Inspection on 18/08/05 for Capri

This inspection was carried out on 18th August 2005.

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

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

Other inspections for this house

Capri 20/06/07

Capri 16/11/06

Capri 21/11/05

Capri 06/01/05

Capri 11/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Capri 48 St Johns Road Sandown Isle of Wight PO36 8HE Lead Inspector Mark Sims Unannounced 18th August 2005 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 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. Capri Version 1.10 Page 3 SERVICE INFORMATION Name of service Capri Address 48 St Johns Road, Sandown, Isle of Wight, PO36 8HE Telephone number Fax number Email 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 402314 Isle of Wight Care Ltd Christine Basham Care Home 9 Category(ies) of Dementia - over 65 years of age(2), Mental registration, with number disorder, excluding learning disability or of places dementia - over 65 years of age(1), Old age, not falling within any other category(9) Capri Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: One person is accommodated in the MD(E) category. This named person may remain at the home One person is accommodated in the PD category. This named person may remain at the home. Date of last inspection 6/1/2005 Brief Description of the Service: The home is registered in respect of 9 service users under the broad category of Older Persons, 2 additional places under the category of Dementia (elderly) and 1 category for older people suffering from a Mental Disability, the home may not accommodate any more than 9 service users. The home is located within St Johns Road, Sandown and is situated within easy access of the main shopping area, its facilities and amenities. The premises is a three storey town house that has been converted to provide residential accommodation and has seven single bedrooms and one shared room that is currently used as a single. The accommodation for the service users is split between the ground floor and first floor with the second floor being used as staff accommodation. Access from the ground floor to the first floor is via the stairs or the home’s stairlift. Capri Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out unannounced and lasted 4 hours, during which time the inspector spoke with the service users, inspected key documents, met with staff and discussed operational issues with the manager. What the service does well: What has improved since the last inspection? What they could do better: A review of the home’s recruitment and selection procedure identified several issues of note that the manager will need to address to ensure the recruitment procedure is robustly and comprehensively managed. Capri Version 1.10 Page 6 The issues identified including failures to secure POVA checks, CRB checks, full details of the applicant’s employment history, two references and photo identification. The need to consider the sleep-in staff waking during the night and undertake monitoring checks on service users were also discussed, as the inspector was concerned that people, as they become frailer, may require closer monitoring at night to ensure their health and welfare is promoted. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Capri Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Capri Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) St 3, St 5. The manager ensures all prospective service users are assessed prior to the offer or decline of accommodation at the Capri Residential Home. Service users or representatives are encouraged to visit the home prior to accepting the offer of accommodation. EVIDENCE: The pre-admission assessment of three service users were reviewed during the inspection, the plans having been completed by the manager during visits to prospective resident and containing information relevant to the person’s health and social care needs and wishes. Copies of the pre-admission assessments are maintained on the service user files and are used in the initial production of care plans, which are used in the delivery of a service to the resident, until fuller and more detailed assessment and plans can be developed. Capri Version 1.10 Page 9 The information documented as part of the pre-admission assessment process was generally instructive and insightful and recorded in a fashion that made it clearly understandable. In conversations with service users it was clear that they felt the home met their needs and confirmed that prior to moving into the home a member of the staff team had visited them and in some cases they to had visit the home or knew of the home because of previous involvement with the service. One service user described at length how she had visited the home prior to admission and had been able/invited to remain for tea, in order to help her in reaching a decision about the suitability of service to meet her needs. Another service user stated that she had been supported by her family in finding the home, which she felt met her needs well, and that they had viewed several possibilities before visiting Capri. Capri Version 1.10 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 standard(s) St 7, St 8, St 10. The care planning process identifies all health, social and personal care needs of the service users, setting out for staff how these needs are to be consistently met. Service users and their relatives felt the staff were respectful and conscious of people’s rights to the promotion of dignity and privacy. EVIDENCE: The care plans of three people currently residing at Capri were reviewed, each containing an abundance of information relating to the service user including • • • • • • • • • Capri Client information/details Pre-admission assessments Medical histories Health Professional visit sheets Details of Health and Social care professional involved with the resident Medication details Personal care plans Risk assessments Assessment tools – moving and handling, etc. Version 1.10 Page 11 In discussions with staff it was evident that these documents were regularly used, reviewed and updated and that staff are aware of the need to document important information in an accurate and timely manner. Service users, whilst not necessarily aware of the content of their individual care plans, knew the records existed and that staff updated these records on a more or less daily basis. The levels of information documented within the care plans, varies in accordance to the needs of the person or the amount of support that person is requiring at any given time. Where people are requiring additional support and monitoring, as in the case of a service user involved with a health review board, the level of documentation increase correspondingly, with all relevant or important information documented for referral to the appropriate professional. In discussion with the resident involved with the review board, it was clear that they felt anxious about the prospect of meeting with the various professionals involved and did not fully appreciate why they needed to go through the review process, although they accepted that the manager and her team were helping and