Inspection on 12/06/06 for Ashcroft House

This inspection was carried out on 12th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashcroft House 01/02/10

Ashcroft House 17/11/09

Ashcroft House 23/06/09

Ashcroft House 25/06/08

Ashcroft House 27/06/07

Ashcroft House 23/01/06

Ashcroft House 11/10/05

Ashcroft House 02/08/04

Ashcroft House 14/04/04

Ashcroft House 11/02/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft House Fairview Close Wilderness Hill Cliftonville CT9 2QE Lead Inspector Tina Thomas Key Unannounced Inspection 12th June 2006 10:00 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 Ashcroft House DS0000040622.V299219.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. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address Fairview Close Wilderness Hill Cliftonville CT9 2QE 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) 01843 296626 01843 571551 Charing Dane Limited Care Home 88 Category(ies) of Dementia - over 65 years of age (49), Old age, registration, with number not falling within any other category (39) of places Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To admit one (1) Service User, under the category of LD, whose date of birth is 10/11/1932. To admit one (1) Service User, whose date of birth is 23/02/1942. To admit one (1) Service User, whose date of birth is 16/06/1941. Date of last inspection 7th March 2003 Brief Description of the Service: Ashcroft House is an exceptionally large detached property, that was previously a hospital, with three floors, which have additional wings, currently the top floor is closed whilst the company considers refurbishment requirements. The Home offers a mixture of care provisions; residential, nursing and dementia. The home is situated within walking distance of local amenities. There is a shaft lift to access the upper levels. Fees at this home range from £303.25£630 Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit conducted over a period of two days, by two inspectors. It included an unannounced two hour visit at 9pm-11pm during the first day of inspection. The site visit was conducted with the assistance of the acting manager Jackie Butler and Head of Care. Additional time was spent in planning the inspection and report writing. Time was also spent observing interaction between staff and service users. A partial tour of the premises was conducted, documents and records were examined, service users files were case tracked and one floor had medications checked. It was acknowledged that staff work hard, but have little support due to low staff numbers, lack of training and supervision. There were areas for immediate concern. Some staff do not have manual handling training Some staff are not suitably CRB checked Some staff are employed without appropriate recruitment checks Privacy and dignity of some service users is not always maintained The home may not be financially viable The home does not have a comfortable environmental temperature The home does not have appropriate infection control systems The manager is not allowed direct contact with the Registered Provider Hot water temperatures in some parts of the home are in excess of 50 degrees C Some service users were not receiving adequate fluids The home was not sufficiently staffed so as to meet the needs of the service users The gas servicing and certificate must be renewed. Requirements 1,2,4,6,7,8,9,11,12,13,14,15,17,18, from the inspection of February 2006 were not fully actioned. Further requirements regarding other areas of practice have been made. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The planning of peoples care must improve. Staff working practices must improve, staff recruitment must improve, and staffing numbers must be improved. The home must work in a more homely manner and be less institutional. It must offer people privacy and dignity and respect. The environment must be improved. The manager must be better supported in her role. Requirements made by the Commission must be actioned in a timely manner, so as to ensure the safety of service users, or a reasonable explanation made for the non-compliance. Ashcroft House DS0000040622.V299219.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. Ashcroft House DS0000040622.V299219.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 Ashcroft House DS0000040622.V299219.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is poor. The judgement has been made using available evidence including a service visit. People do not have the information they need to make an informed choice. Some people have been admitted to the home without suitable consideration as to whether their needs can be met. The home has not actioned previous requirements EVIDENCE: The Service user Guide and statement of purpose have not been reviewed and updated This was a previous requirement:31.12.03,11.04.04,28.02.05, 13.01.06 the final timescale for action was 31/01/06. This requirement has been reissued. (Requirement 1 Part A.) One private service users assessment was viewed and had been conducted well. However their needs were not ultimately met by the home.(Requirement 2 Part A) Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is poor. The judgement has been made using available evidence including a service visit. Care plans do not set out in clear detail the instructions that staff need to meet service users needs. Service users health care needs are not met. Medication practices and medication training is insufficient. Service users privacy and dignity is not upheld. The home has not actioned previous requirements. EVIDENCE: Two service users files were viewed; requirements made at the last inspection in regard to one specific service user had not been actioned. Requirements with regard to the content of care plans were made previously on 31.12.04 & 31.03.06. A general requirement regarding care planning has been reissued. (Requirement 4 Part A) Regarding the care plan that was viewed at the last inspection the following was found: The mental capacity test had not been signed or dated. Instructions for staff were poor: for example: ‘ for staff to prompt and assist………’ There were no instructions for staff indicating how to best do this. