Inspection on 26/04/05 for Cloyda

This inspection was carried out on 26th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cloyda 27/11/07

Cloyda 10/05/07

Cloyda 01/08/06

Cloyda 13/04/06

Cloyda 15/09/05

Cloyda 01/11/04

Cloyda 12/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Cloyda 227 Malden Road New Malden Surrey KT3 6AG Lead Inspector Diane Thackrah Unannounced 26th April 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. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cloyda Address 227 Malden Road, New Malden, Surrey, KT3 6AG 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) 020 8949 1839 020 8949 1839 Mr Vallabhbhai Morarbhai Patel, Mrs Dahiben Vallabhbhai Mrs Avril Smith Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Old Age, registration, with number not falling within any other category (25) of places Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 01.11.2004. Brief Description of the Service: Cloyda is a residendial care home registered with the Commission for Social Care Inspection to provide care for up to thirty five people over the age of sixty five, ten of which may have a diagnosis of dementia. The home is a large detached property, located on a main road close to the centre of New Malden. There is easy access to the A3 and to publis transport. Accomodation is provided over three floors, all of which can be accessed by passenger lift. There is a large garden to the rear of the property. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 26 April 2005 between 10.50 and 14.30. A partial tour of the premises took place and care records were examined. The Registered Providers, Registered Manager, Deputy Manager and two staff members were spoken with. Comments were received from a visiting health care professional. Five service users also gave the inspector with their views on the home. On the day of this inspection service users appeared happy and well cared for. However there are a high number of Requirements that have not been met from the last inspection of the home. Some of these Requirements have been ongoing. What the service does well: What has improved since the last inspection? Decoration and furnishings in the home are being gradually improved creating a homely and comfortable environment in some areas. The complaints procedure has been made more accessible, allowing service users and they’re relatives to know that their complaints will be addressed and taken seriously. Extra activities have been made available for those service users who wish to participate in these. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 6 What they could do better: Service users and their relatives must be given more opportunities for being involved in the drawing up of and reviewing of Service User Plans. The practice of storing medication in the kitchen fridge must not continue. All medication must be stored securely in order to protect the health and safety of service users. More thorough recruitment procedures must be followed based on ensuring the protection of service users. Also, practices for ensure that service users are protected from abuse must be improved. Some service users do not have hot water in their bedrooms and there are no systems in place for ensuring that water temperatures are monitored. This leaves service users at risk for being scalded, and neglects service users rights to having hot water in their bedroom. The health, safety, comfort and well being of service users is being compromised as some flooring in the home is not fitted well and there is a risk of tripping. Service users are also at risk, as some areas in the garden have not been made safe. Two rooms in the home have badly stained carpets that must be replaced. There is a lack of induction and development training for staff members. This leaves service users at risk from being cared for by people who are not competent to do their jobs. There is a need for a quality assurance system to be developed to ensure that the home is run in the best interests of service users. A routine programme of maintenance must be implemented. Also procedures must be implemented to ensure that service users and staff members are not at risk from bad practice in relation to fire safety, the use of hazardous substances, electrical appliances. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 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. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The Service User Guide has been improved. It now contains all information that service users and their relatives need to ensure that they have opportunities for exercising choice. EVIDENCE: A Statement of Purpose and Service User Guide have been developed. Both documents have been produced in clear formats. As a result of a Requirement made at the last inspection of the home, a copy of the home’s complaint procedure has been added to these documents. There is also information about how to make a complaint to the local office of the Commission for Social Care Inspection. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 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) 7 and 9 There have been improvements in the arrangements for reviewing Service User Plans, aimed at ensuring that the existing and changing health, social and personal care needs of service users are addressed. However service users and their family members are not fully involved in this process. This places service users at risk of receiving care that does not take into account their wishes. Some progress has been made in the way medication is handled in the home, however, ongoing shortfalls in the safe handling of medication places service users at risk. EVIDENCE: Individual plans of care have been developed for each service user. These provide good detail about the needs of service users, and about how staff members should address these needs. Service User Plans address how service users will be treated with dignity and respect and include information about what service users can do independently. There was documentation detailing that Service User Plans had been reviewed on a monthly basis, and updated to reflect changing needs. Current practice in the home is that the Registered Manager or Deputy Manager review and update Service User Plans. Service users and their relatives must be given further opportunities for being involved in the drawing up, and reviewing of their Service User Plan. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 11 All policies and procedures in relation to the safe handling of medication are now in place. There were two items of medication stored in an unlocked kitchen fridge. This issue has remained unaddressed since the last inspection of the home. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 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) 12 and 15 Social activities are varied and take into account the preferences of service users. Meals are wholesome and balanced and promote the health and well being of service users. EVIDENCE: A number of service users were taking part in an exercise group in the lounge at the time of this inspection. There are two smaller lounges were other service users were watching television. Staff members provide a daily structured activity such as quizzes or art and crafts. One service user said that they liked spending time in their bedroom. Some service users have chosen to have a television in their bedroom. The Registered Manager said that extra activities have been provided since the last inspection of the home. These have included visits by entertainers on a two weekly basis. The menu for the day was displayed on the notice board. This did not indicate that there was a choice of meal, however one staff member stated that if a service user does not want the meal displayed, they could be provided with an alternative. The meals served on the day of this inspection appeared wholesome and were well presented. Some service users ate in the main dining room and others ate in the lounge. Staff members provided sensitive and discreet support to service users. There has been in-house training in Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 13 feeding for staff members. The cook confirmed that she was currently undertaking a training course in ‘Feeding and Nutrition’ Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 14 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) 17 and 18 There are systems in place for ensuring that service user’s legal rights are upheld. There has been no progress in improving recruitment practices to ensure that service users are fully protected from abuse. EVIDENCE: Service users are supported to use the postal voting service if this is their wish. There is a policy on Confidentiality and staff members must read this as part of their induction programme. The Registered Manager said that she has provided service user’s family members with information about services offered by the local branch of ‘Age Concern’ Four staff members have been recruited in the home since the last inspection. Criminal Records Bureau and Protection of Vulnerable Adult list checks were not available for two of these staff members. In addition, to written references were available for only one of these new staff members. These issues remain unaddressed despite Requirements being made following the last two inspection visits, so an immediate requirement was issued and complied with within the timescale. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 15 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) 19, 24, 25 and 26 Some improvements have been made to the décor in the home providing a more pleasant environment for some service users to live in. Limited improvements have been made regarding maintenance and health and safety. These outstanding matters leave service users living in unsafe and uncomfortable surroundings. Hygiene standards in the home are good. EVIDENCE: A number of bedrooms have recently been redecorated. Improvements have been made to the front of the property including cracked areas in the driveway being made good. The garden pond has been covered but the covering does not provide sufficient protection. In addition there is a vegetable patch in the garden that is uneven and poses a health and safety threat to service users. The Registered Manager said that lighting in bedrooms has been reviewed and currently meets the needs of service users. However, lighting in the ground floor toilet is not sufficient and poses a risk to safety. These issues remain unaddressed despite Requirements being made at the last inspection visit. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 16 Several areas in the home have badly fitted carpets or flooring. These areas include the ground floor hallway and the first floor bathroom. A toilet on the first floor and bedroom 20 has flooring which is very badly stained. The Deputy Manager said that the Registered Providers carry out daily maintenance checks on the building, however, there were no records to back this up. Some bedrooms do not have locks. One service user said that they would like to have lock on their bedroom door. Water temperatures in some bedrooms were distributing water at a temperature close to 43 degrees. However, no hot water could be obtained from bedroom 18 and only tepid water could be obtained from bedroom 4. There were no records indicating that water temperatures are monitored, despite this being made a Requirement following the last inspection visit. Bedrooms viewed were homely and had been personalised. The home was clean and free from offensive odours throughout. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 17 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) 27, 29 and 30 Staffing numbers are sufficient to meet the needs of current service users. However, induction training does not fully provide staff members with the information they need to be competent to do their jobs. The procedures for the recruitment of staff are not robust with much of the information required prior to employment not in place. This has been an ongoing issue and does not provide safeguards to offer protection to service users. EVIDENCE: Service users spoken to said that staff members were helpful. A visitor to the home reported that staff members were caring and that numbers seemed appropriate. Staffing numbers were sufficient at the time of this inspection. In addition to care staff there is a cook and a cleaner. Staff files indicated that the home had not undertaken all of the necessary recruitment checks to ensure protection of service users. Criminal Records Bureau and Protection of Vulnerable Adult list checks had not been requested for two staff members. Two references were available in only one file. This issue has not been addressed despite it being raised at the last two inspections of the home. Staff members spoken with did report that they had been interviewed for their post, and that they had been required to provide one reference and identification documentation. Staff members are not provided with the General Social Care Council code of conduct. At the last inspection the Registered Providers were required to provide a Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 18 training and induction programme that would meet National Training Organisation standards and specifications. This has not been implemented. The Registered Manager said that the majority of the care staff team have completed, or are currently undertaking training at NVQ Level 2 in Care. Staff members spoken with confirmed this. There were records indicating that some training has occurred in food hygiene, chiropody, fire safety, dementia awareness, bereavement support and health and safety. