Inspection on 21/11/05 for Capri

This inspection was carried out on 21st November 2005.

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 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 18/08/05

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 Inspection 21st November 2005 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 Capri DS0000012471.V249483.R01.S.doc Version 5.0 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. Capri DS0000012471.V249483.R01.S.doc Version 5.0 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 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 402314 Isle of Wight Care Ltd Christine Jacqueline Basham Care Home 9 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9) of places Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 may remain at the home. 18 August 2005 Date of last inspection 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 place 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 DS0000012471.V249483.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken unannounced and formed the second statutory inspection of the year for Capri Residential Home. The inspection focused on those core standards not addressed at the 18th August 2005 inspection and various sources of evidence were considered in the formulation of judgements, records, observations and discussions with service users and staff/management. What the service does well: What has improved since the last inspection? What they could do better: A second issue raised at the last inspection and involving the home’s recruitment and selection practice, had largely been addressed, with the manager taking steps to ensure she had appropriate references, submitted for Criminal Record Bureau checks, and initiating ‘protection of vulnerable adults’ (pova) disclosures. However, as a number of shifts require staff to work in isolation, the securing of a POVA check alone is not sufficient to guarantee their suitability, the regulations stating that people can commence employment within the home on Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 6 return of a suitable POVA check but that this must be under supervision and as part of a planned induction programme. Another issue affecting both Capri and the sister home is the policies and procedures files, which have not been reviewed or updated since 1 February 2003 and as a consequence may have led to service users being supplied with out of date and inaccurate information. 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. Capri DS0000012471.V249483.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Capri DS0000012471.V249483.R01.S.doc Version 5.0 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 the following standard(s): None No standards were reviewed within this section, as core Standard 3 was reviewed at the last inspection and core Standard 6 does not apply to this service. EVIDENCE: Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 9 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): Standard 9. The home has purchased a new medication system, which should ensure that staff appropriately and safely support service users with their medicines. EVIDENCE: Since Standard 9, service users’ medications, was last reviewed the manager has overhauled the entire system and has opted to replace the previous medication set up with a ‘Monitored Dosage System’ (MDS). MDS should technically be far easier for homes to manage, as the medication is dispensed, by the pharmacist, directly into a sleeve that comprise 28 slots, each slot containing the individual medicine to be administered. For staff the process of booking the medication into the home is simplified because each drug is dispensed into its own sleeve and the prescription and administration instructions are clearly displayed on each individual sleeve. The downside of such a system is the increased volume or bulk of the medication packaging to be stored, although to combat this problem the manager has purchased a new drugs cabinet. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 10 In addition to the new way the medications are presented the pharmacy also supplied new ‘Medication Administration Records’ (MAR), the MAR sheets being equipped with a specific space for documenting that each drug has been properly booked into the home and checked. On reading through the MAR sheets it was evident that the staff are indeed taking advantage of this system and properly accounting for the medications received into the home and dispensed to service users. Training on the use of the new system was provided to the manager, who has taken on responsibility for cascading the information to staff. The manager is also currently the only staff member to have complete and accredited medication training, although she states that several staff have been booked onto an ‘advanced medication’ training course provided by the local college. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 11 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): None No standards were reviewed within this section, as all core standards were reviewed at the last inspection and found to be being met. EVIDENCE: Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 12 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): Standard 16. The information provided to service users re the home’s complaints process was out of date and inaccurate. EVIDENCE: The complaints process, as with many of the policies and procedures of the company, were out of date and had not been updated or reviewed since 1 February 2003. Whilst the general information contained within the policy (copies of which were on display within both the entrance hallway and dining room) remains unchanged, i.e. the address and telephone number of the regulatory body, their title did change in April of 2004, a fact not addressed or acknowledged by the company through its policy. It is important when dealing with service users and/or their relatives to remember that any information provided should be accurate and up to date and that as part of a services drive towards the promotion of good standards of practice, etc., a positive quality auditing system should be established, including the regular reviewing and updating of key documents. In discussion with staff it was ascertained that whilst their knowledge of the complaints process was nominal, their reaction to any concerns or complaints raised would be acceptable, i.e. if possible the person would resolve the issue at source if a minor or small concern or bring the complaint to the attention of the manager or responsible person if more serious or significant. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 13 Staff also indicated that they would make a record within the service user’s plan on both occasions, to ensure it could be followed up and monitored. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 14 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): Standards 23 & 25. The private accommodation provided at Capri was felt by the service users to be meeting their needs. The lounge was felt to be cold and service users were requiring blankets or rugs as supplementary heating systems. EVIDENCE: A brief tour of the premises afforded the inspector the opportunity to speak with a couple of service users within their own bedrooms. It was clear from both the set up of the rooms and the comments of the people living within the bedrooms, that the accommodation was felt to be meeting their personal needs and that they appreciated the ability to stamp their own identity on their bedroom, as this clearly established the space as theirs. People were also clear about their responsibility or role in respecting other people’s space and right to respect, etc., because the home is so small and modest. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 15 One person who smokes within their room was aware of the need to close the door at these time and switch on the air purification unit supplied, ensuring that odours and fumes are contained within the one area, whilst nullified by the purifier. On arriving at the home the inspector spent the initial stages of the visit within the open planned lounge diner, where the ambient air temperature was felt to be cool, despite the cold crisp conditions outside of the home. In addition to the cold experience by the inspector the two service users sat within the lounge were also wrapped within blankets or rugs, which also led the inspector to feel they to felt the room was chilly, although when asked both parties stated they were fine. On checking the radiators it was difficult to judge the level the thermostats were set at, as one thermostat was inaccessible as it was positioned behind a chair that was occupied. The home’s main thermostatic control was set at 25ºc, which should have been sufficient, although the lounge/diner does experience regular changes of air, as the staff regularly use the back door to access the laundry, which could have attributed to the cold air. The manager has undertaken to inspect the radiators and ensure the temperature remains pleasant and comfortable for the service users. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 16 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): Standard 28 & 29. Insufficient numbers of staff currently possess a National Vocational Qualification (NVQ) at level 2 or above, although five staff are presently enrolled on courses. The home’s recruitment and selection procedure is generally robust and thorough, although the home must remember not to cease supervision until details of the Criminal Records Bureau check are returned. EVIDENCE: The training programme for the company ,and in particular Capri, this year has focused on ensuring staff attain essential or core skills and qualifications, moving and handling, fire safety, health and safety, food safety, etc. Out of the ten carers employed, one person currently holds an NVQ qualification at level 2 (whilst studying for her level 3 award) and four staff are enrolled on NVQ courses, although they are not expected to complete their training until next year. The manager in planning her training strategy for next year should factor in the need to sustain the 50 threshold even if staff leave or move on, which should mean additional staff being given the opportunity to complete an NVQ. During the visit the inspector reviewed the files of three staff members who had been recruited prior to the last inspection but whose recruitment files were incomplete at the time. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 17 On reviewing the files it was evident that the manager has made efforts to improve the home’s recruitment and selection practices, with all prospective employees having completed an application form, which now included details of the person’s employment history, educational history, medical history and references. In addition to the application form the manager had also obtained references for each person and had submitted requests for Criminal Records Bureau (CRB) checks, and Protection Of Vulnerable Adults (POVA) checks. One issue which did come to light whilst reading through the employment files was that the Criminal Records Bureau checks had not been received back prior to the individual being allowed to work with service users unsupervised. The manager has been reminded that on receipt of a POVA clearance a staff member may commence employment, although they should continue to work under supervision until such time as the full disclosure report from the CRB is returned. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 18 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): Standards 33, 35 & 38. The quality auditing systems of the home are confusing, although generally adequate given the size of the home, to ensure it is run in the best interests of the service users. Service users are appropriately supported and their financial interests safeguarded by the home. Health and Safety of service users and staff is being addressed through a programme of staff training and education and risk assessment, both environmental and personal. EVIDENCE: As stated above the quality auditing systems of the home are a little confusing and perhaps a little in conflict with one another. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 19 As mentioned throughout the report the home’s or company’s policies and procedures files / key documents are out of date, having last been reviewed and updated on 1 February 2003. It is important that any quality assessment strategy has built into it a schedule for reviewing and updating key policies and procedures and for ensuring that changes in best practice or guidance, etc., are factored into the updating and reviewing processes. Whilst the company might have allowed parts of the quality auditing programme to slip, other areas such as the Regulation 26 reports and the environmental risk assessments, etc. are being carried out accordingly and documented evidence exists to verify that these processes are being conducted appropriately. During a recent health and safety audit the assessor found no cause for concern or comment and was happy with the home’s risk assessments. The small size and/or nature of the service seems to allow for regular contact between the manager and the residents, allowing people to discuss both positive and negative aspects /experiences of the service and/or any changes, etc., they might wish to see introduced. It is the policy of the company not to become involved in the management of service users’ monies, although where a person wishes to retain control of their own financial arrangements every effort to support them is given. As an alternative arrangement to holding monies for service users the home offers a tick system, whereby the home will purchase items for a service user or pay for services and then recoup the money at the end of the month by invoice. Receipts for all purchases are obtained and made available to the families upon request. The manager is presently holding money for one resident who is responsible for spending or deposing of her money as she see fit, that person approaching the manager for the amount of cash required as and when necessary. The home is fortunate that one of the staff’s husbands is a trained health and safety instructor who is willing to arrange for appropriate health and safety training programmes to be operated within the home. The company also contracts with Peninsular, a management company that provides all of the home’s health and safety policies and assessment documentation. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 20 In an attempt to ensure the staff and services users remain safe whilst in the home the manager conducts regular fire tests, etc. and has recently attended a seminar at the Ventnor Botanical Gardens on fire safety training, purchasing a training pack and information system for staff. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 21 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 x X X X X 3 X 2 X STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP16 Regulation Requirement Timescale for action 30/12/05 2 OP29 Regulation The manager must ensure the 22 complaints process (and all policies and procedures) are reviewed and updated. Regulation This issue was raised at the 30/12/05 19 last inspection: The manager must ensure all elements of the regulation relating to staff recruitment are satisfied prior to new employees commencing unsupervised work. 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 2 Refer to Standard OP25 OP28 Good Practice Recommendations Ensure the heating arrangements within the lounge are adequate to meet the needs of the service users. Ensure sufficient flexibility exists within the staff team to maintain a 50 ratio of staff possessing an NVQ 2 or above. This should be achieved via the training plan. Capri DS0000012471.V249483.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW 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 DS0000012471.V249483.R01.S.doc Version 5.0 Page 24 - 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!