providing valuable support. In discussion with the manager and on reviewing the service user’s records, it was evident that the staff team had indeed made every effort to support the service user with the forthcoming review and that contact had been maintained with all parties involved, co-ordinating visits and arranging meetings, etc. In addition to supporting the client with this specific issue there was also significant evidence of the support provided in maintaining the person’s dayto-day safety and wellbeing, with risk assessments and care plans available for a range of health and social care needs. One oddity noticed almost throughout the home was the habit of bedroom doors being left open, even when the room was occupied. Whilst the practice is not uncommon in isolation it seemed strange that so many bedroom doors should be held open, although on asking the service users about this phenomenon they all made it clear that this was their personal preference. All of the doors held in the open position were fitted with appropriate devices that in the event of the fire alarm sounding should release and allow the door to close. In more general conversation people were quick to praise the staff employed at the home for their attitude and described them as polite, friendly and supportive. The residents also believed that their privacy was respected, despite there being no space available for meeting people in private, other than their own accommodation. Capri Version 1.10 Page 12 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 standard(s) St 12, St 13, St 14, St 15. Service users are supported in the maintenance of community contacts and are welcome to receive visitors to the home at any time. Discussions with service users supplied evidence of their satisfaction with the home’s social activities programme. The risk assessment and care planning process are used to support people in exercising and retaining control over their own lives. The food served at the home was widely praised by the service users and appeared to be well presented, well balanced and individually portioned during mealtimes observed. EVIDENCE: In discussion with service users it was evident that members of their families visit regularly and spend time socialising in both the communal areas of the home and their own bedrooms, depending on what is occurring. Visiting hours within the home are not set and people were noticed coming and going throughout the inspection, with people stopping to talk or chat with staff on their way to visit their relative and other service users they have befriended. Capri Version 1.10 Page 13 During the inspection one particular visitor caused a great deal of excitement both within the service user group and staff team, being the newly born great nephew of one of the service users. It was noticed throughout his stay and his parents’ how involved everyone in the lounge was in the visit, with all residents and staff pleased to meet him for the first time. It was also evident how close all of the service users within the lounge were and how well they knew each other, a benefit of the small size of the home and the relative stability within the service user group. The relationships between parties involved in the home and the general ethos or philosophy of the service, which aims to create a homely feel, appearing from observations to have been attained, with the interactions between service users, staff and visitors noted as being friendly and supportive. In addition to the visits made to the home by relatives and representatives, several of the service users are actively involved in the wider community, as confirmed by them in conversation and evidenced via the care plans and staff recollections. However, as there is an element of risk associated to the service users’ involvement in community based activities the manager has produced risk assessments and protocols for staff to follow should issues arise whilst the service users are away from the premises. There was also considerable evidence noted throughout the inspection of the support provided to service users when exercising choice and control over their lives. One major event being the health related review, mentioned earlier, which required a great many staff hours to support the wishes of the service user, as stated. It was also evident in talking to other service users that they felt happy with the level of autonomy they had over their own day or life. People discussing their preferences for quiet time alone within their bedrooms and how they use this time to undertake activities which they enjoy, puzzles, crosswords, watching DVDs, etc. Others demonstrated their right to choice and self-determination through actions, one service user making drinks for herself, a process that had been risk assessed accordingly. As with all inspections a brief tour of the premises was undertaken, which on this visit included a visit to the food storage facilities and kitchens. Whilst the food stocks were not the most expensive products available the range of Capri Version 1.10 Page 14 cooking materials was extensive and included fresh, frozen and preserved or tinned food items. The meal prepared during the visit was not the main meal of the day but tea or supper, which appeared well cooked and reasonably nutritious. Observations of the food being served and consumed evidenced that it was appetising and each meal was served in accordance with the person’s own preferences or dietary need/demands. When asked about the food provided people were generally satisfied with the cooking and access to snacks and drinks between meals. People were also pleased with the variety of meals prepared and the simplicity of the menu options. Capri Version 1.10 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 standard(s) St 18. The home has taken appropriate steps to safeguard service users from abuse. EVIDENCE: The manager makes available to staff guidelines on both the protection of vulnerable adults from abuse, which includes details of locally agreed procedures, and details of the staff’s right to raise concerns regarding any aspect of the service they feel unhappy with, in an environment and/or atmosphere free from blame and retribution (Whistle Blowing) in accordance with the ‘Public Disclosure Act 1998’. In discussions with the staff it was not clear that they fully appreciated the content of the policies referred to above, although they were aware that such policies existed and that these and other policies / procedures were available to inform their practice if more senior advice and support was not readily available. The service users themselves also seemed to appreciate living within an environment that is open and relaxed and stated several times when asked that any concerns or issues would be directly referred to the manager, who was seen as approachable and supportive. Capri Version 1.10 Page 16 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 standard(s) St 19, St 24, St 26. The tour of the premises evidenced that the home is well maintained and that a good decorative standard is continued throughout. Bedrooms visited during the inspection had clearly been personalised by the