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 11 A dependency assessment score was 18 but there was no indication as to what 18 meant. The second service users care plan States ‘HIGH DEPENDENCY LEVEL’. It referred to a fractured femur but did not indicate left or right, or when this had occurred. The falls risk assessment was not relevant and was vague. This service user had a history of anorexia, but this was not mentioned in the nutritional assessment, resulting in 4 points being missed off, bringing the score to 21. An action plan was not completed based on the result. No weight was recorded. (This service user was at high risk of malnutrition) This service user had a grade 4 pressure sore, the Skin assessment was only partially completed and the wound assessment was blank. The dressing record was blank. The skin integrity score was incorrect. It should be 44 not 39,but the fracture had not been taken into consideration. The care managers care plan clearly indicates 2 carers were needed to deliver care. This is not mentioned in the homes care plan. The incontinence assessment was in place but it did not indicate the pads used and or their allocation. GP records were blank. Daily record says for TLC (Tender Loving Care), pain relief, and encouragement with fluids. The daily records recorded no care for this service user for a period of four days. The inspectors visited this service users room, the food, fluid and position change chart were seen, the majority had not been completed and did not record what the service user had been given. This service user was in the final stages of their life. This demonstrates the homes inability to effectively manage death and dying. Evidence of care given to this service user was poor. Care planning was poor. Daily records were poor, when they were in fact completed. Requirement issued regarding this matter (Requirement 32 Part A) The privacy and dignity of service users were compromised. The inspectors witnessed several examples: one service user had his head pushed back with the carers hand on his forehead, whilst being assisted to eat, another service users bed had been striped and the mattress had been left with areas of faeces on it. The service user had climbed back on to the mattress to sleep. Another service user had her clothes for the next day in a pile on the floor. She had two pairs of knickers spread over her bedside table. Incontinence aids were visible in service users own rooms. A male laundry worker was in a service users bedroom whilst personal care was being delivered. An immediate requirement was issued regarding protecting service users privacy and dignity Some Service users were thirsty; one asked the inspectors to get her a drink. Drinks were left out of the reach of service users, the inspectors viewed the Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 12 minutes of a staff meeting where staff expressed that they did not have time to give service users drinks. An immediate requirement was made regarding service users receiving adequate fluids. The staff member also expressed that sometimes service users weren’t got up till lunchtime, or sometimes after lunch because of lack of staff numbers. Medication, on the top floor was assessed. The medication fridge temp was too high and needed defrosting.. It contained eye drops, that were in a box and they were leaking, they were not dated on opening. The Controlled Drugs (CD) cabinet contained hearing aids, syringes, and labels. The CD register contained several recording errors. A requirement was made regarding appropriate recording of medication administered and for it to be met on 09/12/05 and 31/03/06. The requirement remains. (Requirement 7 Part A) In one instance the returns book shows that medication was returned to the chemist before 7 days after the death of a service user. It is to be kept by the home for 7 days A general requirement that appropriate medication practices are adopted has been issued. (Requirement 5 part A) There was no evidence to show that a requirement made at the last inspection regarding the safe use of syringe drivers had been incorporated into the medication policy, the requirement therefore, remains. (Requirement 6 Part A) Staff have ½ day medication training with Baxter’s Chemist. This is insufficient. A requirement has been issued(Requirement 33 Part A) At the last inspection a requirement was made that the manager is required to conduct a full medication audit and submit a detailed report with an action plan to the Commission (CSCI) by 28/02/06. This has not been actioned and the requirement remains. (Requirement 8 Part A) Ashcroft House DS0000040622.V299219.