Inspection on 10/07/08 for Elm House

This inspection was carried out on 10th July 2008.

CSCI found this care home to be providing an Adequate service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm House 25/01/08

Elm House 23/01/07

Elm House 14/02/06

Elm House 08/06/05

Elm House 20/01/05

Elm House 21/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Elm House 192 Wivenhoe Road Alresford Colchester Essex CO7 8AH Lead Inspector Diana Green Unannounced Inspection 10th July 2008 11:00 DS0000017727.V368224.R01.S.doc Version 5.2 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 DS0000017727.V368224.R01.S.doc Version 5.2 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. DS0000017727.V368224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm House Address 192 Wivenhoe Road Alresford Colchester Essex CO7 8AH 01206 824443 01206 824443 jrassell@partnershipsincare.co.uk 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) Partnerships in Care Ltd Manager post vacant Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places DS0000017727.V368224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home may accommodate 3 persons of either sex who fall within the category of learning disability The home may accommodate one named person, aged 65 years and over, falling within the category of learning disability The total number of service users accommodated in the home must not exceed 3 persons The home may provide assistance to one additional person during the day in order they may use the rehabilitation kitchen. The staff member assisting this person must be additional to staff provided in the home. 25th January 2008 Date of last inspection Brief Description of the Service: Elm House is a registered care home providing accommodation for three people under the age of 65 years who have an acquired brain injury. This is one of two homes in the area owned by Partnerships in Care. An acting manager is currently managing both homes following the resignation of the registered manager in October 2005. The home runs two programmes of care: one for community rehabilitation and the other being long term supported living assistance for service users requiring maintenance of their rehabilitative state, who may also have behavioural problems, which can be managed within the home. Elm House is a detached house situated on the outskirts of the village of Alresford, approximately five miles from the town of Colchester. The home is within walking distance to the village amenities, which include a shop, pub and train station. Single room accommodation is provided, two of which have en suite facilities, one with a bath the other with a shower. The communal bathroom has a shower. The home has a comfortable, safe and fully accessible dining room, lounge and sitting room for shared activities or private use and a large back garden. Car parking for visitors is available at the front of the house. Previous inspection reports are available from the home, Partnerships in Care and CSCI website www.csci.org.uk. As at July 2008, the fees for accommodation were stated as ranging from £309.00 to £332.00 per day. DS0000017727.V368224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place on 10th July 2008. All of the Key National Minimum Standards (NMS) for Young Adults, and the intended outcomes, were assessed in relation to this service during the inspection. The report has been written using accumulated evidence gathered prior to and during the site visit, including the homes (AQAA) Annual Quality Self Assessment. The Annual Quality Assurance Assessment (AQAA), a self-assessment that focuses on how well outcomes are being met for people using the service, was completed by the home and returned to us prior to the visit to the home. Information received in the self-assessment provided us with some detail to assist us in understanding how the registered persons understand the service’s strengths and weaknesses and where they will address these. The inspection process included reviewing documents required under the Care Home Regulations. A number of records were looked at relating to the residents, staff recruitment and training, staff rosters and policies and procedures. Time was spent talking to the staff, and the acting manager. The residents accommodated at Elm House have sustained an Acquired Brain Injury (ABI) and have varying degrees of permanent cognitive disability following the early stages of recovery. This includes changes in concentration, awareness, perception and insight and, in some cases, long term and/or shortterm memory loss. Discussion with the residents regarding care delivery was not appropriate. The home has been without a registered manager since October 2005. What the service does well: Elm House provides specialist care for people with acquired brain injury, which includes an active rehabilitation programme and access to specialist services. Assessments are robust to ensure resident needs can be appropriately met at Elm House. There are regular reviews of residents needs undertaken by a multi-disciplinary team. Healthcare access is good and there is regular monitoring of changing needs with prompt referral to GPs and other healthcare professionals. DS0000017727.V368224.R01.S.doc Version 5.2 Page 6 Residents’ behaviour is closely monitored through a risk management approach that aims to uphold their choice and develop their independence. The premises are well decorated and provide a very comfortable and homely place for residents to live. The