Inspection on 19/01/09 for Autumn Vale

This inspection was carried out on 19th January 2009.

CSCI found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Autumn Vale 07/03/07

Autumn Vale 06/03/06

Autumn Vale 29/06/05

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

CARE HOMES FOR OLDER PEOPLE Autumn Vale The Circle 26 Clarendon Road Southsea Portsmouth Hampshire PO5 2EE Lead Inspector Annie Kentfield Unannounced Inspection 19th January 2009 13:30 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 Vale DS0000062949.V373816.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. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn Vale Address The Circle 26 Clarendon Road Southsea Portsmouth Hampshire PO5 2EE 023 9282 6034 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) autumn.vale@yahoo.co.uk Lutchmy Care Services Mr Bhimsen Seedeehul Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (26) Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in MD category must be at least 30 years of age Date of last inspection 11th August 2008 Brief Description of the Service: Autumn Vale is a detached period house located in an attractive residential area of Southsea, close to shops and amenities. The home provides accommodation and care for up to 26 male and female service users who have mental health problems. The residents are aged between 40 and 80 years. There are 17 bedrooms; 9 are shared bedrooms and all are arranged over three floors. Bedrooms have a wash-hand basin and there are a number of shared bathrooms and shower rooms. Residents have a communal sitting room and dining room and access to a garden with seating areas. The home has a passenger lift that provides internal access between the floors but the main entrance of the building is only accessible for residents who are independently mobile. The home is owned by Lutchmy Care Services and the Registered Manager is Mr. Bhimsen Seedeehul. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. We made an unannounced visit to the home on 19 January 2009. This was with two inspectors (Carole Payne and Annie Kentfield) and the visit lasted for six hours. During the visit we spoke to some of the residents both in the communal areas and in the privacy of their own rooms. We also spoke to a representative of Lutchmy Care Services, the deputy manager and two members of staff. The registered manager, Mr Seedeehul, was not available when we visited. We looked at some of the home’s records including care plans, medication records and staff recruitment and training records. We received the Annual Quality Assurance Assessment (AQAA) from the home. This is a self-assessment document for the service to tell us what they do well, what they could do better, and what further improvements are planned. We also visited the home on 11 August 2008. The reason for this inspection was to undertake a specialist pharmacist inspection following concerns regarding the handling of medication in the home, which had been brought to the attention of The Commission for Social Care Inspection. During this visit we looked at the medication records, procedures, storage, talked to the manager and watched some medicines being given to people. We found that people do not always get the medicines they are prescribed. In August 2008 we made three regulatory requirements and a recommendation with regard to the handling of medication in the home. When we visited the home on 19 January 2009 we found that the home are correctly recording medication that has been administered but there is no clear audit trail of medication received into the home, administered or returned. We made an immediate requirement during our visit that all medication coming into the home must be checked and recorded as correct. What the service does well: One resident told us how much they enjoy their life at the home. They said they could be independent and go out when they want to. They also are able to enjoy hobbies and interests they like. Some of the residents had the opportunity for a holiday in 2008 and two breaks were arranged for a small group of residents in Bournemouth and Isle of Wight, accompanied by some of the staff. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 6 The routines of the home are flexible and informal and residents’ rights to spend time on their own, in their own room, is respected, and privacy maintained. What has improved since the last inspection? What they could do better: The home must ensure that medication is correctly checked and recorded to provide a clear audit trail of medication received into the home, dispensed, or returned to ensure that residents receive their medication as prescribed at all times. The medication policies and procedures for the home should be reviewed in line with good practice guidance for care homes, from the Royal Pharmaceutical Society of Great Britain. The policy and procedures for the safe storage of controlled drugs must be reviewed to meet amended legislation on the storage of controlled drugs in the home. The individual plans of care for people in the home should demonstrate a person centred plan that reflects and reviews individual needs, wishes and goals in all aspects of care and support, including daily living and social activities. The assessment of any risks must provide a clear action plan and guidance for care staff on how risks are to be minimised or action taken to manage events. Action plans should be regularly reviewed and updated. The home must ensure that residents are supported to manage their own money. Good practice guidance is available on the Commission Professional website for care providers www.csci.org.uk Staff recruited to work in the home must be suitable to work with residents and checks on new staff, required by regulation, must be in place before staff start work in the home. The home must develop efficient systems for monitoring the quality of care provided and ensure that all regulatory requirements are met. Policies/procedures/codes of practice should be reviewed and regularly updated. The home should ensure that all required policies are in place and easily accessible for staff in the home, to provide clear guidance on good practice. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Autumn Vale DS0000062949.V373816.