Inspection on 28/11/05 for Church Lane

This inspection was carried out on 28th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Lane 12/03/08

Church Lane 24/09/07

Church Lane 19/05/06

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Church Lane 21 Church Lane Bearsted Maidstone Kent ME14 4EF Lead Inspector Marion Weller Announced Inspection 28th November 2005 10:00 Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 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 Church Lane DS0000065345.V255791.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 Adults 18-65. 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. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Church Lane Address 21 Church Lane Bearsted Maidstone Kent ME14 4EF 01622 730867 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) CareTech Community Services (No.2) Ltd Vacant Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th July 2005 Brief Description of the Service: Church Lane provides residential care and accommodation for twenty adults with a learning disability, some of whom also have a physical disability. The home is divided into three units, ‘Azalea’, ‘Begonia’ and ‘Clematis’, dependent on the needs of residents. Care Tech Community Services Ltd owns the home. Church Lane is located in a residential area in the village of Bearsted near to Maidstone. Local shops, pubs and a church are within walking distance. There is a main line station approximately ¾ mile away. A local bus service to Maidstone, where there are all the usual facilities of a large town, passes nearby. The home is a large property, set in its own gardens and provides car parking to the front of the building. Accommodation is over three storeys. There is no passenger lift. Residents with a physical disability are accommodated on the ground floor. Church Lane provides a staff team who work a roster to give 24-hour cover. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted by Marion Weller, Regulatory Inspector, who visited Church Lane from 10.00a.m until 4.45p.m. During that time the Inspector spoke with some service users and staff. Parts of the home, records and files were inspected. Progress made since the last inspection report was discussed. Due to the nature of the service provided it was not possible to fully discuss life in the home with some of the service users and difficult to reliably include all reflections of the service in the report. The homes manager has not made application for registration with CSCI and was on leave during the inspection. Two area Managers from the owning company responsible for Church Lane, together with the peripatetic manager working at the home were present throughout the visit. Some comment cards were received prior to the inspection. Resident’s relatives generally responded that they liked the home and the staff. They were aware however of the difficulties the home had experienced recently regarding the appointment and retention of a home manager. For some, this was an important issue they would like to see resolved. Responses from health professionals raised some specific issues of concern that were fully discussed and in some instances, acted upon during the inspection. Statements on comment cards included: “It has been my experience that the residential service provides an excellent standard of care and commitment” “It is still early days, but I am happy” “Satisfied overall, but not many activities for clients to do at weekends” The managers and the staff gave their full cooperation throughout the inspection. What the service does well: Service users enjoy living in the home and are treated as individuals who have different interests and aspirations. Staff members aim to support individuals to partake in activies that are suited to their preferences and capabilities. Service users are encouraged towards independence and have opportunities for personal, educational, emotional and social development. Service users are able to make choices and, where they are unable, staff are supportive and caring. The home provides a clean, comfortable and homely environment. Service users enjoy the range of communal areas and the garden. Their rooms are highly personalised. The home has an open and inclusive atmosphere. The senior staff are particularly good at keeping the CSCI informed of any situation that adversely Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 6 affects the well being or safety of any service user and take appropriate action to address or resolve the situation identified. What has improved since the last inspection? What they could do better: The statement of purpose and service user guide should be comprehensively reviewed to clarify fire evacuation procedures for service users, particularly those with physical disabilities. The manager should complete the stated aim of finding a simple and practical way to ensure all service users and /or their representatives are made aware of the detailed information included in the documents provided by the home for service users reference and guidance. Risks to service users must be reduced by improvements in the systems and formats used for care planning, daily record maintenance and medication administration. Service users would benefit from a comprehensive review of staffing levels and the recruitment of a fully substantive staff team who understand their needs and the way the home operates. Service users must be fully protected by the systems in place for staff recruitment. A review of the staff call system should be undertaken and documented to ensure that service users needs are fully met during any 24-hour period. Individuals’ health and safety needs to be enhanced by improvements to current arrangements and records. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 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. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2 3 5 Prospective Service users have most of the information they need to decide whether Church Lane is the right home for them. EVIDENCE: The home has a statement of purpose and a service user guide. The statement of purpose is a detailed and generic document written by the owner organisation and can be flexibly adapted to meet each individual home’s circumstances. Both documents have been revised recently to include most of the detail missing on previous inspections. The home provides three service user guides, one for each unit, which are tailored to the differing abilities of service users and can be provided in different formats. Although reference was made to additional costs paid for by service users, not all are fully documented in the guides. The home is aware of the complex nature of the documentation they provide and the potential for it to be viewed as impractical for the client group. As a consequence of this the home is introducing different procedures to insure that existing and prospective service users; relatives and carers are made aware of the details included in both documents. The area manager called this process a service users ‘passport’ to the home and ‘talk time’ with service users in the home. Both systems are designed to ensure individuals have all the information they need to make informed decisions and choices. The area managers stated their intention to ensure the information documents required by regulation at Church Lane are revised comprehensively and copies sent to the CSCI Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 10 The area manager stated that the home has a pre admission assessment document that is comprehensively completed by staff prior to a service user being offered a place at the home. Records had previously shown that assessments, particularly those requiring additional information regarding a service users physical disability needs, were not comprehensively undertaken. Records seen on this visit showed that the situation had improved. It was now easier to make a decision as to whether the home could appropriately meet the person’s needs. Each resident has a contract between the home and themselves which they or a representative sign. The contract is easy to read and service users are aware of their rights and the responsibilities of the organisation. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 10 Service users are supported to make choices about their lives. Service users are put at risk by inadequacies in the care planning system used. EVIDENCE: Service users care plans were presented in lever arch files. The files seen were very large, cumbersome and impractical to use. New members of staff or agency staff would find the amount of detailed information held in each file far too much to take in. Daily records maintained were of a tick box variety with little space to record the actual care and support given. A staff handover book is used in addition to the care plans and daily records. This further fragments information concerning individual service users care needs and significant events and adds to the workload of staff. The peripatetic manager said that the home was aware of the issues and agreed that service users welfare and safety would be better promoted by care plans being more user friendly, easily accessible and directive, so that all staff are better informed about exactly how to meet service users needs. The manager said that a new care plan format had recently been devised. Some staff had already received care-planning training and more was planned during 2006. Work on the reorganisation of Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 12 care plans was due to start as soon as guidance was received from the owner organisation. Service users are encouraged to exercise individual choice within the constraints of group living. Where service users are unable to make informed judgements staff are supportive and caring. Service users are supported to take risks as part of maximising their independence. Care plans contained risk assessments, which provided guidance for staff. Strategies for managing risks and behaviour, which might challenge are recorded. A service user who hade been protected by the use of bed sides had records that clearly showed the action was taken with their own and their representatives agreement. Some service users benefited from appointeeship provided by a nominated Company Director. A clear external system of auditing service user accounts maintained by the home is now employed. The external auditor had visited the home, unannounced on the 25th November 2005. The auditor had looked at samples of receipts issued, made a check on bankbook balances and other financial records maintained for service users. Personal allowance accounts were inspected and service users ease of access to money, as appropriate to their needs and wishes. Service users finances were not fully inspected on this occasion. The peripatetic manager demonstrated an understanding of the importance of confidentiality. Records were kept securely. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 16 17 Service users enjoy individual lifestyles, which include opportunities for social, educational and recreational experiences. EVIDENCE: Service users are supported towards independent living skills and have the opportunity for personal, emotional, educational and social development. They are treated as individuals who have different interests, aspirations and needs. Service users are offered a range of experiences appropriate to their individual needs and abilities including therapeutic, fitness, creative, religious and leisure activities. At the time of the visit service users were busy pursuing their own interests within the home or were going to or returning from activities. The peripatetic manager said that some service users attend colleges and day centres; undertaking subjects that personally interest them or to further develop their literacy, numeracy and life skills. Comments were received prior to the inspection that stated there was a lack of activity at the weekends. The manager said service users usually had more leisure time at the weekend and the home can appear to be quieter. A service user said they sometimes just chose to lie in bed on Sunday and listen to music. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 14 Service users were very much part of the local community and visited the local pubs and shops. Went to church, out for coffee and attended local centres that provide suitable activities or events that were of interest to them. Current service users do not benefit from holidays paid for by the home. The situation can be approached flexibly however. The area manager said that new service users would be asked if they wished the facility to be included in their contract. Fees would need to be increased in line with the request. Staff respect residents rooms as private. Bathrooms and toilets are lockable. Service users were addressed in a friendly and courteous manner by staff. Service users have a choice of meals; they are involved as much as possible in shopping, preparing and cooking of the food. Special diets are provided where necessary. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19.20. Service Users are potentially put at some risk by inadequacies in the system for medication and care planning. EVIDENCE: Records comprehensively detail the personal care support that individual service users need to maximise their independence whilst respecting their privacy and dignity. Service users are able, as far as possible, to exercise choice in daily care routines. As discussed elsewhere in the report, the care planning system puts some constraint on staff that may not be so aware of individual service users needs and who need to access information easily. Permanent Staff on duty had a good understanding of the preferred routines of each resident and were flexible, responsible and diligent in their approach. Service users are registered with a local GP Surgery. Five GP’s are available within the practice. Prior to the inspection the surgery had recorded an issue concerning difficulties they had encountered in ensuring all residents had access to flu inoculations this year. This appeared to be a problem with the home accessing consent from service users and their representatives. The situation was known to the home. The area manager stated his intention of ensuring the situation was resolved. The preparatory work to gain consent had already been undertaken. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 16 During the last inspection it was recommended that the home seek specialist guidance from the CSCI Pharmacy Inspector to ensure that improvements continued in the administration of medication. The Pharmacy Inspector visited on 23rd August 2005. The inspection looked only at pharmaceutical standards in the home and the outcome is as follows: Medication management within the home was generally satisfactory. The home had company medication policies and had developed policies specific to the home. The identity of the staff member administering medication was unclear due to the practice of double signing the Medication Administration Records (MAR) The temperature of the drug fridge was recorded, however the temperature of other medication was not monitored. The home was given a copy of The Royal Pharmaceutical Society Guidelines for the Administration and Control of Medicines in Care Homes for reference. Administration of alternative therapies was authorized by the GP. The home had a policy for the administration of Homely Remedies but all administration was authorized by the GP, possibly delaying treatment. MAR sheets for new residents were handwritten after confirming current medication The home used the rear of the MAR appropriately to record medication given and dropped. The upper unit of the home was unoccupied, the medication storage was satisfactory, however the area was very dark and administration of medication should take place in a well-lit area. The unit on the first floor had adequate storage. Residents usually received their medication in the office. The drug fridge was locked and the key left in the lock. The inbuilt thermometer had been left in the lower drug room when the fridge was moved. In the large unit on the ground floor medication was stored on open shelves in a dark, cramped storage room fitted with a wash hand basin. Space was allocated for each resident’s medication, spare medication was stored in these areas or on the top shelf. Storage was not consistent and could cause errors to be made. Medication was dispensed here and carried to residents around the home. During this inspection it was seen that the home had purchased a trolley to transport medication safely to service users. The medication room on the ground floor had been refurbished and medication storage had been improved by the installation of a large lockable metal cupboard. Lighting had been improved. The metal drugs storage cupboard fixed to the wall space was seen to store medicines for internal and external use. The minimum and maximum temperature of the drugs fridge was being recorded daily. There were no daily records for the ambient temperature of the drugs room. The key to the drugs fridge was in the lock. The home had a copy of the British National Formulary as a source of reference. MAR sheets continued to be signed by two people and therefore the identity of the staff member administering medication was Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 17 unclear. No controlled drugs storage cupboard or register was available. The manager said that no service users are currently prescribed controlled drugs. If it became a necessity, an appropriate cupboard would be purchased and properly installed. The home has notified the CSCI of two incidents recently where service users medication was not administered by staff at the correct time. Appropriate action was taken immediately when the error was discovered to safeguard the service users involved and to inform their representatives. The prescribing GP and dispensing Pharmacist signed records for the covert administration of medication to service users, where it was necessary. Records included the agreement of the service users next of kin and Care Manager. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23. Service Users and their relatives know how to make a complaint and their views will be listened to and acted upon. EVIDENCE: The home provides a written complaints procedure which was available to service users and their representatives. The procedure explained the process of investigating complaints with clear timescales. The procedure included the contact details of the CSCI and of the responsible individual in the owning company. Making service users more aware of how to make a complaint or raise a concern was to be included in the new system to be introduced in the home, mentioned earlier in the report, of a residents ‘passport’ to the home and ‘talk time’ with service users. A service user spoken with knew how to make a complaint and exactly who to speak to. The Peripatetic Manager said they used complaints received in a positive way to improve practice. The home had procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of service users. The managers and staff spoken with demonstrated an understanding of adult protection procedures and how they would refer to the concerned agencies without delay. The managers confirmed that residents who lacked capacity were given access to advocacy services. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Service users benefit from living in a comfortable and homely environment where they could have familiar belongings to help them feel more at home. Service users would benefit from a full review with regard to the use of the staff call system and their individual needs. EVIDENCE: Those parts of the home inspected were clean and free from any odour. The premises are accessible to all current residents, with access and facilities for service users with a physical disability on the ground floor. The home has a garden to the side and back of the premises. Funding has been secured for a ramp and additional fencing, once completed, access will be improved. The managers said this work was due to start soon. The unit currently identified for more independent service users is vacant. The fire door in the lounge area has been replaced but work is not yet fully completed. The new door has no glass and has made the room rather dark. The short flight of steps leading down from the area would benefit from a second hand rail being fitted. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 20 Adequate recreational, dining, toilet and bathing facilities are available to service users within each area of the home. All bedrooms are single occupancy and highly personalised. Radiator covers have now been fitted in most areas to which service users have access. Laundry facilities are provided within each unit, some are domestic in nature. Service users are supported to do their own washing wherever possible Previous inspection identified that a staff call system was provided but not to all rooms used by service users. The managers stated that the system was rarely used by service users and was of limited benefit. It was agreed that a full review in consultation with service users and their representatives should be undertaken with regard to its use and benefit to service users. The managers agreed that the review should be undertaken in relation to the identified needs of service users and with reference to their risk assessments. A written summary of findings and decisions taken should be shared with the CSCI Specialist equipment, aids and adaptations are provided to meet the needs of individuals. A new bath for use by service users on the ground floor is to be installed. Some work on the overhead hoist-tracking device had already been started. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 The specialised care needs of service users could not always be reliably met by the home due to its reliance on the use of agency staff. Service users would benefit from a comprehensive review of staffing levels. EVIDENCE: The staff spoken with had a good understanding of their role. Job descriptions are provided to all staff with the exception of team leaders. A full job description for the team leaders role and responsibilities within the home was accessed from the Personnel Section of the owning company on the day of the inspection. A copy is to be provided to the CSCI Service users will benefit from the clarification of the role. The training records maintained by the home had improved. Each staff member had a staff training analysis sheet. A full staff-training matrix had been completed and was seen. Access to training courses required for individuals was being arranged. A number of comments were received prior to the inspection that staffing levels were not sufficient to meet the needs of service users. Rota’s were inspected. The home covers vacant shifts with the use of agency staff. The home continues to have difficulty recruiting and retaining sufficient permanent Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 22 staff. The area manager identified a number of vacant posts on the day of the inspection. A possible recruitment strategy was discussed. The homes dependence on agency staff, even when there are sufficient numbers of them increases the workload of staff directly employed by the home. The current situation is not conducive to service users well being or the motivation of permanent staff. Service users on the ground floor of the home benefit from sufficient staff due to their levels of dependency, while those on the first floor do not. These individuals are put at some degree of risk because of the number of staff provided. Staff support residents with cooking, cleaning and laundry tasks to develop their independence. No ancillary staff are employed by the home. The managers agreed to comprehensively review the staffing levels to confirm that there are enough staff hours at appropriate times to ensure that resident’s needs are met. The peripatetic manager stated that staff supervision had not been offered regularly recently. Plans were in place to improve the situation. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 40 41 42. While service users can be confident that the quality of their care is promoted by the philosophies and ethos of the home, the effectiveness of the overall management of the home is reduced by the lack of a consistent approach and clear leadership. EVIDENCE: The home is going through a difficult period with regard to the appointment and retention of a registered manager. A peripatetic manager has recently been seconded to the home to help support and induct the new manager who was appointed in August 2005. An application to the CSCI for registration and CRB clearance has not yet been received for the home manager who was unable to be present during the inspection. A previous manager resigned unexpectedly in August 2005, also without making application for registration. The management of the home has been inconsistent since the previous registered manager resigned in 2004; as a consequence, the home lacks a clear sense of direction and leadership. The peripatetic and external managers Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 24 present during the inspection had a good understanding of the areas in which the home needed to improve. They reported that planning was in place and discussed how improvements were to be resourced and managed. The peripatetic