standard of cleanliness is good, laundry is cleaned efficiently and infection control practices are high. What has improved since the last inspection? What they could do better: Staffing levels were found to be inadequate at the site visit due to staff sickness that had not been covered. The one senior care assistant on duty had responsibility for the care of two residents together with a number of other duties to perform. This placed residents at risk in the event of an emergency and did not allow any flexibility for residents. DS0000017727.V368224.R01.S.doc Version 5.2 Page 7 The complaints procedure needed to be updated with the CSCI’s current contact details. The statement of purpose needed to be reviewed to describe in detail the service provided at the home. Several radiators were uncovered and there was no risk assessment in place. An electrical safety cupboard was also found unlocked. There were a number of medication issues that need to be improved. For example, the medication policy/procedures were in need of review, were not localised to the care home and did not provide sufficient guidance for staff. Medication supplies were not available for several days for one resident. When residents go on leave staff are removing medication from labelled boxes (secondary dispensing) rather than obtain a dosset box dispensed from the pharmacy. There was no arrangement in place to monitor the temperature of medication storage to ensure it remains within recommended safe temperatures. More leisure activities are needed for residents; the service is aware of this and plans to improve in this area. 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. The summary of this inspection report can be made available in other formats on request. DS0000017727.V368224.R01.S.doc Version 5.2 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 DS0000017727.V368224.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based on sampled standards 1, 2 & 3. People planning to live at Elm House can be assured their needs are assessed prior to admission to ensure the care home can meet their needs and that changing needs are fully considered when re entering the home after a period of time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a Statement of Purpose and Service User Guide that were comprehensive documents. The Statement of Purpose was viewed as part of the inspection and whilst it met regulatory requirements it had not been reviewed for some time. In particular the document should describe in more detail the service provided. The Service User Guide was last reviewed during March 2008 and provided comprehensive information for residents. However the complaints procedure needed to be amended to provide details of the CSCI Regional Cambridge office address rather than the local office. There were three residents at the home including one who was on leave. There had been no admissions since the previous key inspection. It was therefore not possible to verify admission procedures from the care files. However from discussion with the acting manager it was evident that potential residents would be assessed over a period by a multi-disciplinary team at Elm Park (the DS0000017727.V368224.R01.S.doc Version 5.2 Page 10 main unit). The records viewed confirmed that residents also received regular reviews from the team including the Consultant Neuropsychiatrist. One resident was visiting the home following a period of stay in hospital. The manager explained that this was to ensure they were gradually reintroduced to the home and to ensure their needs could be met. The completed Annual Quality Assurance Assessment (AQAA) stated that monthly resident meetings have been implemented to ensure that individuals have a say about the running of the home and that all residents are now involved in their care planning, risk assessments and programme planning. The service user guide had been updated to provide information of the two independent advocacy services that had been arranged on behalf of residents since the previous key inspection. These were ‘WISH’ for female residents and ‘RETHINK’ for male residents who visits the service monthly. During the site visit an advocate from ‘WISH’ was observed visiting a resident. DS0000017727.V368224.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 6, 7, 8 & 9. People living at Elm House can expect to have control of their lives and to be fully involved in planning their care and independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA informed us that the service continued to include all residents who are able in their Care Planning, Risk Assessment and Programme Development so that their views and wishes can be incorporated as appropriate. These were then discussed with residents to ensure that they understood the content and are provided with a copy if they choose. Two care plans of the people living at Elm House were viewed. Both included good detail of the residents’ care needs to enable care staff to understand and support individual needs and had been regularly updated. Each resident had an allocated named care worker who routinely meets with them to discuss any concerns, issues etc. and ensures that any issues are reported to senior staff to act upon as required. Care plans for different elements of care (physical health, behaviour, personal care, DS0000017727.V368224.R01.S.doc Version 5.2 Page 12 community access, communication etc.) were seen. Risk assessments (for example verbal aggression, physical