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 Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New residents move into the home following an assessment of their care needs, to make sure that the home is able to offer them the care they need. The service has not developed a person centred approach to assessment and care planning. The home does not provide intermediate or rehabilitative care (standard 6). EVIDENCE: New residents have moved into the home since we last visited. The annual quality assurance assessment states that the home has a pre-admission assessment process and these assessments are carried out a representative of the registered provider. The assessment gathers relevant information from the resident and the local authority care manager who is involved with the care of the resident, about the care and support needs of the resident. We looked at Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 10 three assessments and spoke to a resident who had recently moved into the home. The assessment process did not record that residents and their family/friends were actively involved in the assessment. The assessment process does not include gathering a personal history in consultation with the resident. It was difficult to review the home’s assessment process because of the number of hand-written notes that were included in the files and it was not clear if these were part of the assessment and care plan for the residents. The annual quality assurance assessment (AQAA) told us that all prospective residents are encouraged to visit the home, and stay for a day, before making the decision to move into the home. This was confirmed when we spoke to one resident and looked at other records for new residents. One new resident told us that they felt well cared for and were happy with the support they receive. Another resident told us that although they would prefer a single bedroom, they did not mind having to share a room. The home has not developed person centred care planning. Person centred planning is a process designed to enable individuals requiring support to increase their personal self-determination and improve their independence and is accepted as good practice in social care. The annual quality assurance assessment said that the service user guide and statement of purpose for the home has been updated and we have asked the home to send us a copy of these documents. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Aspects of medication handling in the home do not meet regulatory requirements. Care staff do not have access to current guidance on good practice in the safe administration of medicines in care homes. Individual plans of care and risk assessments are not regularly and consistently reviewed and updated in consultation with individual residents. This means that residents may not have all of their health care and support needs met consistently. Individual preferences and choices are not consistently recorded and reviewed. EVIDENCE: When we visited the home on 11 August 2008 we found that people were not always getting the medicines they are prescribed, and complete and accurate records were not kept of medicines given to people. We required the registered person to take action by 30/8/08 to ensure that: complete and accurate records must be kept of all medicines given to people so as to show Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 12 that people get their medicines correctly. Also to ensure that when people look after their own medicines, assessments must be carried out to ensure they receive any support they need to do this safely and to minimise any risks to themselves or other people who use the service. We also made another requirement for action by 30/10/08 that: staff must have access to clear and comprehensive policies and procedures for the receipt, recording, storage, safe handling, administration, self-administration and disposal of medicines, specific to the home’s current practices, so as to ensure that staff follow current best practice. When we visited the home on 19 January 2009 we noted that the medication administration records had been correctly completed but medication received into the home in December 2008 had not been checked and signed as received, and correct. Medicines are supplied to the home as inner trays for the home to put into the outer cassette. The inner trays are labelled with the residents name and address, but not with what medicines they contain. There is a risk of staff in the home putting the wrong persons inner tray into the outer cassette and thus the wrong medicines being given to people. This unnecessary risk was discussed with the registered provider. A print off of what has been prescribed each month is inserted into the back of each dossette box. The service is therefore taking responsibility for ensuring that the correct instructions and medications is inserted into the correct box, to ensure that service users receive medication safely. In November, sheets were seen recording that for each service user all the medicines had been received. In December there was no record of the checking of medication received into the home. The Medication Administration Records had not been completed to confirm that each medication had been received. There was no record of boxed medication received into the home such as paracetamol, and aspirin, so there was, therefore, no audit trail to check that the amount of medication held corresponded with the medicines given, ensuring that service users receive their medication according to prescribed instructions. One handwritten entry on the Medication Administration record had not been checked and signed. The senior carer said that this was because the medicine had not been received yet. Only medicines received should be added to the MAR chart, when they enter the home so that they can be checked at the point of receipt. One liquid medicine, Gaviscon was written up to be given as directed by your doctor. The label on the medicine had the same instruction. There was no record of the indications or frequency at which this medication could be given. Staff demonstrated an awareness of this but it was not documented. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 13 Salbutamol was written up to be given two puffs as required. There was no written indication as to any limit, within the 24-hour period. Staff indicated that they would give the salbutamol as frequently as was required, and although it was stated they would consult the doctor if they were concerned there was no written details of the indications in which this was required. There was one medication record, which was completely handwritten. Abbreviations had been written to indicate the frequency or time of administration of each medicine. There was a separate sheet, which stated what the abbreviations meant. In order to ensure that people receive their medication safely instructions must be clearly stated in accordance with the prescribed instructions. One service user was prescribed GTN spray and there were instructions as to when this should be administered. However this was not signed and dated by the person giving the instruction, who should be suitably qualified to do so. One service user was prescribed Lactulose to be given as and when required but there was no written guidance for care staff on when or why this should be administered or other relevant information. The home has a policy for the safe administration of medication. The service does not have a copy of the Royal Pharmaceutical Society’s guidelines for the safe administration of medicines in care homes. The home maintains a record of medication returned to the pharmacy. It was confirmed that the home does not currently accommodate any residents who administer their own medication. It was confirmed that the home does not currently have any controlled drugs that have been prescribed for residents. The registered person must update the home’s policy and procedures for controlled drugs to meet amended legislation on the safe storage of controlled drugs in the event of controlled drugs being in the home. It was confirmed that only a small number of staff that have undertaken medication training undertake responsibility for ensuring that people receive their medicines safely. Two care plans that we looked at indicated that individuals must have their fluid intake monitored to ensure that they have enough fluids during the day. Fluid intake was not recorded in the daily records of care and staff told us that they make sure that residents have access to drinks. However, although residents had an afternoon drink and it was indicated that hot drinks are available at meal times and on request no cold drinks were out in the lounge or in people’s rooms visited. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 14 Another care plan stated that monthly weight checks should be recorded for an individual, however, the weight checks had not been regularly recorded and a significant increase in weight had not been identified and followed up. Weight checks had been completed in July and August 2008 and then in December and January. The last check recorded a weight gain of two stone in a sixmonth period but this had not been followed up for further investigation. A member of staff did an immediate check and found that staff have been recording the wrong weight for this resident. The registered provider told us that the home operates a key worker system but was not able to produce a list of residents and their key workers. In two care plans the risk assessments were not clear and lacked detail, and did not provide clear guidance for care staff on what they must do to minimise risks or events that may happen. This included action to be taken to minimise the risk of fire. Although it was identified that there was a risk of fire the risk assessment did not clearly identify how people in the home were to be protected against the risk. One person was at risk of constipation. Staff recognised what might be the signs of constipation, and that they would act if they identified these signs, but the risk assessment did not include details of preventative measures that might be taken, such as encouraging a good fluid intake and how monitoring might be sensitively undertaken. Discussion with staff in the home demonstrated that appropriate action is taken to safeguard residents in the home, but this is not recorded and regularly reviewed. The AQAA told us that the home has carried out nutritional screening and assessments for everyone in the home but we did not find evidence of this in the care plans. Care staff support residents to access healthcare support and one resident told us that they had been supported to give up smoking with help from NHS smokestop services. Care plans did not provide evidence of residents being consulted or involved in the review of their care plans and/or risk assessments on a regular basis. We were told that key workers and the representative of the registered provider review plans of care, however, we did not find evidence of key worker reviews and it was unclear about the agreed frequency for reviewing individual plans of care. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a range of activities and outings to residents. Individual social and cultural needs and expectations are not recorded in people’s plan of care and are not monitored or reviewed individually to demonstrate that personal preferences and choices are always being met. EVIDENCE: One resident was spoken with who said how much they enjoy their life at the home. They said that they could be independent and go out when they want to. They are also able to enjoy hobbies and interests. During the visit one resident was playing a game with a member of staff in the lounge, another was doing some colouring. Eight residents were sat watching the television. A list is kept in a diary of activities held in the home and the individual service users who have participated. This was not kept individually so that the social needs of individuals could be monitored and reviewed as part of their individual plan of care, and supporting the keeping of information about people with Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 16 respect for confidentiality. Activities include excursions and trips to see a football match. There was a weekly programme of activities in the main entrance and this included activities such as newspapers (a resident told us that they go out to buy some newspapers each day) and board games and arts and crafts on alternate weeks. The programme did not list any activities for weekends. One resident had a visitor at the time of the inspection from another home. They were sat chatting in the lounge. Another resident was doing some crochet in their room. Another resident said they like to stay in their room and listen to the radio. Some residents were in their own rooms. Two said that they liked to spend time in their rooms. One resident had all the things around them that they could enjoy and that were special to them. One resident told us that they had enjoyed two holidays last year; to Bournemouth and the Isle of Wight. We saw photographs of the four residents who went on the holiday to Bournemouth with a member of staff. Individual rooms had easy lock doors with an over-ride facility so that they could be opened easily from the inside. Residents are offered keys to their rooms if they wish. One resident was spoken with who shares a room they said that although they would prefer a single room they did not mind sharing. One resident told us that the meals in the home are good. The menu board in the dining room had not been changed from the day prior to our visit so residents did not know what was on the menu for that day. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The legal rights of residents in the home are not robustly promoted and protected. The procedures for responding to allegations and/or suspicion of actual or potential abuse of residents are not consistently followed or reviewed. EVIDENCE: The home told us in the annual quality assurance assessment (AQAA) that residents’ money is kept in a single bank account belonging to the home and residents do not have their own bank accounts. The AQAA did not tell us what action the home is taking to ensure that residents have their own bank accounts or are supported to manage their own money and affairs independently. It was not possible to ascertain how interest that may accrue is allocated to each resident. The individual care plans that we looked at did not contain details of how residents’ financial and legal rights are protected. One of the care plans that we looked at contained details of a mental capacity assessment that the representative of the registered provider had completed on 25/6/08 but there was no information as to the reasons why the assessment had been completed. The AQAA told us that staff in the home have received training in awareness of safeguarding adults from abuse. However, we were not able to confirm this Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 18 because the home does not have a training matrix that shows all of the training that staff have completed, and records of training are in individual staff files. At the time of our visit, the provider could not find a copy of the home’s safeguarding policy and procedures and we have asked the home to send us a copy. In October 2008 we spoke to one of the registered providers about an incident in the home that had been reported to us under Regulation 37 of the Care Home’s Regulations 2001. The provider was not aware that any events or incidents affecting the safety of a person in the home must be reported to the local authority under agreed safeguarding procedures, to be investigated. The AQAA recorded that in the last 12 months, 3 safeguarding referrals have been made and investigated. The home has a formal complaints procedure and this is on display in the entrance to the home. The registered person must make sure that the details of the address and telephone number of the Commission for Social Care Inspection are correct in the event of people wishing to contact the Commission. The AQAA stated that the home has not received any complaints in the last 12 months. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a homely and safe environment for residents. Although residents are not always able to move into a single bedroom, they can move into different rooms if the opportunity arises. The service is aware of where improvements to the building need to be made and there is ongoing replacement and refurbishment. EVIDENCE: There is a keypad entry system to the front door, keeping the service secure. The inspectors were told that there had been improvements made to the home since the last inspection. The home has completed a programme of refurbishment to the lower ground floor of the home and this has included installing new toilet and shower facilities for the residents, and a new laundry Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 20 room. The work has also included building a new office on the lower ground floor. One inspector looked around part of the home and found that there were homely touches, to make the service feel more like a home to the people living there. There had also been some upgrading to bathing facilities. In the afternoon some residents were sat in the dining area having a cup of tea. Other residents were sat in the lounge. Chairs are positioned around the edge of the room and there is a large screen television, which was on one of the walls. The home has one lounge and dining room that is an open plan room on the ground floor. The home does not have a second lounge if residents choose to sit in a room without television; however, some of the residents were in their own rooms when we visited. Nine of the bedrooms are shared. The shared bedrooms either have a curtain divider fixed to the ceiling or there are portable screens that offer residents some privacy. Bedrooms do not have en-suite facilities but there is a washhand basin in each room. Residents have access to shared toilets, bathrooms and showers. People are not always able to have the option of a single room when moving into the home but the home told us that people have the option to move into different rooms when the opportunity arises. One resident was spoken with who shares a room they said that although they would prefer a single room they did not mind sharing. We were told that the home has a no smoking policy indoors but residents have a summerhouse in the garden or the front porch where smoking is permitted. The deputy manager told us that the home plans to upgrade the passenger lift within the next 12 months because the lift is now “old and inefficient”. The AQAA also stated that further plans for improvement in the next 12 months will be to repair a garden shed that is used for storage and to replace the kitchen extractor fan with a proper size cooker extractor. The AQAA confirmed that the home has an action plan in place to deliver best practice in prevention and control of infection and confirmed that all staff have received training in good practice in infection control. During our visit we noted that the home was clean and tidy and staff have access to gloves and aprons when required to support good practice in managing the risk of infection or cross infection. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 21 Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not ensure that their recruitment procedures are robust and thorough to meet regulatory requirements and demonstrate that staff are suitable to work in the home. The records of staff training and development need to be kept up to date and be accessible to demonstrate evidence of the home’s stated commitment to providing a team of competent and skilled staff. EVIDENCE: Three recruitment files were seen. Two staff members had started work shortly before a POVA First check had been received. The deputy manager did not realise that there needed to be proper recruitment checks in place, including a POVA First before a person starts working in the home. Once this check has been completed the person can then start work under supervision as stated in the Department of Health’s guidelines for the Protection of Vulnerable Adults. This ensures that people working in the home are suitable to work with vulnerable adults. However, we were contacted by the home in July 2008 requesting advice on recruitment checks. The home was referred to the professional guidance that is available for care providers on the Commission website on meeting regulatory requirements with regard to staff recruitment. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 23 The AQAA told us that the home encourages residents to sit in on the interview plan when recruiting new staff. However, we did not find evidence to support this. The home told us that prospective new staff are able to meet the residents as a group, whilst in the process of completing the application form in the residents dining room. Individual lists of training completed are kept on files. No training matrix could be found on the day of the inspection, in order to ascertain that all staff had completed required training and updates as required to ensure that they maintain the skills required to meet the needs of people in their care. The individual lists of training completed included reference to general as well as specific training completed including training in mental health and communication. The AQAA stated that 4 out of 15 staff have achieved level 3 in care, of the National Vocational Qualification (NVQ) and 5 staff are working towards an NVQ in care at levels 2, 3 or 4. Autumn Vale DS0000062949.V373816.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lines of management and accountability in the home are not clear and regulatory requirements have not been met. There is a lack of supporting evidence to demonstrate that the home has efficient systems in place to monitor the quality of care provided to ensure good outcomes for people in the home. EVIDENCE: When we visited the home we were told that the registered provider owns another care home and the management of both homes is shared between two people, one of whom is the registered manager for Autumn Vale and the other person is the registered manager for the other care home. However, the registered manager for Autumn Vale, Mr B Seedeehul was not in the home Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 25 when we visited. The staff rota does not indicate what days the registered manager is in the home. The annual quality assurance assessment (AQAA) was completed by the deputy manager, Mr D Seedeehul and not by the responsible person, or registered manager of the home. We were told that the records for the home have recently been moved into a new office space and some records were difficult to find during our visit. During our visit the registered provider was not able to find a copy of the policy and procedures for safeguarding adults. The AQAA says that the home reviews the quality of the service provided in a number of ways: surveys, talking to residents in groups or one to one, staff meetings, annual performance review and clinical supervision. However, the AQAA did not provide supporting evidence of the outcomes of the home’s quality audits and what has improved for people living in the home. The evidence in the AQAA indicates that the home’s policies/procedures/codes of practice are not up to date and some policies are not in place. Some of the policies have not been updated since 2003 and others have not been reviewed or updated since 2005 or 2007. Policies and procedures are important documents that demonstrate the statement of practice in the home and provide guidance for care staff. The AQAA did not tell us whether the home has a policy/procedure/code of practice on the new legislation relating to mental capacity. During the visit we found that some aspects of the medication procedures in the home do not meet regulatory requirements. The home has not developed person centred care planning. Residents do not manage their own money. To ensure that residents finances are protected the registered person must ensure that any money held for individuals is kept in an account in the name of the service user to which it belongs. This is a regulatory requirement under Regulation 20 (1 – 3) of the Care Homes Regulations 2001. Failure to comply is an offence. The home were not fully aware of their legal requirements to ensure that satisfactory checks are in place before staff start working in the home, to ensure that new staff are suitable to work in the home. The home confirmed in the AQAA that equipment in the home is regularly serviced as recommended by relevant health and safety legislation, however, Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 26 the AQAA says that the servicing of fire equipment in the home was last done in October 2007. The registered provider has since confirmed that fire equipment servicing is up to date. We were told that assessments are in place for any hazardous substances kept in the home. Autumn Vale DS0000062949.V373816.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 2 18 2 3 X X X 2 X X 3 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X X 3 Autumn Vale DS0000062949.V373816.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 OP9 Regulation 13(2) Requirement The registered person must make arrangements to ensure the safe recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Medication procedures must be reviewed in line with good practice guidance for care homes produced by the Royal Pharmaceutical Society of Great Britain. Medicines must be supplied to the home fully labelled with a dispensing label indicating to whom the medication is to be administered and at what dosage and frequency. 2. OP38 13(4) Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Staff must have clear and written guidance on how risks or events are to be managed or minimised that is regularly Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 29 Timescale for action 28/02/09 28/02/09 3. OP29 19 and Schedule 2 reviewed. Staff recruitment procedures must be thorough and robust to protect people living in the home. The home must ensure that all checks on new staff, as required by regulation, are in place before staff start working in the home. 28/02/09 4. OP35 20 The registered person must ensure that any money held for individuals is kept in an account in the name of the resident to which it belongs. 28/02/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is strongly recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home that the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. This recommendation from the visit of 11/08/08 has not been carried out and is repeated. 2. OP7 It is recommended as good practice for the home to develop person centred care planning to assist residents to outline their own needs, wishes and goals and to enable individuals to increase their personal self-determination and independence. Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Autumn Vale DS0000062949.V373816.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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