manager, currently responsible for the day-to-day operation of the home, was aware of their responsibilities and competent. Lines of accountability within the home and with external management are clear. External management was seen to be supportive and keen to overcome the current difficulties and move on. Management, both internal and external, had sought to keep the CSCI informed of any issue that could adversely affect the well being or safety of service users. Records showed some deficiencies in the care planning system; supervision processes and staff recruitment plans. Service users benefited from an open and inclusive atmosphere, which encouraged them to approach both the manager and staff with ease. Resident’s safety had been improved by the replacement of a fire door and refurbishment plans to bathrooms and the garden area were in evidence. Systems were in place to reduce the risk from fire, including staff training and regular fire drills. The manager stated the intention to clarify with the Fie Officer the most appropriate way to evacuate the building in the event of a fire. The current system could place some individuals at potential risk. Staff were seen to be diligent in ensuring COSHH requirements were adhered to except in that a container for soap powder was being refilled, consequently valuable data, designed to inform and protect the user had been obscured by wear and tear. Residents were protected by the arrangements for food hygiene, although this could be improved by the recording of hazard analysis records. The manager and staff spoke of training in safe working practices. Manual handling courses were reported to include training on specific disability equipment used by service users. Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 2 X 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Church Lane Score 2 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 2 2 X DS0000065345.V255791.R01.S.doc Version 5.0 Page 26 Yes 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 YA1 Regulation 4 (1) Schedule 1 Requirement The registered person shall compile a Statement of Purpose, which shall include the aims, and objectives of the home, the facilities and services provided and a statement as to the matters listed in Schedule 1. In that: The inspection identified that the emergency procedure for evacuation of the building in the event of fire needs to clarifed with the Fire Officer. Any revision to the procedure in relation to securing a service users safety, must be included in the document, shared with staff and service users where possible, or their representatives. Copies of both the homes revised Statement of Purpose and the Service User Guide(s) must be provided to the CSCI as discussed and agreed during the inspection. Timescale for action 01/02/06 Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 27 2 YA6 YA41 15 (1) (2) The registered person shall, after consultation with the resident where possible, or a representative of theirs, prepare a written plan as to how their health and welfare needs are to be met. In that: Care Plan formats must be revised. Once revised, formats adopted must ensure that all staff have easy access to the information about the service users conditions/diagnosis, up to date information from health care professionals involved in their care and details of any restrictions placed on the service user as a result of their diagnosis. Care plans must show exactly how identified needs are to be met. Daily records should comprehensivelly evidence how a service users identified care needs have been met and monitored. Fragmentation of individual service users information must be eliminated in daily records. A review of the benefits to service users of the staff ‘handover book’ should be undertaken as discussed. 01/03/06 3 YA20 13(2) The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medications received into the home. In that: Staff training and competency testing for the administration of rectal diazepam must continue to be organised for all the staff 30/01/06 Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 28 team. The medication fridge must be kept locked and secure. Written procedures must be in place for appropriate access and storage of the fridge key. The practice of leaving the key in the lock must stop. Medicine storage is reviewed, improved and updated in accordance with current guidance. Medicine for internal use is stored seperatly to medicine for external use. This requirement is repeated from previous inspection dated January 2005, July 2005 and the pharmacy inspection dated August 2005 Staff should have regular recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact during day to day practice. In that: the manager reported supervision had not taken place regularly for staff members due to the current difficulties regarding the availablity of a home manager. The registered person shall ensure that, at all times suitably qualified, competent and experienced people are working at the home in such numbers as are appropriate for the health and welfare of service users. The temporary employment of staff at the care home will not prevent service users from receiving such continuity of of care as is reasonable to meet DS0000065345.V255791.R01.S.doc 4 YA36 18(2) 30/01/06 5 YA32YA33 18(1(a) (b) 28/02/06 Church Lane Version 5.0 Page 29 their needs. In that: The homes current situation regarding reliance on agency staff should be closely examined by the manager. The situation should be addressed by the formulation of a suitable recruitment plan. Sufficient staffing numbers must be provided in all units in the home to meet the needs of service users. A full staffing review should be undertaken, without further delay, as discussed at the inspection. (This requirement is repeated from previous inspections dated 30th December 2003, 13th July 2004, 14th January 2005. 8th July 2005) The registered person shall ensure that, as far as possible, all parts of the home to which residents have access are free from hazards to their safety, any activities in which they participate are free from avoidable and unnecessary risks to their health or safety. Such risks are identified and eliminated. In that: Cleaning chemicals must not be decanted and stored in unmarked containers.. Radiators must have low surface temperatures or be guarded. In that: Work must continue to complete all of the radiators Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 30 5 YA42 13 (4) (a) (b) (c) 28/02/06 identified as needing to be guarded in service user areas. A second handrail leading down the steps from the top floor flat should be fitted. Work to replace and secure the fire door in the top floor flat must be completed. (This requirement is repeated from previous inspection dated 14th January 2005 and 8th July 2005.) 