aggression, wandering, eating & drinking etc.) were recorded. There was evidence of these being regularly reviewed during residents review meetings and at Care Programme Approach (CPA) reviews, demonstrating that the service ensured residents’ needs could be met through comprehensive multi-disciplinary and residents’ representatives involvement. The AQAA informed us that monthly residents’ meetings had been set up to ensure that each resident is given the opportunity to express their views and ideas relating to household issues, food, activities, programme issues and any other relevant issues. The minutes of these meetings were viewed during the site visit and confirmed they were accessible to residents. Each resident has access to an independent, specialist advocacy services who will represent them in meetings if required and to put forward the views of the resident to senior staff. The systems for managing residents’ monies were discussed with the acting manager. Monies are held in a Residents’ Joint account, which is coordinated by Elm Park. Small amounts for personal expenditure are released on request and collected by a member of staff. At Elm House, residents’ monies are held in a safe and transactions recorded with receipts of expenditure held. We were advised that the service was investigating other arrangements for managing residents’ monies. This was also confirmed from the AQAA submitted by the service. The care records viewed confirmed that individual risk assessments (for example behaviour, going out in the grounds, going out in the vehicle, cooking in the practice kitchen) were undertaken for each resident demonstrating that they were supported in taking responsible risks and that risks were minimised as far as possible. Policies and procedures in place demonstrated the home’s commitment to minimising identified risks and hazards and promoting the health and safety of residents. DS0000017727.V368224.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled inspected standards 12, 13, 15, 16 & 17. People living at Elm House cannot be assured that staffing levels will be sufficient to ensure they will always be provided with the opportunity to engage in activities that fully meet their social needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Due to the complex needs of people living at Elm House none were able to enjoy employment or educational opportunities. We were told that resident’s activity programmes were arranged to enable them to rehabilitate into the community. A resident’s activity plan viewed detailed activities that included listening to music, drawing, hair and beauty sessions and multi-sensory session (i.e. aromatherapy, had massage etc.), out for coffee and shopping. However the number and flexibility of activities was restricted by the staff availability and other duties they were expected to DS0000017727.V368224.R01.S.doc Version 5.2 Page 14 undertake. For example during the site visit, there was one senior care worker on duty to provide care for the two residents as another care worker was on sick leave and had not been replaced. In addition to personal care and supervision for the two residents, the senior care worker had spent an hour supervising another member of staff who was not working that day and was also required for liaison with workmen who were undertaking work in the home, an advocate who was visiting the home and answering the telephone. These levels are not acceptable as they place residents at risk, and do not enable individuals to fully participate in the local community. However the AQAA informed us that the service planned to review all of the residents’ programmes to ensure there is space for spontaneous leisure activities as well as structured rehabilitation. Staffing levels will need to increase to enable this to take place. The AQAA stated that the service encouraged and assisted residents in maintaining close links with family and friends by facilitating trips home, visits and leisure trips out with family and friends. Visiting was open access and the home’s statement of purpose referred to the visiting policy. The home’s daily routines were observed to be relaxed in the main apart from some interruptions as referred to in Standard 13. The records confirmed that staff addressed residents by their preferred name and they were observed to engage with them in a friendly and respectful manner. During the site visit we found that a resident had moved to another room to enable their room to be used for short-term rehabilitation. The acting manager stated that the resident had been fully involved in the decision. However this could not be confirmed from the records and furthermore a former resident’s bed was being stored in the room. The current resident’s clothing was observed stored on the bed, posing an infection control risk. The AQAA stated that weekly menu planning sessions now take place to ensure that all residents who are able play an active role in choosing their meals for the week. Due to the cognitive and communication difficulties of one resident their likes and dislikes have been based on staff knowledge and feedback from their family. During the site visit it was evident that the system for the home’s meal provision had changed since the previous inspection to enable the people who live there to maintain the maximum possible level of independence, choice and control in their lives. The acting manager explained that menus are planned with residents’ involvement and food purchased from the local supermarket. Advice for staff was available to assist them in encouraging residents to choose healthy options. Two residents were able to do their own cooking with support and were involved in shopping for their own meals. This was also confirmed from discussion with one of the residents. The lunchtime meal was observed and confirmed that a full choice was offered. DS0000017727.V368224.