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. The judgement has been made using available evidence including a service visit. Day to day activities are rigid and practices are institutional. Service users have little autonomy and choice Leisure activities have been improved. Access to food, for service users is limited due to the homes practices EVIDENCE: Routines in the home are institutional and offer little choice. Documentation viewed instructed that night staff were required to lay out an outfit for each service user to be worn in the morning including, all correct underwear. Service users are therefore not enabled to make choices in regard to their dayto-day attire. During the evening when the inspectors visited it was observed that all service users except 2 were already in bed by 9.00pm. Night staff expressed that they had to get certain people up in the morning because they had to feed 4 people before the day staff came on duty. They said they felt guilty getting people up when they didn’t want to get out of bed at 6.00 am particularly in the winter. They said this is when some service users get aggressive. A requirement has been issued regarding this matter. (Requirement 3 Part A) Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 14 Planned activities show some improvement. The activities person was running a gardening club. She demonstrated knowledge of service user likes and dislikes, service users had planted up, flowers, herbs and tomatoes. The activities person had bought in to the home, from her own home, engineering mags for men. Upstairs there was a rota of activities but it was noted that the timings of these aren’t always adhered to because the activities person was sometimes called away to fulfil other tasks. The home has a visitor’s book, which clearly shows that visitors come and go at selection of times. Feed back from a care manager and a visitor shows that service users can see their visitors in the privacy of their own room if they choose and staff are happy to facilitate this. Financial records(Standards 14 and 35) were viewed for two service users: The balance of one was incorrect and the balance total had not been completed on the second. Only single signatures were used to evidence transactions. One member of staff said that errors were because they had changed systems in April and they didn’t have time to complete all the work they were given properly. Procedures are complex and are causing staff distress and concern. Staff expressed that pocket money is paid into Charing Dane bank account and service users have to wait 9 weeks for their money. A requirement has been made regarding this matter. (Requirement 29 Part A) Ashcroft House DS0000040622.V299219.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. The judgement has been made using available evidence including a service visit. The complaints procedure is insufficient. Complaints are not adequately recorded. Service users are not protected from abuse EVIDENCE: The complaints procedure does not state all time scales. Requirement made regarding this issue (Requirement 9 Part A) It was found that not all complaints and concerns are logged. There was evidence that some complaints are dealt with appropriately and are well recorded. Staff have not had and it is not arranged for staff to have adult protection training. Some Staff spoken to do not have knowledge of adult protection issues or where or how to report abuse. A requirement was made at the last inspection that both complaints & adult protection procedures and complaints records must be made accessible to all staff at all times. This now has the additional wording: The complaints procedure must have timescales for action and staff must have a clear understanding of these policies. Requirement made regarding this issue. (Requirement 9 Part A) Two members of staff have been charged by the police regarding theft. These people do not work at the home any longer. These people should have been referred to POVA for them to decide if they are suitable to work with venerable people in the future. The home has failed to do this. Requirement made regarding this issue (Requirement 20 Part A) Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 16 Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 17 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): 19,20,22,24 Quality in this outcome area is poor. The judgement has been made using available evidence including a service visit. The home is not safe, clean or well maintained, this puts service users at risk. EVIDENCE: The top floor or the home is now closed to residents. Overseas staff that are charged rent, use it. It is a concern that they do not have any private access. The training room remains on the top floor. At the last inspection a requirement was made that a new schedule of accommodation must be submitted the CSCI whenever changes are made to the environment by 31/03/06. This has not been actioned and the requirement has been reissued. (Requirement 10 Part A). The rooms on the top floor are still registered with the Commission, the Registered Provider must inform the Commission of its intention regarding this floor, the provision made to protect service users privacy, and compliance with Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 18 the local council regarding the letting of property. Requirement issued regarding this matter (Requirement 19 Part A) Whist some furnishings have been improved there was no evidence that a programme of routine maintenance and renewal of the fabric and decoration of the premises has been produced and implemented, with records kept. Some beds, commodes and armchairs were very aged. A requirement regarding the environment with timescale of 31/03/06 has not been action. The requirement was that an action plan including timescales must be submitted to the CSCI for the replacement of old, worn out furniture. To include wardrobes, beds, drawer units, bedside tables and chairs. Sufficient numbers of adjustable beds must be provided for those needing nursing care. This requirement has been reissued (Requirement 11 Part A) The home is not safe: In several areas of the home the hot water is in excess of 43 degrees C., in some areas it was in excess of 50 degrees. In some areas hot taps run cold or have no running water. An immediate requirement was issued regarding this matter. Some windows and frames are stuck together with tape. Others do not open. Two areas of the home have Water damage on the ceiling and down the