Inspection on 27/04/06 for Autumn House

This inspection was carried out on 27th April 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 but made no statutory requirements on the home.

Other inspections for this house

Autumn House 23/09/08

Autumn House 11/10/07

Autumn House 30/11/06

Autumn House 19/10/05

Autumn House 29/04/05

Autumn House 18/11/04

Autumn House 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Autumn House 25 - 27 Avenue Road Sandown Isle Of Wight PO36 8BN Lead Inspector Chris Johnson Unannounced Inspection 27th April 2006 10:30 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 Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Autumn House Address 25 - 27 Avenue Road Sandown Isle Of Wight PO36 8BN 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) 01983 402125 Mrs Janet Holmes Mrs Debra Ann Young Care Home 34 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (34), Physical disability over 65 years of age (3) Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home accommodates one person under the age of 65 years. MD(E) applies to specifically named residents and will cease upon those residents no longer being accommodated at the home 19th October 2005 Date of last inspection Brief Description of the Service: Autumn House is a large period property situated in a busy part of Sandown. The property has been extended in recent years and provides accommodation on the ground and first floors for up to 34 older people and is registered to provide care for up to 20 older people with dementia. The first floor can be accessed via a passenger lift, though there are parts of the first floor that are only accessible for those residents who are fully mobile. There is limited parking in the street and staff park in the courtyard area of the building. There is a very small area of garden to the rear of the property. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and compliance with regulations and previous requirements. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out over two days 27/4/06 and 3/5/06. During this visit a tour of the premises was completed that included looking at service user’s bedrooms and all communal areas of the home. Staff and care records were inspected; staff were spoken with and observed in their interactions with residents. Residents and relatives were spoken with individually. All regulatory activity since the last inspection was reviewed and taken into account. This included complaints made to the home, allegations of which there had been several and notifications sent to the Commission for Social Care Inspection. The manager and proprietor assisted the inspectors throughout the visit and verbal and written feedback was given at the end of the inspection. Two immediate requirements were made following the first day. These had been dealt with satisfactorily by the second day. These are discussed in the main body of this report. What the service does well: The opportunity for residents to receive visitors is good and residents are free to make their own decisions about how they spend their time. Visitors to the home said that they were made to feel welcome that staff were kind and polite and one person remarked, “ They always know who you are”. Support with healthcare is generally good although there were some exceptions to this. Staff treat residents with respect and sensitivity and satisfactory systems are in place for residents to address any concerns or complaints that they may have. The meals in the home are good, offering both choice and variety. Good standards of hygiene and cleanliness are maintained throughout the home and this was remarked upon by everyone that the inspectors had contact with. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 6 The manager is accessible, approachable and sensitive to the needs of residents. What has improved since the last inspection? What they could do better: A number of requirements have been made as a result of this inspection. Many of these relate to record keeping and can be addressed quite easily however they are vital in ensuring that the intended outcomes for residents are met. An improvement is needed in the standard of written documentation held in the home. At present improvements are needed in the assessment process to reduce the danger of someone moving into the home whose needs cannot be met. Care plans do not provide enough detail and are not reviewed regularly. This means that these plans could not be used in an emergency by people unfamiliar with the residents and there is a likelihood that peoples’ needs will be overlooked. An improvement is needed in the written information available to staff regarding residents care needs and any associated risks. The management of medication needs to be improved and although access to health care is generally good the recording systems used and the methods to communicate information is lacking, meaning that some healthcare needs can be overlooked. Poor practice at times, means that residents confidentiality is not fully respected. The lack of detail in care plans, risk assessments, poor recruitment practices and the lack of staff training in some areas do not fully protect residents. Placing them at possible risk of harm or abuse. The home does need to be more proactive in identifying problem areas to ensure residents safety, privacy and dignity. The home needs to develop its quality assurance system. As currently the home cannot fully demonstrate that it is run in the best interests of residents. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 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. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 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 Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 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): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Improvements are needed in the assessment process to reduce the danger of someone moving into the home whose needs cannot be met. EVIDENCE: Autumn House does not provide intermediate care. This standard is therefore not applicable and was not assessed. Pre admission assessment and care notes were looked at for four residents. All residents had been assessed prior to admission to determine whether the home could meet their needs. Care management assessments had also been obtained however in most cases these had not been received until either the day of admission or soon after this date. This information should be obtained prior to admission and form the basis of the overall assessment. Further to this it was found that some assessments received from care managers highlighted needs or behaviours that had not been addressed within individuals care plans. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 10 Residents and relatives told the inspectors that they considered that care needs were being met at the home. All relatives spoken with confirmed that they had the opportunity to visit the home and that this had helped them in choosing the home. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. An improvement is needed in the written information available to staff regarding residents care needs and any associated risks. Support with healthcare is generally good although, the recording systems used and the methods to communicate information is lacking. Meaning that some healthcare needs can be overlooked. Staff treat residents with respect and sensitivity. However poor practice at times, means that their confidentiality is not fully respected. Improvements need to be made to the medication procedures to ensure residents wellbeing. EVIDENCE: Several care plans were examined. A care plan was in place for each resident case tracked. These do however require further development as currently they do not provide sufficient detail and do not fully cover all needs as identified at assessment. Care plans and risk assessments need to be reviewed more frequently. It was found that in some cases that although a change in the person’s level of need had been identified this information had not been recorded on the care plan. Likewise this was also the same with risk assessments. One resident had displayed aggressive behaviour towards Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 12 another resident and this had resulted in an adult protection referral. However there was no evidence that the person’s risk assessment had been reviewed following this incident. Care plans lack detail regarding the signs, symptoms and triggers regarding residents with mental health problems. The proposed review date on many of the plans looked at was set at ‘6 months’. This is too prescriptive and does not take account of changes in need or circumstances. Relatives and social care professionals are often not involved in formulating care plans. Records were available to demonstrate that residents’ healthcare needs are monitored and they are given sufficient support to access healthcare as necessary. Residents said that they had access to a range of services such as GP’s, Dentists, Chiropodists and district nurses. Residents said that staff contacted healthcare support as and when they needed it and that it was dealt with for them. Relatives commented that the home was good at keeping them informed of any changes in health. Residents’ health is monitored and their body weight, condition of skin etc are checked and recorded frequently. However this information is not always followed up. It was noted that one resident had lost 5kg over a period of a month. This had been recorded in their notes but there was no evidence that medical advice had been sought or that staff had been made aware. Medication is generally well and appropriately managed. Records are well maintained and policies and procedures are correctly followed. However the home needs to put in place clear guidance for staff regarding the use and administration of ‘as required’ (PRN) medicines. Several residents had been prescribed PRN medicines and there was not any guidance to inform staff regarding the use of these and there was not any consistency between different members of staff as to how they recorded or administered this. The staff member administering the medication said that advice had been sought from the GP however this had not been recorded. The home stores a lot of medicines and the medication trolley is not large enough to hold it all. Consequently when medication is being administered the excess medicines are stored in an insecure box on top of the trolley. During the morning and lunchtime medication rounds this does not present a problem, as there are two staff to supervise the medication. However in the evening there is only one staff member leaving the medicines held in the box unsafe. A requirement was made at the last inspection that unused medication is returned promptly. It was noted that the home was still storing a lot of unused medicines. Not only is this unnecessary, it also adds to the problem of storage. Some medication requiring refrigeration was found to be stored in the domestic fridge in an insecure container. This is also a potential hazard that could easily be remedied by obtaining a separate lockable fridge for medicines requiring cold storage. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 13 All residents spoken with felt that their privacy was respected. The inspectors were of this opinion through general observation. There were however some examples of poor practice in respect of maintaining residents confidentiality. It was noted that care plans were left unattended in the dining room and these contain residents’ personal information. Medical notes for each resident are all recorded in the same book. This would seem unnecessary as this information is then duplicated and entered onto each person’s individual file. Staff speak respectfully to residents and those spoken with and observed were seen to respect residents privacy and dignity. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The opportunity for residents to receive visitors is good and residents are free to make their own decisions about how they spend their time. EVIDENCE: Residents told the inspectors that they were free to spend their time as they chose. From examination of records, residents’ preferred daily routines had been recorded. This included their preferences regarding time of getting up and general likes and dislikes. Residents’ meetings are held quite frequently and from examination of the minutes the inspectors saw that residents are consulted about such issues as food and activities. All relatives spoken with remarked upon the ‘welcome’ that they received from the staff and management when they visited the home. One person said, “They always know who you are”. Residents said that they were free to receive visitors as often as they wished and visitors spoken with confirmed that there were no restrictions on the time or frequency that they could visit. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 15 Residents reported that they were happy with the quality and choice of the food on offer and from examination of the food records and menus it was evident that residents have a healthy and varied menu with plenty of choice. Visitors confirmed this and one commented, “The food is lovely”. They said that that they were able to confirm this as they had been invited to stay for a meal and eat with their relative on several occasions. It was noticed that menus for the forthcoming two weeks were on display. It is advised that this is reviewed, as it is not easily understandable or appropriate to the needs of many of the residents. Standards of food hygiene were observed to be maintained and records were available to confirm this. Some of the residents are very independent go out unaccompanied. All are free to pursue their own interests and hobbies. Residents who are more able are encouraged to maintain their independence. One person commented, “ I do my own laundry. It keeps me going”. For the residents who need more support, staff try to encourage participation in activities suited to their abilities and preferences such as games or listening to music or creative activities. Residents are consulted during meetings regarding the type of organised activities that they prefer. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Satisfactory systems are in place for residents to address any concerns or complaints that they may have. The lack of detail in care plans, risk assessments, poor recruitment practices and lack of staff training do not fully protect service users, placing them at possible risk of harm or abuse. EVIDENCE: The home has a complaints procedure and this is included in the Service Users Guide issued to residents and or their representative on admission to the home. Most people spoken with were aware of their right to complain. All said that they felt confident that they could speak with the manager if they felt that something was wrong. At the time of this inspection there were several ongoing adult protection investigations. Since the previous inspection in October 2005, there have been four such referrals. There have also been some complaints. There has been one complaint regarding the neglect of a resident’s personal care needs. The owner of the home investigated this. However the response to this was judged as being unsatisfactory. There have been two further allegations of neglect regarding residents’ personal care needs. Conclusions to these investigations are yet to be reached. What has been commented on by Social Services is that the home has not always cooperated fully in these investigations. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 17 At the last two inspections of the home concerns have been raised and requirements have been made regarding poor recruitment practices adopted by the home, that fail to adequately protect residents. Similar concerns were raised at this inspection and an immediate requirement notice was issued. These concerns are discussed in standard 29 of this report. In discussion with staff it was found that training in adult protection and prevention of abuse is poor. This must be improved to ensure that staff are more familiar with the issues, that they recognise the signs and are aware of reporting procedures. Some staff were also were observed to use poor moving and handling techniques when assisting residents to mobilise. This must also be addressed to ensure the safety of residents. Residents spoken with said that they felt safe in the home and well cared for. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 18 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): 19,20,24 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Good standards of hygiene and cleanliness are maintained. The home does however need to be more proactive in identifying problem areas to ensure residents safety, privacy and dignity. EVIDENCE: The general environment of the home was satisfactory. Good standards of hygiene are maintained and this was commented on by all spoken with. During the first day of the visit following a tour of the building and a look at residents bedrooms a number of issues were highlighted that needed attention. One immediate requirement was issued following the discovery of a fuse/electrical cupboard located in a service user’s bedroom that was unlocked. This had been dealt with by the second visit. Other issues brought to the manager’s attention included the storage of a large quantity of toiletries in one bathroom on an open shelving system. Among Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 19 these items were razors and aerosol sprays both of which could present a significant hazard to residents with needs associated with dementia. These were removed and by the second visit the shelving unit had