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 19 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) 33, 37 and 38 There has been no progress with regards to the implementation of a quality assurance system and an annual business plan. A number of required records are not available in the home. Some health and safety issues have been addressed, however, a number remain outstanding. These issues result in some practices that do not promote and safeguard the health, safety and welfare of service users. EVIDENCE: There is a complaints procedure, which has been designed to gain feedback from service users and any other stakeholders. A quality assurance form has been devised since the last inspection of the home, aimed at seeking views about the quality of the home. However, this has not been provided to service users, their family members or friends or any other visitors to the home. A business plan is not in place. In addition, there is no system in place for the monitoring of the service by the Registered Provider in line with Regulation 26. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 20 There are a high number of Requirements identified during this, and a previous inspection of the home that have not been met. Systems have been put in place for the testing of legionella since the last inspection. However, Requirements made about providing safety testing of portable appliances and risk assessments regarding potentially hazardous substances have not been met. There is a cupboard with a lock that contained cleaning materials. However, this cupboard was found to be unlocked during this inspection. Records were available detailing that some staff members have undergone training in fire safety. Staff members spoken with were able to describe good practice for following in the event of a fire. Fire drills occur and there is regular testing of the fire alarm system, fire fighting equipment and emergency lighting. In general, fire exits were free from obstructions. However, garden plants were stored in an outside pathway leading from the fire exit. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 1 x x x x 3 2 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 1 x x 1 x x x 2 2 Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 22 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 7 Regulation 15 (1) & (2)(c) Requirement Timescale for action 16.07.05 2. 9 13 (2) 3. 18 19 (1)(a) 4. 19 12 (1)(a) 13(4)(a)& (c) 23(1)&(2) The Registered Providers must ensure that service users and their relatives are given oppurtunities for being involved in the drawing up and reviewing of the Service User plan. The Registered Providers must 16.07.05 ensure that all mediction retained in the home is stored securley. (Timescale of 01.01.05 not met) The Registered Providers must 01.01.05 ensure that satisfactory Criminal Records Bureau and Protection of Vulnerable Adults list checks have been obtained for each staff member prior to them commencing work in the home. (Timescale of 01.01.05 not met) The Registered Providers must 16.07.05 ensure that: 1. The garden pond is made safe. 2. The vegetable patch is made safe. 3. There is a programme of routine maintenance, with records being maintained and made avialable for inspection. (Timescale of 01.02.05 not met) 4. lighting in the ground floor toilet is adequet. 5. The carpets in the ground floor hallway and first Version 1.30 Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Page 23 5. 25 6. 29 7. 30 8. 33 floor bathroom are refitted and do not have rucks. 6. The carpet in bedroom 20 and flooring in the first floor toilet are replaced. 12 (1)(a) The Registered Providers must 13 ensure that: 1. Water which is (4)(a)&(c) at a tempreture close to 43 degrees is available from outlets in bedrooms 4 and 18. 2. Water tempreatures are monitored on a regular basis and records of this monitoring are maintained and made available for inspection. 19 (1)(a) The Registered Providers must Schedule ensure that all information 2 detailed in Schedule 2 (as ammended) is obtained for each staff member prior to them commencing work in the home. (Timescales of 01.06.04 and 01.12.04 not met) 18 The Registered Providers must (1)(a)(c)& ensure that: 1. There is a staff (i) induction and development programme which is in line with National Organisation for Social Care specifications. (Timescale of 01.03.05 not met) 2. Individual records are maintained of all training, inculding induction training, for each staff member. 12 (1)(a) The Registered Provider must 24 (1)(a) ensure that: 1. An effective &(b) 26 quality assurance programme, (4)(a)(b)& involving service users, staff (c) & members and visitors is (5)(a) implemented. 2. An annual development plan is developed and made available for inspection. 3. Written reports detailing the quality of the service provision, and in line with Regulation 26 are complied at least monthly. A copy of these reports are provided to the Commission for Social Care G53-G53 S13381 cloyda v211355 260405 stage 0.doc 16.07.05 16.07.05 01.08.05 01.08.05 Cloyda Version 1.30 Page 24 Inspection. 9. 38 23 (1)(a) 12 (1)(a) The Registered Providers must ensure that: 1. Portable appliance testing occurs. 2. Risk assessments are in place in relation to COSHH products. (Timescale of 01.01.05 not met) 3. All fire exits and escape routes are kept free from obstruction. 01.08.05 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. 2. 3. Refer to Standard 24 29 33 Good Practice Recommendations The Registered Providers should ensure that risk assessments are in place were service users do not have a bedroom door key. The Registered Providers should ensure that all new staff members are provided with a copy of the Generl Social Care Council Code of Conduct. The Registered Providers should consider gaining feedback from service users and their relatives through meetings held in the home. Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 25 Commission for Social Care Inspection CSCI 8th floor Grosvenor House 125 High Street, Croydon CR0 9XP 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 Cloyda G53-G53 S13381 cloyda v211355 260405 stage 0.doc Version 1.30 Page 26 - 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!