wall, mushroom type fungi is growing on one of the walls. One sitting room has no call bell. Call systems with an accessible alarm facility must be provided in every room. Requirement made regarding this issue (Requirement 16 Part A). Staff have made an effort to attractively decorate the corridors of the floor that is used for service users with dementia. It was noted that they had used different textures so as to make the decoration tactile i.e. shells and fluffy material. There was evidence that the maintenance manager was given conflicting instructions regarding prioritising his work, whilst he was also trying to meet mandatory requirements i.e. PAT testing. Grounds are kept tidy, safe, attractive and accessible to service users, and allow access to sunlight, service users were encouraged by staff to use the outside areas. The building does not comply with the requirements of the local fire service in so much as the fire risk assessment has not been suitably updated. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 19 The provider should seek clarification as to whether he needs to put automatic door closures on individual bedroom doors and notify the Commission of his findings. Requirement made regarding this issue. (Requirement 21 Part A) The home has CCTV in many areas. The Manager and Staff stated that, to the best of their knowledge this was not active. The inspectors could not find evidence that the CCTV were recording although they were active and some had lights on them that were blinking. To ensure that these are not in use, and to protect service users privacy and dignity these must be removed. Requirement made regarding this issue (Requirement 22 Part A) The home has a selection of bathrooms and showers. These were found to be generally unclean. One shower had a trolley stored in it, preventing its use by service users. Another had faeces on wall and this was not cleaned off during the two days of inspection. The majority of sinks and toilets in service users own bedrooms that were viewed were dirty. It was identified at the last inspection that the sluice had a foul odour. This continues to be so. The sluice has not been recently serviced. . The home provides grab rails and other aids in corridors, bathrooms, toilets, communal rooms and where necessary in service users’ own accommodation. However, these are sometimes insufficient. Service users share hoist slings. They are not laundered in between use. This unhygienic, undignified and is a possible source of cross infection As mentioned previously some of the furnishings in individual rooms are very aged, uninviting and institutional. One service user required an adjustable bed but did not have one, and no attempt had been made to source one. One service user had no lampshade in their room. The weather was extremely hot during the inspection, possibly above 80 degrees. It was found that the radiators were on at a very low level, but this added to the heat. The inspectors were informed that the heating was off, but the fact that the radiators were generating heat had not been investigated. Immediate requirement made regarding this matter. As previously mentioned, some windows do not open, so there is no natural ventilation, in some rooms and areas in the home. The home is not clean, hygienic or free from offensive odours: In some rooms the beds had been made, without changing fouled sheets, this included one room that was ready for re-letting. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 20 Staff are not adhering to infection control policies and procedures. Examples were a laundry member of staff placed a bag of soiled and dirty linen on top of the clean linen trolley and was pushing it around the ground floor. A domestic placed her bucket on top of a service users bed. The head of care and manager witnessed this. Staff were observed not to be conducting universal precautions by wearing no gloves and aprons. A general requirement regarding infection control has been issued (Requirement 23 Part A). During the night visit it was observed that there were strong odours in the home. In the sluice there were 3 full yellow sacks of foul or infected waste. The night carer said that they had been left by the day staff and he would be putting them out to the bin in the morning. These should have been placed in the appropriate bin immediately. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30 Quality in this outcome area is poor. The judgement has been made using available evidence including a service visit. The home does not adhere to safe recruitment practices. Staff are not suitably inducted or trained. Staff numbers are not sufficient to meet the needs of the service users. The home has not actioned previous requirements, this puts service users at EVIDENCE: Staffing numbers and skill mix of qualified/unqualified staff are not appropriate to the assessed needs of the service users, the size, layout and purpose of the home. An immediate requirement was made regarding this matter. A requirement was made at the last inspection with a timescale of 28/02/06 that The registered provider & manager are required to review staffing levels and provide sufficient numbers of care staff. Evidence to be sent to the CSCI by 28.02.06. This has not been actioned and therefore reissued. (Requirement 11 Part A). There is a recorded staff rota but it does not show which staff are on duty at any time during the day as it is either incomplete or inaccurate at times. Rotas that were sent to the Commission prior to the site visit showed that there was no trained nurse on duty most nights. This information however, was found to be incorrect. The home has one trained member of staff on duty of a night. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 22 Other staff that were on rota to work on the night shift, were not those that that were actually working. Staffing levels were low, there were insufficient staff on duty and call bells were ringing constantly. It was agreed by the manager, the head of care and care staff that there are insufficient numbers of staff for the needs of the service users and for staff to complete their work to a sufficient degree. During inspection it was reported that an ‘external consultant’ to the home, would not allow the manager to increase numbers of staff on duty. The director claims that the home uses the staffing forum, which is a recognised tool to determine staff numbers. The staffing forum is a tool only, and the ratios of care staff to service users must be determined according to the assessed needs of service users. It was evidenced that some staff are working day shifts then continuing on to the night shift without sufficient breaks in between During the night visit by inspectors, the trained member of staff said there were 6 members of staff on duty. There were only 5 staff on duty. She was unaware f the staffing levels on the floor that caters for dementia users. There were 24 service users on the floor that caters for dementia service users. Five of these were double- handers. Some of the service users on the upper floor have behavioural problems including violent episodes. Two staff are not sufficient as when the double- handers are receiving care other service users are left unsupervised. The Registered Provider must explain how staff effectively manage. Requirement made regarding this matter (Requirement 24 Part A). Less then 50 percent of staff are trained to NVQ Level 2 this target should have been achieved by 2005. A requirement was made with a compliance date of 31/12/06 that 50 of care staff must have the NVQ Level 2 in care qualification. This requirement remains. (Requirement 13 Part A). Staff files that the inspector viewed showed that staff did not either have induction or did not complete induction and foundation training. Requirements were previously made with completion dates of 14.04.04,and 31.03.06. This has not been actioned and the requirement has been reissued (Requirement 14 Part A) The home does not protect service users through thorough recruitment checks. Staff files viewed showed that care staff are frequently employed without POVA checks or Criminal records checks. Sometimes references are not in place before staff are employed. Often staff files do not contain photographs this is a requirement of schedule 3 of the care home regulations. Often files do not contain interview records; often gaps in employment history are not investigated. Work permits for overseas staff give the address of other care homes. A requirement was made regarding theses issues at the last inspection Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 23 with a compliance date of 31/03/06 this has not been actioned and the requirement has been reissued. The home does not have a staff training and development programme in place. which meets National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The home does not have any training plan, the manager does not have a training budget. Staff do not receive suitable induction, foundation, mandatory or service specific training. On the night visit neither of the two staff who were working on the floor with dementia service users demonstrated any knowledge of their client group, despite one having had dementia training. Neither were trained to NVQ Level 2, neither had completed mandatory training. A requirement was made that Care staff must complete a more advanced dementia training programme. Previous requirement: (1) 13.01.06 (2) 30.06.06 This has not been actioned. It has been reissued. (Requirement 15 Part A) Manual handling training is delivered by the receptionist, and a senior carer. The receptionist demonstrated little knowledge of manual handling regulations and expressed that she just read what was ‘in the book’ Whilst done with good intention by herself it is an additional role to her receptionist duties. It could not be decided if this was outside of her duties, as she did not have a job description. Some staff were moving service users without having completed manual handling training. An immediate requirement was issued regarding this matter. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 24 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): 31,32,33,34,35,36,37,38 The Manager does not have autonomy to fulfil her duties. Company practice does not allow for an ‘open culture’ Quality assurance is poor. Financial procedures are complicated. Health and safety is compromised. Previous requirements have not been action this puts service users at risk EVIDENCE: The Manager is not registered with the Commission, she is a registered nurse. The Provider has not provided her with a contract, or job description (requirement 25 Part A), she has not had an induction and does not have supervision. She has no autonomy over policy, staffing, or budgets, other than that for cleaning and clinical supplies. Documentation showed that the homes ‘external consultant’ had informed staff that the manager’s role was the same as the head of cares. The manager’s role is specific. As neither has a job description it is hard to distinguish what the Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 25 home perceives for each role. The manager as a trained nurse has specific professional accountability. The head of care does not have the same professional boundaries. There are not clear lines of accountability within the home; there is evidence that the homes ‘advisor’ appears to instruct staff. The manager has been advised by the homes ‘external consultant’ that she is not to have direct contact with the Homes registered Provider. This was