Inspection on 05/10/06 for 27 Larchwood Close

This inspection was carried out on 5th October 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27 Larchwood Close 10/07/07

27 Larchwood Close 24/01/06

27 Larchwood Close 30/08/05

27 Larchwood Close 05/01/05

27 Larchwood Close 10/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Larchwood Close (27) 27 Larchwood Close Banstead Surrey SM7 1HE Lead Inspector Joseph Croft Key Unannounced Inspection 05th October 2006 09:30 Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 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 Larchwood Close (27) DS0000013471.V308041.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 Adults 18-65. 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. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larchwood Close (27) Address 27 Larchwood Close Banstead Surrey SM7 1HE 01737 370115 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) www.mencap.org.uk Royal Mencap Society Mrs Mary McCallion Care Home 7 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: SIX (6) AGED 35 YEARS - 65 YEARS, ONE (1) OVER 65 YEARS The home may accommodate 1 (One) resident with both a learning disability (LD) and a physical disability (PD) within the total number of residents accommodated. 24th January 2006 Date of last inspection Brief Description of the Service: Larchwood (27) is a large detached property located in a residential area in Banstead, Surrey and is registered with the Commission for Social Care Inspection as a care home providing personal care for six people with a learning disability. Accommodation is on two floors accessed by stairs and comprises of six single bedrooms, a lounge, dining area, kitchen, utility room, office, shower rooms and a bathroom. The home has a large garden to the rear of the property which is easily accessible and private parking is available to the front of the property. Weekly fees are from £500 to £668. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. This inspection was conducted on two separate days due to the home not having appropriate and experienced staff on duty on the first day of the inspection. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the acting manager, staff, and residents who were at the home at the time of the inspection. Comment cards from residents and visitors were used as part of the evidence gathering for this inspection. There were insufficient responses from relatives to be able to form appropriate judgements. Comment cards from residents and visitors were very positive about the home and the care residents receive. There are currently seven residents living at the home. Residents were friendly and conversed with the inspector. During discussions residents stated they were happy living in the home, that the food was good and they liked the activities offered. Residents’ bedrooms had their personal belongings such as televisions, pictures, and family photographs. Residents stated that they like the staff, and they help them to make choices regarding their daily lives. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support them. A requirement made at the previous inspection that the walls and floor in the utility room must be appropriately finished to ensure it is readily cleanable to prevent the spread of infection had not been complied with. A further requirement has been made in regard to this, which must now be complied with. Feedback was provided at the end of the inspection to the acting manager. The inspector would like to thank the staff and residents for their cooperation during the inspection. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 6 Fifteen requirements have been made in regard to this inspection. What the service does well: What has improved since the last inspection? What they could do better: A Service Users Guide must be produced in a suitable format for residents to easily understand, and each resident must be offered a copy to keep in their bedrooms. All care plans must be reviewed on a minimum of a six-month basis. All staff working in the care home must receive training on all aspects of the medical condition of Diabetes. Prescribed medication must be appropriately stored in a locked medical cabinet that is securely fixed to a solid wall. Records of complaints from residents must include the date, name of the Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 7 person complaining, nature of complaint, action taken, and the date feedback was provided to the complainant. All staff must receive up to date training in regard to the Protection of Vulnerable Adults. The walls and floor in the utility room must be appropriately finished to ensure it is readily cleanable to prevent the spread of infection; this requirement has been carried over from the previous inspection and must now be complied with. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as appropriate for the health and welfare of residents, and that the employment of any persons on a temporary basis at the care home will not prevent residents from receiving such continuity of care as is reasonable to meet their needs. A review of the staffing for the home, including a review the roles and responsibilities of shift leaders and their competence, must be undertaken. The acting manager must submit an application form to be considered for registration as manager to the Commission For Social Care Inspection. The registered person must develop a system to ascertain the views of residents, their families, representatives and other associated professionals in regard to the quality of care residents receive at the home. 