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based on inspected standards 18, 19 & 20. People living at Elm House can expect to have their personal and healthcare needs met but medication practices do not always ensure they are safeguarded from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents had their named care worker who was responsible for communicating any changes in personal and healthcare needs to the team. The AQQA informed us that since the previous inspection arrangements had been made to ensure all residents had access to an independent advocacy service. During the site visit an advocate was observed visiting one of the residents. From the records viewed and in discussion with staff it was evident that advice and support was obtained from physiotherapists, occupational therapists, speech and language therapists and dieticians. The service user guide stated that residents have a choice of GP. However most were registered with the local dispensing practice that supported the home and GPs also attended the home on request. The records confirmed that DS0000017727.V368224.R01.S.doc Version 5.2 Page 16 health care professionals saw residents regularly as part of their rehabilitation. These included occupational therapists, physiotherapists, speech and language therapists and a Consultant Neuropsychiatrist. The medication systems for the home were discussed with the senior care assistant. The home’s medication policy and procedures were viewed and found to be brief, not providing staff with sufficient guidance. The guidance referred to seven-day organisers, which were no longer used and were last reviewed in March 2005 therefore required updating. There was no list of staff signatures and initials to enable identification of who administered medication at a specific time and therefore effective auditing of practice. Medication was stored in a lockable metal medication storage cupboard that was secured to an external wall in the office. There was no monitoring of room temperature storage undertaken to ensure medication was stored within safe recommended temperatures (25°Centigrade). There was no separate storage for Controlled Drugs (CD) that is now a requirement for all care homes. The kitchen domestic type refrigerator was used for storage of medicines such as eye drops that required cold storage and temperatures were monitored to ensure this remained within recommended levels. Medication was supplied through the local GP dispensing practice in individual containers. Prescriptions were seen by the home for checking and were returned to the pharmacy for dispensing. Senior staff with appropriate training (confirmed from the training records) administered all medication. The medication for three residents was checked. Medication Administration Records (MAR) sheets were handwritten and were generally well recorded. However several anomalies were found, for example no strength of medication was recorded for two medicines, one prescribed lotion had no frequency recorded and codes (i.e. used for not given or refused) were not explained. One prescribed cream and another medicine had run out and was not followed up. The resident was therefore without both for 3 days. A resident was on leave and we were informed that their medication was removed from a labelled box and placed in an envelope for the period of leave. This is secondary dispensing and an illegal practice and places residents at risk of not receiving their medication as prescribed. DS0000017727.V368224.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon inspected standards 22 & 23. People living at Elm House can expect to have their concerns and complaints listened to and acted upon and to be protected by safeguarding adult procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints policy and procedures that included timescales for a response. The procedure was included in the statement of purpose and was displayed in the entrance hall of the home but needed review to clarify the CSCI’s role in receiving complaints and the new telephone number of the commission. No complaints had been received by the home or the CSCI since the previous key inspection. We were told that staff confirm they have read the procedures by making their signature and this was evident from the staff file viewed. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. Local procedures for Southend, Essex and Thurrock were available for staff guidance. Regular updated training was provided for all staff on safeguarding vulnerable adults and confirmed from the training records viewed. Since the previous key inspection and following an allegation, one safeguarding alert had been made. From discussion with the acting manager it was evident that this had been investigated appropriately in line with procedures and the staff member dismissed and referred to the POVA list. DS0000017727.V368224.