confirmed by another member of staff. An immediate requirement was made regarding this matter The inspectors viewed documentation that showed that the manager was expected by the homes ‘external consultant’ to conduct the work of a trained member of staff to make up for the deficit of trained staff. It was considered that the management role of the manager could be performed by the administration staff. The manager is not enabled to communicate clear lines of accountability to staff. (Requirement 26 Part A). The manager was witnessed undertaking tasks that should have been performed by care staff, once again compensating for the deficit of staff. The management style of the home is not ‘open’ Documentation showed that staff have recognised that they can not fulfil their duties due to the lack of staff but this has not been actioned. One member of staff was ‘threatened’ with a disciplinary if they did not sign a job description, which did not adequately describe the role they were employed for. It was contrary to their terms and conditions. Requirement made in regard to the home having a more ‘open’ culture. (Requirement 27 Part A). There are no apparent quality assurance procedures within the home. A requirement was made regarding this matter with compliance dates of 30.04.05 and 31/03/06. The home has not actioned this. The requirement has been reissued. (Requirement 17 Part A) The home does not comply with regulation 26 visits, which should be in place when the registered provider does not have day-to-day control of the home. Requirement made regarding this issue. (Requirement 28 Part A) There is no annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. Requirement made regarding this issue (Requirement 30 Part A). There is no continuous self-monitoring, using an objective, consistently obtained and reviewed and verifiable method (preferably a professionally recognised quality assurance system) and involving service users; and an internal audit takes place at least annually. Policies, procedures and practices are not regularly reviewed in light of changing legislation and of good practice advice from the Department of Health, local/health authorities, and special/professional organisations. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 26 Action is not progressed within agreed timescales to implement requirements identified in CSCI inspection reports. An immediate requirement was issued regarding this matter. The Commission has questioned the financial viability of the home, as there is little evidence of financial input. The environment is poor, there is little input into staff training, staffing levels are low and some of the practices could be considered mean against the service user. The home has insurance cover. However, the Commission has questioned whether the insurance has been breached due to conditions at the home. There is no apparent business and financial plan for the establishment; the Commission is currently reviewing the homes accounts to assess viability. Staff are not suitably supervised. Care staff do not have supervision 6 times per year. The managers work programme does not allow sufficient time for her to supervise staff adequately. Requirement made regarding this matter. (Requirement 31 Part A) Other areas of this report document poor levels of record keeping i.e. care plans and service user care plans Other areas of this report document a lack of regard to health and safety for staff and service users i.e. raised water temps, lack of infection control procedures. The fire risk assessment and environmental risk assessments must be more detailed and kept under regular review. A previous requirement was made regarding this issue with compliance date of 31/04/06. This has not been actioned and this requirement reissued. (Requirement 18 Part A). Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 27 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 1 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 1 2 2 2 x 1 1 1 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 1 1 1 1 1 Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 5 sch 1 Requirement The Statement of Purpose and Service Users Guide must be amended to include all of the required information. previous requirement:31.12.03,11.04.04, 28.02.05,13.01.06 and 31/03/06 Thorough and detailed preadmissions assessments must be conducted and recorded for all prospective service users. previous requirement: 30.11.04 & 13.01.06 The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. Care plans must be more detailed in some areas; for example, skin integrity assessments and specific details about providing care, such as fluid intake, personal care, movement & handling needs. Reviews must be conducted regularly and be a true review of assessed needs. DS0000040622.V299219.R01.S.doc Timescale for action 16/08/06 2. OP3 14,15 16/08/06 3 OP14 12. (2) (3) 16/08/06 4. OP7 12 13 14 15 16 16/08/06 Ashcroft House Version 5.2 Page 29 Daily reports must record all aspects of care provided and be linked to the care plan. previous requirement: 31.12.04 & 31.03.06 5 OP9 12 13 16 17 23 sch 3 12 13 16 17 23 sch 3 Appropriate medication practices 01/08/06 must be actioned and adopted by the home in line with robust policies Medication administered via 16/08/06 syringe driver must be recorded showing; 1) the name and strength of medicine and dosage, 2) what solution the drug was diluted with, 3) total volume & syringe size, 4) batch numbers, 5) rate the syringe driver is set at and duration. 6) time of new or refill of syringe driver is commenced and ceased, 7) amount wasted when changed or discontinued, 8) record of administration site, with condition of site observed. 9) name & signatures of staff administering. 