been enclosed by secure lockable doors. The proprietor was also asked to seek the advice of the Fire Authority regarding the use of storage in an under stairs cupboard. This had been cleared of all storage and made secure by the second visit. A number of issues relating to residents dignity and or privacy were raised in respect of the physical environment. These included; incontinence pad lists displayed on the doors to residents’ ensuite bathrooms, health information posters displaying pictures of stools providing details of irregularities and common causes. Rooms also contained large numbers of incontinence pads. These could be kept more discreetly and provision should be made to store excess quantities elsewhere within the home. It was also noted that one ground floor bedroom window offered no privacy to the occupant from the main road. Whilst efforts had been made to address these issues by the second visit it was clear that checks need to carried out more frequently on the safety and general condition of residents rooms. All bedrooms seen reflected the residents’ individuality and they had been able to personalise their rooms with their own belongings. The home has a range of equipment available to assist residents with mobility including grab rails, hoists and bath hoists and call bells. Records and certificates were available to demonstrate that the equipment is regularly checked and maintained. The home is currently having a large extension built and it is the intention to submit an application to increase the number of bed spaces. There were concerns regarding residents’ access to the garden during building works. The area being developed had been safely fenced off. However additional adaptations are required to enable residents to safely gain access to the garden. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Whilst the staff are kind, considerate and caring. The Recruitment practices do not offer sufficient safeguards to residents. EVIDENCE: The home maintains a reasonably consistent staff team. All people spoken with including residents, relatives and a care manager were in agreement that care staff were kind, considerate, caring and respectful. From discussion with staff and through indirect observations of their practice the inspectors were in agreement with this. On the first day of the visit, an immediate requirement was made regarding four members of staff who were working at the home without any evidence that either a Criminal Records Bureau check had been completed or a check against the Protection of Vulnerable Adults list had been made. Checks had been completed in their country of origin however to fully safeguard residents checks must also be completed in the UK.The inspectors were informed by the proprietor of the home and the manager that these staff did not undertake personal care duties. However this was found to be incorrect as they were observed to take and assist residents to go to the toilet. Further to this, these staff were observed to use poor moving and handling techniques when assisting residents to mobilise. Initially the proprietor could not produce any evidence that these four members of staff had work permits to work in the Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 21 UK. These were made available on the second day of the visit. Immediately following the first day of the visit the proprietor amended the rota to ensure that the staff members were supernumerary until such time as these checks had been completed. The proprietor did provide a letter from the recruitment agency detailing the levels of checks that are made and advising the proprietor that these checks were sufficient. Appropriate Criminal Records Bureau and Protection of Vulnerable Adults checks had however been carried out on staff recruited from the UK since the last inspection. It would appear that the proprietor had been ill advised regarding the employment checks necessary on staff recruited from abroad. However the proprietor and manager must make themselves thoroughly conversant with their obligations and it is their responsibility to ensure compliance. Protection of Vulnerable Adults checks had been completed on staff recruited within the UK, prior to them starting work at the home. Further concerns were raised regarding pre employment checks. It was noted that one employee had not declared several convictions on their application form, that later showed on their Criminal Records Bureau check. There was no evidence that this had been followed up. The standard and information requested from referees must also be improved. Currently the information sought from referees is insufficient and does not provide sufficient detail regarding the status of the referee, or provide the referee with details of the post and associated responsibilities such as the job description so that they can comment on the person’s ability to perform the tasks. Whilst there was evidence that staff complete an induction period improvements are needed in the level of information recorded. Many of those examined did not have dates of when they had been completed. It could not therefore be verified whether these were completed within an acceptable timescale. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 22 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): 31,32,33,35,37 and 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The manager is accessible and sensitive to the needs of service users. The standard of record keeping needs to be improved to ensure that service users’ best interests are safeguarded. At present the home has no quality assurance system in place and therefore cannot fully demonstrate that the home is run in the best interests of residents. EVIDENCE: The manager has worked at the home for several years and has a good relationship with residents, relatives and care professionals. The manager is very ‘hands on’, hard working and knows all the residents individually. Everyone spoken with said that she was approachable and easy to get on with. People commented upon her willingness to deal with issues as they arose, that she was responsive and maintained good contact with relatives and other professionals. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 23 Currently the manager is undertaking an NVQ level 4-registered manager award and is aware of the need to complete this within previously agreed timescales. This requirement has been repeated in this report due to the nature and number of requirements made as a result of this inspection. It is evident that the manager will clearly benefit from the training and should provide the manager with a greater understanding of her role with respect to legislation and regulation. This inspection has highlighted a number of areas that require improvement many of which are related to the standard of record keeping. Record keeping does need to be improved and this is within the manager’s remit. Supervision notes are not kept and although the manager had kept a record of dates when staff had been supervised she was unable to confirm the content of staff supervision or staff appraisals. Staff training records were incomplete and it was not possible to fully assess whether all staff had been appropriately trained. Similarly improvements are needed in the standard of records kept of residents’ finances looked after by the home. Several residents’ monies were checked and although they were found to be stored safely and the balances were correct the recording and organisation of the records was haphazard. At present there is no system in place to ascertain the views of relatives, representatives or stakeholders and this means that the home is unable to assess whether it is meeting its aims and objectives and to put an improvement plan in place. Generally safety within the home is promoted, inspection of the fire logbook showed that regular and thorough testing of the homes fire detection equipment had taken place. Certificates were available to demonstrate that equipment and aids used in the home are regularly serviced and tested. Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 24 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 2 X 2 2 Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 25 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 OP3 Regulation 14 (1) Requirement That care management assessments are obtained prior to admission for any resident who is fully or partially funded. All care plans must be reviewed. They must be more detailed and provide specific support instructions and fully address all assessed and identified needs including the identification of any risks and how these are to be managed. Care plans must be kept under regular review to reflect changes in support needs and associated risk. Appropriate action must be taken to ensure that concerns regarding weight loss are monitored and that medical advice is sought. Written guidance must be produced in respect of any resident prescribed PRN medication. The registered manager must ensure that any unused medication is returned promptly. (Previous timescale of DS0000012463.V288731.R03.S.doc Timescale for action 31/07/06 2 OP7 15 (2) (b) (c) 30/09/06 3 OP7 15 31/07/06 4 OP8 13 (1) (b) 31/07/06 5 OP9 13 (2) 31/07/06 6 OP9 17 & Schedule 3 31/07/06 Autumn House Version 5.1 Page 26 8 7 OP9 OP18OP29 13 (2) 19 and Schedule 2 8 OP18OP29 19 Schedule 2 9 10 11 12 13 OP18 OP18OP30 OP19 OP19 OP31 13(6) 18 (1) 13 (4) (a) (c) 13 (4) (a) (c) 9 14 OP33 24 (1)(2) (3) 15 OP37 17 (1) (2) (3) 19/10/05 not met). The registered manager must ensure that medicines are stored safely at all times. Staff must not be employed in the home unless all checks required by legislation have been carried out and are satisfactory. This requirement has not been met from the last two inspections of April 2005 and October 2005. The four staff identified at the inspection must not undertake personal care and must be supernumerary and be supervised at all times, until such time as all satisfactory checks have been completed. All staff must receive training in adult protection and prevention of abuse. All staff must be trained in moving and handling before assisting residents to mobilise. The fuse cupboard in bedroom 17 is to be made secure. The garden must be made safe and accessible. The manager must meet the minimum qualification requirement for registered managers. The registered manager must establish a quality assurance system at appropriate intervals for monitoring the services and care delivered in the home. This must be done in consultation with the service users and their relatives/ representatives to gain views and opinions. Results of quality assurance monitoring must be made available to The Commission for Social Care Inspection. The registered manager must ensure that all records are kept DS0000012463.V288731.R03.S.doc 31/07/06 28/04/06 28/04/06 31/08/06 31/07/06 28/04/06 31/07/06 30/09/07 30/09/06 31/07/06 Page 27 Autumn House Version 5.1 Schedules 3 and 4 securely, confidentially and up to date. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations It is recommended that the service satisfaction questionnaire that the home has introduced be developed as part of the home’s quality assurance and quality monitoring system. That a copy of the guidelines produced by the Royal Pharmaceutical Society of Great Britain is obtained. It is recommended that a larger medicine trolley be purchased. It is recommended that the menus be produced in a more suitable format relevant to the needs of service users. More frequent checks should be carried out of residents’ bedrooms to ensure their safety, privacy and dignity. 2 3 4 5 OP9 OP9 OP15 OP19 Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Autumn House DS0000012463.V288731.R03.S.doc Version 5.1 Page 29 - 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. 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