checks as a method of ensuring that prospective employees are not on the register so that they could commence their supervised induction whilst waiting for the return of their CRB. The home also has some staff members off sick and currently does not have access to relief staff to cover these shortages. Therefore the current staff members have been undertaking additional hours in order to cover the shortages. Although these shortages have not had a direct impact on the delivery of care as the residents have stated that there physical needs are always met, and positive comments have been made about the staff team, it has impacted on the staff team who reported that they “were tired and exhausted at the end of the shift” that “staff morale was low”, “they are always rushing around”, and The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 17 “have no quality time with the residents”. Some staff members reported that they have worked 10 days without a break in order to cover the shortages. Staff confirmed that they know they could say no to extra shifts but undertake these so that the rota is covered and in order to support there colleagues. The staff members did confirm that on the whole most of the managers were willing to assist them to work with residents and to undertake tasks. A relative spoken to also raised concerns over the staff shortages, and gave examples of times were there has only been one care staff on duty and perhaps a manager. Comments were made that the situation has improved recently but the person still had concerns both for the residents and the staff well being. The staff members confirmed that they had undertaken all of the mandatory training and commented on the positive training opportunities provided. There are currently 12 staff members who have completed the National Vocational Qualification (NVQ) level 2 and some staff have now started their level 3. The inspector examined 4 staff files and majority of the files contained the required information. The inspector was informed that the Human Resource department probably had any missing documents within their files. Although the application form used did state that all employment should be recorded with gaps explained, the completed forms examined of staff recently employed, did not contain full employment and there was no evidence that the gaps identified were explained. The inspector and the manager had a discussion about this and the inspector confirmed that the manager must gather this information before an applicant is employed. The staff files did not contain evidence of the training undertaken by staff and the manager did state that this was area that she was now working on. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager provides leadership and manages the home in the best interests of the residents. The health, safety and welfare of residents and staff were generally promoted and protected. EVIDENCE: The Registered Manager has managed the home for the last two years and with the support of the deputy managers they seek to improve the home to ensure that the residents receive a good standard of care. There were clear lines of accountability within the home and with the external management. Residents and relatives felt that all of the management team were approachable, and supportive. The inspector was informed that the area manager visited regularly and undertook monthly audits of the home, however there were no reports of these visits and the outcomes at the home since 27/07/05. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 19 The home has many systems in place in order to obtain feedback from the residents and in order to discuss the running of the home. These include regular resident and amenities meeting and family meeting. All residents and their relative’s receive an annual best value questionnaire, and the home has a suggestion box within the home. The inspector examined the system for managing resident’s finances. The system is electronic and each resident has an account were their money is held. Receipts are obtained for all transactions and the records completed. The money held in the ‘float tin’ was checked and was found to be satisfactory. The inspector was informed that all of the required health and safety checks were undertaken to ensure the building was safe. The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 20 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 3 X 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13 (2) Requirement A medication competency assessment must be developed and completed on all staff that administers medication. Minimum staffing levels in order to meet the dependency needs of the residents must be maintained at all times. A full employment history must be obtained for all new staff members and any gaps explained, before they commence employment. Reports of the monthly unannounced inspection visits undertaken must be available for inspection in the home. Timescale for action 01/08/06 2 OP27 18 (1) (a) 01/07/06 3 OP29 19 (1) (b) (i) 01/08/06 4 OP33 26 01/08/06 The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 22 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 4 5 Refer to Standard OP7 OP7 OP7 OP8 OP15 Good Practice Recommendations If there is more than one file containing information about residents, this should be made clear in the working file. The residents file should clearly reflect which personal service plan is the current updated plan reflecting the residents current needs. A photo of the residents should be on their care plan, and details of their martial status. All risk assessments should be reviewed on regularly or at least on an annual basis. The assessment should evidence the date and outcome of this review. The fans and walls in the kitchen should be cleaned. The home should have separate recycling bins from those used by the public. These bins should be adequate in size for the amount of waste used by the home. The grass in the rear garden would benefit from being cut. The staff files should contain evidence of training undertaken. 6 7 OP19 OP30 The Leys DS0000036269.V292931.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000036269.V292931.R01.S.doc Version 5.1 Page 24 - 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!