09/12/05 Clear and accurate records of administration must be kept of all medication administered with written evidence of them being prescribed. 09/12/05 16/08/06 6 OP9 7 OP9 12 13 16 17 23 sch 3 8 OP9 12 13 16 17 23 sch 3 The manager is required to 16/08/06 conduct a full medication audit and submit a detailed report with an action plan to the Commission (CSCI). Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 30 9 OP16 12 13 20 22 23 10 OP18 12 13 20 22 23 13,23 11 OP19 12 OP24 12 13 14 16 23 13. OP27 17,18 sch 4 Both complaints & adult protection procedures and complaints records must be made accessible to all staff at all times. The complaints procedure must have timescales for action and staff must have a clear understanding of these policies. A new schedule of accommodation must be submitted the CSCI whenever changes are made to the environment. An action plan including timescales must be submitted to the CSCI for the replacement of old, worn out furniture. To include wardrobes, beds, drawer units, bedside tables and chairs. Sufficient numbers of adjustable beds must be provided for those needing nursing care. The registered provider & manager are required to review staffing levels and provide sufficient numbers of care staff. Evidence is to be sent to the CSCI by 28.02.06 16/08/06 16/08/06 16/08/06 16/08/06 16/08/06 14 15 OP28 OP29 50 of care staff must have the NVQ Level 2 in care qualification. 7,9,19 sch (1)Recruitment procedures must 2 be thorough, exploring gaps in employment history, interview records must be completed and POVA and CRB checks must be completed before employment starts. (2)To contact the Home Office to confirm the need to identify work place on the work permits. Evidence of compliance to be submitted to the CSCI 18 31/12/06 16/08/06 Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 31 16. OP30 12,18 (1)Induction programmes must be completed by all new staff with topics covered in depth. Previous requirement: 14.04.04 (2) All staff must have completed basic dementia training. Care staff must complete a more advanced dementia training programme. Previous requirement: (1) 13.01.06 (2) 30.06.06 The Registered Provider must inform the Commission as to how he plans to address the shortfalls described in Standard 19: Some windows and frames are stuck together with tape. Others do not open. Two areas of the home have Water damage on the ceiling and down the wall, mushroom type fungi is growing on one of the walls. One sitting room has no call bell. Call systems with an accessible alarm facility must be provided in every room. For the Home to develop and implement an annual quality monitoring system. Producing a report, copy must be sent to the Commission. Previous requirement: 30.04.05 The fire risk assessment and environmental risk assessments must be more detailed and kept under regular review. 13.01.06not inspected. 16/08/06 17 OP19 23 16/08/06 18. OP33 10, 12, 15,24 16/08/06 19 OP38 12 13 16 17 23 sch 4 16/08/06 20 OP19 39,13,23 Rooms that are being let to staff, 16/08/06 are still registered with the Commission, the Registered Provider must inform the Commission of its intention regarding these rooms, and the provision made to protect service DS0000040622.V299219.R01.S.doc Version 5.2 Page 32 Ashcroft House users privacy, and compliance with the local council regarding the letting of property. 21 OP18 Care Standards Act Section 82(1)(2)(3) 22 OP19 23 (4)(5) Staff who may be unsuitable to work with vulnerable adults are referred, in accordance with the Care Standards Act, for consideration for inclusion on the Protection of Vulnerable adults register. The building does not comply with the requirements of the local fire service in so much as the fire risk assessment has not been suitably updated. The provider should seek clarification as to whether he needs to put automatic door closures on individual bedroom doors and notify the Commission of his findings. 16/08/06 16/08/06 23 OP19 12 4 a To ensure that CCTV are not in use, and to protect service users privacy and dignity CCTV must be removed. The premises must be kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. The Registered Provider must inform the commission how his staff effectively manage in such short numbers The Manager must have a job description The registered manager must be enabled to communicate a clear sense of direction and leadership, which staff and service users understand and are DS0000040622.V299219.R01.S.doc 16/08/06 24 OP26 12,16,13 16/08/06 25 OP27 18 1 a 16/08/06 26 27 OP31 OP32 12 1 a b 12 5 a b 16/08/06 16/08/06 Ashcroft House Version 5.2 Page 33 28 29 30 OP32 5 26 12 (2)(3) OP33 OP14 31 OP33 24 32 33 OP36 OP11 18 12 schedule 3 34 OP9 12 13 16 17 23 sch 3 able to relate to the aims and purpose of the home. The process of managing and running the home are open and transparent. The Provider must ensure that regulation 26 visits are performed Money held on behalf of service users must be suitably accounted for. The provider must explain to the Commission why the money intended for service users is held in a company account and why it takes service users nine weeks to receive it. There is an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. A copy must be forwarded to the Commission Care staff must have regular formal supervision Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. Policies and procedures must reflect the quality of care expected Staff must have suitable training regarding the administration of medication and a system in place to assess staff competency 16/08/06 16/08/06 16/08/06 16/08/06 16/08/06 16/08/06 16/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 34 No. Refer to Standard Good Practice Recommendations Ashcroft House DS0000040622.V299219.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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