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. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are not provided with up-to-date information about the home to enable them to make an informed choice. The arrangements for assessing needs are satisfactory ensuring the aspirations and needs of residents are assessed. EVIDENCE: The home has a Statement of Purpose, which the acting manager stated had been produced before he took up his post, possibly written in 2004, although there was no date on the document to evidence this. On reviewing this document it became evident that it requires updating to include the changes that have taken place at the home during the last two years. The acting manager stated he is currently producing a new Statement of Purpose that will include all as stated in schedule 1 of The Care Homes Regulations 2001 as amended, and a copy will be forwarded to the Commission For Social Care Inspection Surrey Local Office within the next two weeks. The current Statement of Purpose included information in regard to the staff team, training, Mencap, day care services, consultation, complaints procedure and monitoring of the service. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 10 The home has a Service Users Guide that is kept in residents’ care files. This document was viewed and found not be in a suitable format for residents to be able to easily understand the contents. A requirement has been made that the registered person must ensure a Service Users Guide is produced in a suitable format for residents to easily understand, and each resident must be provided with a copy. The acting manager stated the last resident to be admitted to the home was in 2004, however, future admissions would include obtaining a pre-admission assessment from prospective residents’ care managers, and the acting manager would visit the person concerned at their current address to undertake an assessment to ensure the home could meet their needs. The process would then be for prospective residents to visit the home for a meal, then for a day, and if required, an overnight stay at the home. The home uses the Mencap policy and procedure in regard to admissions to the home. All residents are funded by social services. Evidence of pre-admission assessments was viewed for the three most recent admissions. The care managers undertook these assessments, from which the care plans were developed. Assessments included information in regard to personal and family contact, support networks, health, behaviour, employment /education, mobility, bathing, dressing, leisure, and medication. Unfortunately, due to their low levels of understanding, residents spoken to could not remember if they visited the home before they moved in. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has care plans and risk assessments in place that ensure the needs of the residents are met. EVIDENCE: On the day of the inspection four care plans were sampled. These detailed how the emotional, social and physical needs of individual residents are to be met. Care plans are produced from the pre-admission assessments and include information in regard to residents likes, dislikes, choices, health care, personal care, religious and cultural needs, communication and how residents prefer to be supported with their personal care needs. The inspector viewed evidence that statutory annual reviews had been undertaken. However, it was noted that this was the only time care plans were reviewed. A requirement has been made that all care plans must be reviewed on six month basis. Due to the low levels of understanding, some residents spoken to were not able to understand the concept of ‘care plans’, but were aware they have a certain member of staff who they can talk to, and who supports them when Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 12 required. Residents discussed the activities they like to attend, which reflected the recordings in their care plans. During discussions, staff were able to give an account of the content of care plans for the residents with whom they key work, and were aware of the need to review care plans. Residents stated that they make choices about themselves, the activities they like to do and the food they would like to eat. Staff stated that residents are involved in making decisions about their lives; records of decisions made by residents are maintained in their care plans and the daily records kept by the home. Risk assessments sampled evidenced that they were had been reviewed on the 15th April 2006. Risks assessed included going out independently, fire, finances, bath/showering and using the stairs. The resident and their keyworker had signed their risk assessments. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers residents choice and opportunities in their daily life. EVIDENCE: The acting manager stated residents were encouraged and supported to be as independent as they are able. Care plans sampled evidenced this and the activities residents chose to partake in, which included bowling, cinema, pitch and putt, swimming and cooking. During discussions residents stated that they choose the activities they like to do, which also include, cooking, board games, shopping and trips into the local community. Only one resident is currently in employment, which is on a Saturday morning at a local fast food outlet. During discussions, the acting manager and staff stated residents have access to the local community with staff support. These include visiting a local social Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 14 club, church, local towns for meals, shopping, pubs, and the cinema. The home maintains records of activities residents have attended, which were viewed by the inspector. During discussion, the acting manager stated residents are encouraged to make choices about their daily lives, and supported to be independent in regard to daily living skills. Some residents are able to access public transport with staff support. Care plans sampled included information in regard to residents’ cultural and religious needs. During discussions the acting manager stated staff receive training in regard to equality and diversity during their induction. Mencap provide training in regard to diversity. Evidence of dates of this training was viewed. During discussions, residents stated they go to the local church every week. Parents and families are welcome to visit the home, and residents are encouraged to maintain contact with them. Residents can meet with their visitors in the privacy of their bedrooms. One resident visits his dad at home on a regular basis. Opportunities to meet other people are provided through attendance at day centres, church services and local clubs. During discussions, some residents were able to state they have family who they visit. The acting manager stated that some residents are able to have weekend visits with their parents and families. Records of family contact are maintained in the daily records kept by the home. Residents state they have keys to their bedrooms, but they chose not to lock their bedroom doors. Staff stated residents receive and make telephone calls in private through the use of a cordless telephone, which can be taken to their bedrooms, and residents receive their own letters, but require staff support to read them. During discussions, staff and residents stated they could choose to spend time on their own in their bedrooms. During discussion staff and residents stated they all help with chores around the home. Residents stated they enjoy helping around the house, and they have help from staff when doing their own washing, ironing and cooking. Daily chores undertaken were recorded in care plans. The home has two cats that residents are responsible for. Residents stated they enjoy looking after the cats. Menus were submitted with the pre-inspection questionnaire and these evidenced residents are provided with balanced meals that included meat, fresh vegetables and fruit. It was noted that only the main meal of the day is written on the menu. The acting manager stated this is because residents have a choice of cereal and toast for breakfast, and are out at day centres during the day when they take sandwiches of their choosing with them. This Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 15 was confirmed during discussions with staff. On the day of the inspection, one resident was observed making sandwiches for the following day. The acting manager stated menus are hand written because residents choose the meals for the coming week on a Sunday. The home has produced a book with colour photographs of foods and meals that help residents to choose the week’s menu. The food is bought fresh on a weekly basis. Menus were observed displayed on the notice board in the dining room; they are colour coded, which informs residents whose turn it is to help with the cooking on that particular day. The acting manager stated all meat and vegetables are fresh. During a tour of the kitchen, fresh fruit and vegetables were observed stored in the kitchen and fridges. Records of fridge/freezer temperatures are maintained. One resident has a special diet due to a medical condition. Foods this person is allowed to eat were observed recorded in their care plan. However, a requirement in regard to this persons’ condition has been made under Standard 19 of this report. During discussions, residents stated they liked the food at the home, and they are able to choose what they like. There were no bad comments made in regard to food on residents’ comment cards received at the Commission For Social Care Inspection Surrey Local Office. Training records evidenced that staff had received training in Food Hygiene and handling, however, it was noted these require to be updated. Requirements in regard to these have been made under Standard 42 of this report. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Physical and emotional health care is offered in such a way as to promote residents independence. The residents are not protected by the home’s storage of medication. EVIDENCE: During discussions, staff stated that personal support is offered to residents who need it. Staff stated this is undertaken in a private and sensitive way to protect the dignity of the resident. Personal support was recorded in care plans, and included support in regard to personal care. The acting manager stated residents are consulted in regard to the support they would like with their personal care, and which member of staff they would like to help them. Residents’ likes and dislikes were recorded. The home uses the key worker system to enable continuity of support to be provided to the residents. Arrangements regarding areas of health care are detailed in residents’ care plans. Records of visits by the GP, and attendance to the Dentist, Opticians, Chiropodist, and other health care professionals are also