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon inspected standards 24, 26 & 30. People living at Elm House can expect to have a clean, comfortable and homely place to live that is appropriate for their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA indicated that the home had improved since the previous inspection by ensuring regular maintenance checks take place each week and the decoration plan had started, resulting in the home looking fresher, airier and brighter. In addition a smoke shelter has been built in the garden for any residents who smoke to make use of. The premises are domestic in size and in keeping with the local community and were in the process of being redecorated throughout. A full tour of the premises was made including communal rooms, residents’ rooms, bathrooms, the laundry and the kitchen. All areas were cleaned to a satisfactory standard and there were no unpleasant odours. A maintenance person is employed by the organisation to DS0000017727.V368224.R01.S.doc Version 5.2 Page 19 maintain Elm House and other establishments. The home had a car to enable access to local amenities, transport to outpatients and outings. The records and staff practices confirmed that the building complied with the requirements of the local fire service and environmental health. All residents’ rooms were single and two rooms had en-suite facilities. Rooms were comfortably furnished in accordance with the client group. All rooms were above average size with space for personal possessions (music system, TV’s etc) and other items of furniture. The records viewed confirmed that regular maintenance of equipment was undertaken as required. The premises were observed to be clean and free from odour. Appropriate staff hand washing facilities (liquid soap, paper towels and foot operated bins) were provided throughout all relevant areas. The laundry room was domestic in size, clean and well organised. There were two washing machines and two driers. Systems were in place to minimise risk of infection via the use of disposable gloves and alginate bags for any laundry soiled by body fluids, placed directly in the washing machines; washing machines had the capacity to carry out sluice wash cycles. DS0000017727.V368224.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled inspected standards 32, 33, 34 & 35. People living at Elm House can expect to be cared for by experienced and skilled staff who are clear of their role and responsibilities but staffing levels do not always ensure residents’ needs can be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The senior care assistant was observed to be sensitive to residents’ needs and to have a good rapport with them but clearly felt unsupported being the only staff member on duty and having numerous other duties to attend to (ref. Standard 34). From discussion with the senior care assistant and an inspection of records it was evident that care staff are skilled, experienced and competent to meet residents’ needs. However the AQAA informed us that there were .85 care staff from a total of 3.85 with NVQ level 2 qualification which is less than the 50 needed to meet the standard. A further 3.85 were working towards NVQ level 2. The AQQA stated that there is a high staff:resident ratio in the home (currently 2:3) that enables active rehabilitation programmes to take place on a daily DS0000017727.V368224.R01.S.doc Version 5.2 Page 21 basis. However this was not evident at the site visit. There were two residents at the home and a third resident was at home on leave. Staffing levels comprised one senior care assistant; a member of care staff was on sick leave and had not been replaced. The acting manager was at another care home but attended later during the morning. The duty rota viewed confirmed that there were a number of times when only member of care staff was on duty. As discussed in standard 13, these levels are inadequate as staff are also required to undertake other duties (staff supervision, telephone answering, laundry, liaising with workmen, advocates etc.) and do not ensure that residents receive appropriate care and supervision. Furthermore it places residents and staff at risk in the event of an emergency. There had been no new staff appointed since the previous key inspection. The recruitment process was discussed with the acting manager who confirmed that all the required checks are undertaken at the organisation’s headquarters. The staff file missing at the previous inspection was viewed and found to contain all the required checks that had been obtained prior to employment for both (two satisfactory references, Identification, full employment history, Criminal Records Bureau Disclosure (CRB) and POVA first check). The file also contained evidence of induction, appraisal and supervision. The AQAA informed us that the service planned to improve the induction process to ensure it falls in line with the Common Induction Standards. The training records for one care staff member was inspected and confirmed that since the previous inspection training had been provided in health and safety level 2, food safety, fire safety. Manual handling, equality and diversity, safeguarding adults and infection control were also planned for September 2008. DS0000017727.V368224.