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 YA1 Good Practice Recommendations It is strongly recommended that the managers stated intention during the inspection of implementing new procedures to ensure that prospective and existing service users and/or their representatives are appraised of the detailed information in the homes statement of purpose and service user guides is put into practice. Additional information should be provided with regard to service users who have a physical disability and the situation for those individuals regarding fire procedures and arrangements to attend religious services. Information regarding responsibility for payment of holidays and of any activities, including aromatherapy and podiatry should be clearly stated in the service users guide and be consistent with any placement contract. In that: Previous inspections identified that although reference was made to additional costs paid for by residents, this did not include chiropody or toiletries. It continues to be recommended that if residents are requested to pay any additional costs, then all of these Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 31 2 must be documented. The manager said that prospective future service users will be offered the option of the facility of a holiday but this would be at extra cost. This must be clearly stated in documentation given and explained to service users. (This recommendation is repeated from previous inspection dated 30th December 2003, 13th July 2004 and 14th January 2005. 8th July 2005 ) It was recommended that additional information should be added to the pre-admission assessment with regard to physical disability where necessary. The manager said that this work is taking place. (This recommendation is repeated from previous inspection dated 13th July 2004 and 14th January 2005. 8th July 2005) It was strongly recommended that appropriate storage and recording facilities be provided for any controlled drugs. The temperature of the drugs storage rooms are recorded daily. The identity of the staff member administering medication was unclear due to the practice of double signing the medication administration sheets. It is strongly recommended that this practice stops. It is strongly recommended that the manager and medication administartors are conversant with The Royal Pharmceutical Society Gudelines for the Administration and Control of Medicines in Care Homes. It was strongly recommended that a review be undertaken and documented with regard to the use of the staff call system and the needs of individual service users In that: Staff call points continue to be located only in corridors and not in resident’s rooms. The home states that the system has limited viability for the service user group. A review of the system, which should include input from service users and/ or their representatives has still not been undertaken. (This recommendation is repeated from previous inspection dated 13th July 2004, 14th January 2005 and 8th July 2005) It was recommended that a ramp and additional fencing should be provided to the back garden in order to improve residents’ access. The manager reported that funding has been secured for the work to proceed and DS0000065345.V255791.R01.S.doc Version 5.0 Page 32 3 4 5 6 7 8 9 Church Lane 10 has been planned. It was recommended that all staff within the home be provided with current job descriptions. In that: Previous inspection identified that all current staff within the home were provided with job descriptions, with the exception of team leaders. The manager said that the document is now available. A copy should be sent to the CSCI (This recommendation is repeated from previous inspection dated 13th July 2004, 14th January 2005 and 8th July 2005.) It is very strongly recommended that the manager complete their stated aim of recruiting and developing a fully substantive staff group. The aim should be to provide an effective, stable team who know the service users and understand the homes way of working. Whilst the involvement of service users was acknowledged, it was recommended that the need for ancillary staff should be reviewed now that the refurbishments to the units was complete and functioning. In that: The manager said that no ancillary staff are employed by the home. It was mentioned that one support worker undertakes some domestic tasks within their caring hours. It continues to be recommended that a full staff review should be undertaken to ensure that support workers’ involvement in domestic tasks is not to the detriment of service users. (This recommendation is repeated from inspection dated 14th January 2005 and 8th July 2005.) It was recommended that the new manager, who commenced employment in August 2005, make an application for registration and CRB clearance with the CSCI . In that: Although the previous manager resigned unexpectedly without applying for registartion,a second manager has also not applied for registration or CRB clearance through the regulator. It is acknowledged that a CRB clearance has been obtained by the owner organisation for the employee. (This recommendation is repeated from inspection dated 14th January 2005 and 8th July 2005.) 11 12 13 Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 33 14 It was recommended that the manager complete their stated intention of the development of hazard analysis documentation following the environmental health officer’s recommendation. In that: Previous inspections identified that the acting manager was unaware if this had been undertaken. During this inspection, the manager was still unable to evidence records that this had been undertaken. (This recommendation is repeated from previous inspection dated 13th July 2004 14th January 2005 and 8th July 2005) Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Church Lane DS0000065345.V255791.R01.S.doc Version 5.0 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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