maintained. Residents Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 17 have access to all NHS healthcare facilities as required. Incidents of illness are recorded in daily records and healthcare plans. It was observed that one resident has Diabetes, and has their blood sugar levels tested and recorded on a weekly basis. This person’s care plan detailed information in regard to their condition, including the medication and foods they can and cannot eat. However, the acting manager stated that no current member of staff had received any training in regard to this condition. An immediate requirement has been made that the registered person must ensure all staff working in the care home receive training on all aspects of the medical condition of Diabetes. The acting manager was advised by the inspector to contact the local GP for advice and information in regard to Diabetes and the testing of blood sugar levels. This was undertaken on the day following the inspection. The acting manager reported that the GP practice had advised that this person does not need to have their blood sugar level tested by staff at the home, as this is controlled through prescribed medication. The acting manager stated he was advised if there were any concerns noted in regard to the condition of this resident, then they must refer to the GP. Monthly records of residents’ weight were maintained by the home, any significant loss of weight is referred to the GP. The home has a book for the recording of medicines received and returned to the Pharmacist. The acting manager stated the home had recently begun using the Boots blister packs and Medical Administration Records sheets for medication. The medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained. It was noted that the prescribed medication is not appropriately stored in a locked metal medical cabinet. An immediate requirement has been made that the registered person must ensure prescribed medication is appropriately stored in a locked medical cabinet that is securely fixed to a solid wall. The acting manager stated there are no residents who self medicate or are taking a controlled drug. Training records evidenced that staff administering medication had received the appropriate training on March 21st 2006. The home has a local and a Mencap medical policy that staff follow. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues, however, all staff must receive the appropriate training in regard to the protection of vulnerable adults. EVIDENCE: Staff spoken to stated that they had read and understood the Complaints Policy and Procedure, and gave an accurate account of who they would report complaints to. Staff stated they would not hesitate in reporting concerns to the Commission For Social Care Inspection Surrey Local Office. The home has two complaints books that were viewed by the inspector. One book was for residents’ complaints; the other was a Mencap folder for complaints from relatives and visitors to the home. The residents’ complaints book evidenced there had been two complaints since the previous inspection; however, these records were not maintained in line with 22.7 of the National Minimum Standards for Younger Adults. A requirement has been made that the home must maintain a record of the date, name of the person complaining, nature of complaint, action taken, and the date feedback was provided to the complainant. During discussions residents stated they would talk to staff or the acting manager if they were unhappy, or wanted to make a complaint. One resident stated they had made a complaint and it was dealt with. The home has a copy of the Royal Mencap Society Complaints Procedure dated March 2005, and a local Complaints Procedure. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 19 The home follows the Mencap Protection of Vulnerable Adults Policy and Procedure that is dated October 2002. However, a requirement has been made that the home must have a local Protection of Vulnerable Adults policy and procedure that is written within the Surrey Multi-Agency Protection of Vulnerable Adults Procedures. During discussions staff gave an accurate account of what to do if they witnessed or suspected that a resident is being, or had been abused. Staff stated they would have no hesitation in reporting bad practice, and if necessary, they would report their concerns to the Commission For Social Care Inspection Surrey Local Office. Evidence of staff training in the Protection of Vulnerable Adults was observed, however, this training requires to be updated for all staff working at the home. Evidence was seen for two members of staff who are to attend this training, one in November 2006 and one in February 2007. The acting manager stated other members of staff would be booked on the Protection of Vulnerable Adults training. A requirement in regard to this has been made. During discussions, the acting manager gave an accurate account of the procedures to be followed in the case of abuse or suspected abuse of one of the residents. However, the acting manager had not attended training on Protection of Vulnerable Adults since 2003. A requirement has been made that the acting manager must apply to attend the Surrey Multi – Agency training on the Protection of Vulnerable Adults, and forward these dates to the Commission For Social Care Inspection Surrey Local Office. The home has a copy of the February 2005 Surrey Multi – Agency Protection of Vulnerable Adults procedures. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a safe and comfortable place to live, however, a previous requirement needs to be complied with in the utility room. EVIDENCE: Bedrooms viewed during this inspection had been personalised by residents, which included family photographs and other possessions. Bedrooms were spacious, light and airy. On the day of the inspection the home was clean, well presented and free from malodour, and the standard of décor was good. Furniture and fittings were of good quality and the home was safe and comfortable. The home had a utility room but the walls and floor were still in need of finishing to ensure it is impermeable to prevent the spread of infection. This was a requirement made at the previous inspection that has not been complied with. A further requirement is made in regard to this. The home did not have a policy on Infection Control. A requirement in regard to this has Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 21 been made. There is a large garden to the rear of the premises that requires general upkeep in regard to clearing of footpaths. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not supported by competent and qualified staff at all times. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: On arrival to 27 Larchwood Close on the 3rd October 2006, there was one member of bank staff on duty with one resident, who informed the inspector that the manager was not on duty today. Further discussion with this member of staff revealed that today was her first day on duty since October 2005. A second member of staff returned to the home at approximately 11:00am, who had been out with a resident. This member of staff stated she was a bank staff who had been working at the home since the 11th September 2006, and works between ten and twenty hours per week. The most experienced member of staff on duty had left the care home to take one resident out shopping. The inspector was informed that this particular member of staff was returning to the home later that afternoon. These staff were not fully aware of care plans, risk assessments, and were not familiar with the needs of the residents. They did not know the name of the Area Manager, or have the mobile telephone number of the more experienced member of staff who had left the home that morning. The home was not appropriately staffed with experienced and/or competent care staff that could meet the needs of residents. An immediate requirement has been made that the registered person must ensure that Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 23 suitably qualified, competent and experienced persons are working at the care home at all times in such numbers as appropriate for the health and welfare needs of residents. The registered person provided a response on the 9th September 2006, detailing how they are to address this issue, therefore this immediate requirement has been complied with, ensuring that competent and experienced staff are on duty at all times. The acting manager stated that the staffing for the home would be; manager as supernumerary, three fulltime staff, and four part time staff. On the day of the inspection staffing for the home was made up of: the acting manager, one full time member of staff, and four part time staff working between 10 to 27.5 hours per week. The acting manager stated the home are in the process of recruiting two full time staff. The home uses the bank staff who are employed by Mencap. During discussions, bank staff stated they had undertaken all the mandatory training provided by Mencap, however, due to their training files not being kept in the home, it was not possible to evidence this. The duty rota evidenced that there are a minimum of two members of staff on duty for each shift. It was noted that there is no hierarchy to the staffing structure; the acting manager stated staff who cover the sleep-in duty are the shift leaders. However, due to recent findings, it would be prudent for the registered person to undertake a review of the staffing for the home, and include a review of the roles and responsibilities of shift leaders, and the competence criteria for this. A requirement in regard to this has been made. The home follows the Mencap Recruitment Policy and Procedure when recruiting staff. Sampling of staff recruitment files found no short falls. Files sampled evidenced staff had undertaken an Induction programme. The acting manager stated they have a Mencap training plan for the whole area that all staff must attend. The training planned includes Working with Challenging Behaviours, Autism and Aspergers, Presentation skills, Team Building, Epilepsy, Stress management, Dementia and Mental Health awareness. Staff receive training in regard to equal opportunities, learning disabilities and race equality during their induction. The inspector viewed the training and development programme for 2006/2007. Comments have been made in regard to mandatory training under Standard 42 of this inspection report. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s management and administration does not fully protect residents. EVIDENCE: Discussions took place with the acting manager as to why an application for registration had not been submitted to the Commission For Social Care Inspection Surrey Local Office. The acting manager stated this was due to the uncertainty of the direction of the home, as Mencap were in a consulting process in regard to the home changing to that of a Supported Living. However, the acting manager has been in post since January 2006, and therefore must submit an application to be considered for registration to the Commission For Social Care Inspection. The registered person must ensure that when a manager is appointed to the home, an application to register with the Commission For Social Care Inspection is made promptly. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 25 The acting manager stated he had been working with adults who have a learning difficulty for fourteen years, six of which have been as a manager. The acting manager stated he has completed the NVQ in management, and is to apply for the Registered Managers’ Award. However, as the acting manager’s recruitment file is kept at Mencap head office, it was not possible to evidence this. During discussion the acting manager stated that quality assurance is monitored through monthly meetings with residents and staff. Minutes of these meetings were evidenced. The home has not undertaken surveys for residents, their families, friends or other associated professionals. A requirement in regard to this has been made. Monthly Regulation 26 visits continue to be undertaken at the home. Training files sampled evidenced, with the exception of the Protection of Vulnerable Adults, the staff team had received regular mandatory training, however, it was noted that some of this training is now due to be updated. Information provided in the pre-inspection questionnaire submitted to the Commission For Social Care Inspection Surrey Local Office, indicated that the following health and safety checks of the home had been undertaken; fire drills, testing and maintenance of fire detection and prevention equipment, monthly checks on the thermostatic controlled hot water, gas boiler, electrical certificate, COSHH register, fridge/freezer and cooking temperatures. The acting manager stated that the portable electric appliance test was undertaken in July 2005, and that Mencaps’ policy is to have this undertaken every two years. The home has Policies and Procedures written by Mencap. Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 5 (2) Requirement Timescale for action 30/11/06 2. YA6 3. YA19 4. YA20 5. YA22 6. YA23 The registered person must ensure a Service Users Guide is produced in a suitable format for residents to easily understand, and each resident must be provided with a copy. 15 (2) (b) The registered person must ensure all care plans are reviewed on a six-month basis. 18 (1) (a) (c) The registered person must (i), 13 (2), 12 ensure all staff working in the (1) (a) care home receives training on all aspects of the medical condition of Diabetes. 13 (2) The registered person must ensure prescribed medication is appropriately stored in a locked medical cabinet that is securely fixed to a solid wall. 22 (8) The registered person must ensure records of complaints from residents include the date, name of the person complaining, nature of complaint, action taken, and the date feedback was provided to the complainant. 13 (6) The registered person must ensure the home has a local DS0000013471.V308041.R01.S.doc 26/10/06 06/10/06 05/10/06 26/10/06 30/11/06 Larchwood Close (27) Version 5.2 Page 28 7. YA23 8. YA23 9. YA30 10. YA30 11. YA33 Protection of Vulnerable Adults policy and procedure that is written within the Surrey Multi-Agency Protection of Vulnerable Adults Procedures. 13 (6) The registered person must ensure all staff receive up to date training in regard to the Protection of Vulnerable Adults. 13 (6) The registered person must ensure the acting manager applies to attend the Surrey Multi – Agency training on the Protection of Vulnerable Adults, and forward these dates to the Commission For Social Care Inspection Surrey Local Office. 13 (3) The registered person must produce a policy and procedure in regard to Infection Control. 12(1)(a)13(3) The registered person must ensure the walls and floor in the utility room is appropriately finished to ensure it is readily cleanable to prevent the spread of infection. This requirement has been carried over from the previous inspection and must now be complied with. 18 (1) (a) (b) The registered person must ensure that suitably qualified, competent and experienced persons are working at the care home at all times, in such numbers as appropriate for the health and welfare of residents, and that the employment of any persons on a temporary basis at the care home will not prevent residents from receiving such DS0000013471.V308041.R01.S.doc 30/11/06 30/10/06 30/11/06 31/10/06 05/10/06 Larchwood Close (27) Version 5.2 Page 29 12. YA33 13. YA37 14. YA39 15. YA42 continuity of care as is reasonable to meet their needs. 18 (1) (a) The registered person must undertake a review of the staffing for the home, and include a review of the roles and responsibilities of shift leaders, and the competence criteria for this. 8 (1) (a) The registered person must Section 11 of submit an application from the The Care acting manager to be Standards Act considered for registration as 2000 manager to the Commission. 24 The registered person must develop a system to ascertain the views of residents, their families, representatives and other associated professionals in regard to the quality of care residents receive at the home. 18 (1) (c) The registered person must ensure mandatory training for all staff is kept up to date. 05/11/06 05/11/06 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Larchwood Close (27) DS0000013471.V308041.R01.S.doc Version 5.2 Page 31 - 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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