occupant in accordance with their own wishes. The home was clean and tidy with no odours detected during the tour of the premises. EVIDENCE: The tour of the premises evidenced that the home is well maintained and that a good decorative standard is continued throughout. Recently the manager has arranged for the lounge/diner to be re-carpeted, a new stairlift to be installed and a new fire escape mounted at the rear of the property. Capri Version 1.10 Page 17 In addition to the work completed the manager also advised that she has obtained quotes for the replacement of the toilet floor coverings and is seeking a quote for the renewal and extension of the rear balcony, which is small and can only accommodate one to two service users at any one time. The tour of the premises, took in only a handful of service users’ bedrooms, revealing individually set out, decorated and furnished rooms, which clearly reflected the wishes of the occupant and created a personal space that was familiar to them. In conversation with service users it was evident that they were happy with the accommodation and felt it met their immediate needs, most people opting to retire to their bedrooms in the evening to watch their own televisions, etc. The tour of the premises also confirmed that the domestic staff’s approach to cleanliness is good, with no signs of dust, cobwebs or any offensive odours to be detected anywhere around the home. Capri Version 1.10 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) St 27, St 29, St 30. The arrangements for night staffing cover may not always be adequate to meet the needs of the service users. The recruitment procedures of the home were not being adequately followed and cannot therefore be considered to protecting the service users’ wellbeing. Access to suitable and appropriate training is being provided to members of the staff team. EVIDENCE: In discussion with staff the issue of sleep-in nights arose and how staff monitor service users that might need assistance during the night for one reason or another. The staff stated that once they retire to bed they generally only woke in response to bells being sounded and that if service users got up independently they may not know about it. This issue concerned the inspector, as on occasions service users have fallen at night or required assistance with other personal care, which staff may not necessarily know about given the current arrangements. Taking this into consideration the inspector has discussed with the manager the possibility of the staff being woken during the night to complete a mid-shift round of checks, especially on people where problems might occur. Capri Version 1.10 Page 19 The manager stated that for people who are known to require support at night, for whatever reason, the sleep-in staff are required to stay up (become wakeful staff). However, this alone does not seem a sufficient response to the possibility of accidents, etc. A review of the staff files revealed that whilst the manager has access to a full range of recruitment and selection documentation, these documents are not always being fully implemented or the recruitment procedure adequately followed. Out of three recently recruited staff files inspected none contained complete employment checks, with references missing, missing ‘Criminal Records Bureau’ (CRB) checks, missing ‘Protection Of Vulnerable Adults’ checks, applications with insufficient or incomplete employment histories and no interview records, etc. This issue is concerning and the manager has been advised of the need to improve this element of the home’s practice immediately, as the recruitment and selection process is a key component of the protection of vulnerable adults procedure. Also evident on each staff members’ file and co-ordinated by the manager are details of training events completed, training updates to be attended and additional courses undertaken, i.e. NVQs, which are generally designed to increase knowledge, skills and competence and smaller courses such as infection control, medication training and food hygiene. In conversations with the staff on duty it was evident that they were both relatively new to the service and that they had mixed experiences of working in care related fields. They had undertaken an induction on securing their roles and had completed much of the recent training provided. Capri Version 1.10 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) St 31, St 36, St 37. The manager is both appropriately qualified and experienced. Regular staff supervision is being undertaken. Records maintained by the staff are appropriately stored and secured. EVIDENCE: The manager possesses both a National Vocational Qualification at level 4 and the Registered Manager’s Award, ensuring she is appropriately qualified. At the inspection both the service users and staff described the manager as supportive and approachable, and confirmed they appreciate her style of management and her ethos of care. Capri Version 1.10 Page 21 It was also evident that she has developed good relationships with service users’ families and representatives and that her interactions with health and social care agencies are appropriate and professional. The manager also ensures that all staff receive regular supervision and guidance in accordance with their roles and responsibilities, with supervision records indicating that staff are seen formally by the manager 5 to 6 times a year. An annual appraisal is also used to map out training and development needs for staff on a yearly basis, this particular process being far more interactive for the staff, who have to complete self-assessment or appraisal records. Due to the small size of the home and staff team the manager has decided that staff meetings are not essential tools for the dissemination of information and therefore only arranges meetings periodically to discuss issues affecting the day-to-day operation of the home. All records inspected during the course of the inspection were appropriately stored, although the manager is advised to check occasionally that the cabinets located downstairs are locked and secured to prevent unauthorised access. The staffing files and personal information relating to service users is predominantly stored in the upstairs office, within secure filing cabinets and any computerised records are accessible only via a password protected system. Capri Version 1.10 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x x x x 3 3 x Capri Version 1.10 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard St 27 Regulation Requirement Timescale for action 07.10.05 2 St 29 Regulation The manager must review the 18 sleep-in night arrangements, with a view to night staff undertaking a mid-shift check on service users Regulation All staff employed at the home 19 must undergo a rigorous and robust recruitment and selection process. 07.10.05 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 Good Practice Recommendations Capri Version 1.10 Page 24 Commission for Social Care Inspection Mill Court Furrlongs Newport PO30 2AA 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 Capri Version 1.10 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!