CARE HOMES FOR OLDER PEOPLE
Easthill Home For The Deaf Ashey Road Ryde Isle Of Wight PO33 3EB Lead Inspector
Mark Sims Unannounced Inspection 31st January 2006 10:00 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 Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Easthill Home For The Deaf Address Ashey Road Ryde Isle Of Wight PO33 3EB 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 564068 01983 811857 The Hampshire, Isle of Wight and Channel Islands Association for the Deaf People Mr Gerard Lawrence Naggs Care Home 15 Category(ies) of Sensory impairment (15) registration, with number of places Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: Easthill is a specialist home providing care and accommodation to 15 people with specific hearing difficulties under the category of sensory impairment. The home is a two storey detached property offering dining space, two lounges and an activities room. Access to all parts of the building is possible via a passenger lift and stair lift, although most service users are mobile independent individuals. The property is situated at the junction of Pitt Street and Ashey Road and is within half a mile of the towns shops and facilities. Whilst the distance might prevent most service users from walking into the town, the provision of a minibus means that the home is able to facilitate regular trips and outings for people. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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 Easthill Residential Home. The inspection focused on those core standards not addressed at the 13th July 2005 inspection and various sources of evidence were considered in the formulation of judgements: records, observations and discussions with staff / management. The service users were not interviewed at this inspection as the support of an interpreter is required to converse with the people living at Easthill, as they are profoundly deaf. A second (additional) visit has been arranged for the 27th of February 2006, during which the inspector will focus specifically on issues relating to three standards (10, 13 & 14). What the service does well: What has improved since the last inspection?
Significant improvements have been made by the company in addressing many of the shortfalls identified at the last inspection. Staff now have access to e-mails, (although these are not individualised accounts, as they perhaps should be), as well as access to Intranet and Internet services. The recruitment and selection process has been improved dramatically, although there are still some errors being made regards interrogating the information collected and not always collection of adequate supporting documentation. The deputy manager (responsible for training and development) has worked hard to ensure that staff both have the opportunity to access National Vocational Qualification (NVQ) courses and are also well supported should they wish to undertake an NVQ. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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 Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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. All core standards within this section were reviewed during the inspection of the 13th July 2005. EVIDENCE: None. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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’s medication system is muddled and lacks direction of policy guidance. EVIDENCE: The medication system employed at the home requires attention, as medicines were found stored in a haphazard and disorganised manner, which could lead to mistakes in administration. All medications should be stored under the name of the person they have been prescribed for and should be divided in such a way as to ensure they cannot be mixed-up or confused. The manager should regularly audit the medication system, ensuring along with other considerations that medicines are correctly stored at all times. The manager should also provide staff with access to an up to date and informative medication procedure, as no policy or procedure could be found during the inspection. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 10 The company should also consider placing an index on all of its policy and procedural files to aid the locating of specific policies, as currently staff are having to leaf through an entire folder to find the information they require. Whilst the above issues were identified, the company has overseen some positive developments with regards to the management of service users’ medications, with 16 out the home’s 23 staff having completed a BTEC award in the administration of medications. Additionally some of the general practices of the staff should also be praised, as all creams were stored separately from oral preparations, all medications had been checked into the home and documented appropriately and all Medication Administration Records (MAR) completed accurately. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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. Standards 13 & 14 will be reviewed at the additional visit scheduled for the 27th February 2006. EVIDENCE: None. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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 home has had to be creative in communicating to service users how the complaints process operates, as many service users have no written and/or reading skills. EVIDENCE: The above judgement does not mean that all of the service users living at the home now or in the future are unable to read, however the large majority have never been taught this skill and therefore a written complaints process is of little value. In order to overcome this problem and ensure people are familiar with the concept of making complaints and know whom they can approach to raise concerns, etc., the home requires all care managers or relevant supportive resources to communicate, via sign language, how the complaints process works. The home or staff also ask each care manager involved in care placement reviews to check with their client if they have any concerns or complaints and details of people’s feelings or satisfaction with the service can then be documented on the review record. Two care review records were inspected, both emanating from different authorities and both substantiating the claim that service users are asked about areas of concern or complaint and their general levels of satisfaction
Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 13 with the home, both service users communicating their appreciation for the service delivered. The service users also attend regular meetings about the running or day-today operation of the service and can at these meetings discuss concerns or changes they wish to see implemented in the home. The inspector intends to review how people make complaints when he meets with service users on the 27th February 2006. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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): Standard 26. The home was clean and tidy with no odours detected during the tour of the premises. EVIDENCE: A brief tour of the premises was undertaken, specifically to consider issues of cleanliness and hygiene. During the tour it was established with the deputy manager that the home does not employ a dedicated domestic and that all cleaning tasks / duties are undertaken by the care staff. The day carers are responsible for keeping service users’ bedrooms clean and tidy and the night care staff undertake the cleaning of the communal areas of the home. Whilst this arrangement is not ideal, the regulatory body preferring a dedicated domestic staff team to be employed, the home is sufficiently well staffed to
Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 15 enable care staff to complete these tasks and still have time to meet the social and health care needs of the service users. During the tour it was noted that the premises was clean and tidy and that no offensive odours, etc. were detectable. It was also evident that all communal toilets, etc. were equipped with paper towels liquid soaps and that the staff had access to gloves and aprons. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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 27 & 29. Access to training and development is reasonable. Whilst improvements have been made to the recruitment and selection process employed at the home, some mistakes or oversights are still being made. EVIDENCE: As indicated within the summary the deputy manager, responsible for training and development, has been successful in securing a number of places on NVQ level 2 courses or above with 8 staff currently possessing an NVQ 2 and 4 more staff due to complete their courses shortly. These successes mean the home’s percentage of people holding an NVQ level 2 or above will be 75 , well above the 50 ratio suggested. In addition to the NVQ courses made available to the staff the Hampshire Deaf Association (HAD) also offer staff, via the deputy manager, the opportunity to attend core-training events: • • • • • Moving and Handling Health and Safety Fire Safety Infection Control Food Safety, etc. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 17 Staff are also afforded the opportunity to attend courses that are not considered core to the business but are essential for the care and protection of the service users: • • British Sign Language Medication Courses, etc. The HAD has implemented some changes to how it manages the recruitment and selection of new staff, although ultimately the manager has the overriding responsibility for employing new staff members. At this visit it was pleasing to know how the way the system was structured and managed was more ordered and organised and that the employee files were kept in a more logical and neat fashion. Four staff’s files were inspected during the visit and all of them contained detailed application forms, evidence of reference checks and copies of Criminal Record Bureau (CRB) checks, etc. However, it was noticed that the dates for the return of the CRB forms did not coincide with the dates the staff members commenced employment, which is not an issue if a Protection Of Vulnerable Adults (POVA) check has been returned, whilst awaiting the full CRB. However, the files contained no evidence of a POVA check having been returned prior to the staff member commencing employment, which is a breach of the regulations, it was also noted that gaps in employment histories or approaches to relevant references were not always being made, as required in the Care Homes Regulations 2001 and amended Regulations 2004. In addition to this, the files were also missing photographs of the staff member and/or supporting documents that established the person’s identity, as also required in the regulations. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 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 31 & 33. The manager has worked at the home for a large number of years and he is well known to the service users, visitors and health and social care professionals who visit. The best interests of the service users are promoted by the association’s ethos and desire to ensure they are actively involved in the running of the service. EVIDENCE: The manager possesses a professional qualification and is an experienced leader who has worked for the HDA for over 20 years. Currently he has no formalised management qualification, which to date has not affected his role, although as regulatory expectations change and operational goals shift his knowledge base could stagnate affecting this situation and his future performance. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 19 In addition to concerns regarding the manager’s managerial qualifications are concerns with regards to his future commitment to the service, as he is considering retiring. This comment is not intended to question his commitment to the service users, which appears to remain steadfast, but his desire to embrace some of the changes the HAD are proposing and which would require considerable time and effort to oversee and develop. Quality audit or how services ensure they are meeting the needs of the service users are of considerable importance generally and within Easthill are met using a variety of process including: regular unannounced visits being made to the home in accordance with Regulation 26 of the Care Homes Regulations 2001 and a report produced, regular visits by the HDA Chief Executive to meet with service users and staff, regular meetings between service users, the management and staff and regular case or placement reviews with care managers, service users and staff. Whilst it was not possible to discuss these issues directly with the service users at this visit, it will be addressed on the 27th February 2006 visit, although general observations would suggest people are happy with the service provided. Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 20 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 2 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 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X X Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation Requirement Timescale for action 10/03/06 2 OP29 Regulation The home’s arrangements for 13. storing service users’ medication must be amended; and details of the association’s medication policy made available to the staff. Regulation The association must review its 10/03/06 19. procedure for recruiting and selecting new employees, ensuring that all relevant checks, etc. are completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Easthill Home For The Deaf DS0000012483.V283228.R01.S.doc Version 5.1 Page 22 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
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