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 37, 39, 41 & 42. People living at Elm House can expect the home to be well managed with good standards of health and safety that protects them and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an acting manager, a speech and language therapist who had responsibility for covering the management of Elm House and Elm Cottage (another small care home owned by the organisation), spending two days at each service. The duty rotas confirmed which home she was at on which day. A new manager had recently been appointed and was due to commence employment in the next few weeks, which would enable the acting manager to return to her clinical role. It is expected that having a manager in post will ensure the home is managed more effectively in future. DS0000017727.V368224.R01.S.doc Version 5.2 Page 23 The AQAA informed us that a Quality Audit System had been set up and implemented with a monthly timetable of audits planned throughout the year. This was confirmed from the records viewed and in discussion with the acting manager who explained that the home had a quality policy and a quality plan that had been introduced in May 2008. Regular audits were planned to be undertaken in health and safety, care planning, risk assessment, needs assessment, medication, care assessment etc. The acting manager explained that initially herself and the new manager would undertake audits jointly. Reports were available as required under regulation 26 and confirmed from those viewed. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, medication records, statement of purpose, service user guide, staff recruitment and training records, maintenance records and fire safety records. The home had a health and safety policy and procedures for staff guidance. The records viewed confirmed that new staff received health and safety training and regular updated training was provided. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. gas, electricity certificates, annual PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment, fire alarms and emergency lighting, hot tap water temperatures, etc.). During a tour of the premises it was noted that not all radiators were covered and there was no risk assessment recorded to demonstrate that risks had been minimised. Also a cupboard with electrical safety equipment was found unlocked posing a risk to residents. DS0000017727.V368224.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 3 X 3 2 x DS0000017727.V368224.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA20 Regulation 13 (2) Requirement To ensure the safe administration of medicines: 1.There must be no secondary dispensing. 2.Medication must be available as prescribed. 3. Monitoring of room temperatures must be undertaken and appropriate action taken if they exceed the recommended 25° Centigrade. 4. MAR sheets must accurately mirror the instructions on the label/prescription. 5. Policies and procedures must be reviewed and developed to include full guidance for care staff. 6. Medicines with a limited shelf life must have the date of opening recorded on the container. 7.A list of staff signatures and initials must be recorded to enable auditing of practice. 8. Codes used must be explained. Staffing levels must demonstrate that they are sufficient to ensure the residents’ needs are fully DS0000017727.V368224.R01.S.doc Timescale for action 31/08/08 2. YA33 18 31/08/08 Version 5.2 Page 26 met, especially in relation to social needs. The introduction of long shifts must not impact negatively on the standard of care provided to residents. This requirement was not met within the previous given timescale of 01/04/08. New staff employed to work at the home must receive an induction that meets the Common Induction Standards through planned working and have their understanding assessed and ensure that for the duration of the induction training a member of staff who is appropriately qualified and experienced is appointed to supervise the new worker. This process of induction for care staff new to the home and/or inexperienced provides essential training and support to ensure safe and consistent practice that is appropriate and enables managers to assess their competence, understanding and ability to fulfil their role and residents are not subject to potential harm and/or neglect. This requirement was not met within the previous given timescale of 01/04/08. To ensure the safety of residents: 1. Radiators must be covered as part of a risk assessment. 2. Electrical safety cupboards must be kept locked. 3. YA35 18(2) 31/08/08 4. YA42 13(4) 30/09/08 DS0000017727.V368224.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Good Practice Recommendations Standard YA1 The statement of purpose should be reviewed to personalise it to Elm House, to describe the service provided in detail and to include accurate contact details of the CSCI. YA6 Care planning should be further developed to provide a more person centred approach, with greater focus on identifying more preferences, maintaining strengths and abilities and detail on promoting independence and self worth. YA20 Advice should be obtained from a pharmacist to ensure the CD storage cupboard meets the requirement for care homes as set out in the Medicines Regulations 2007. YA8 Management and staff should familiarise themselves with the Mental Capacity Act (MCA) 2005, code of conduct, implementation and how it affects their work and ensure that the service’s assessment and care planning records are consistent with MCA code of practice guidelines. This area should be covered in the homes induction and training programme. YA22 The complaints procedure should be reviewed to include accurate contact details of CSCI. 3. 4. 5. DS0000017727.V368224.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000017727.V368224.R01.S.doc Version 5.2 Page 29 - 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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