Inspection on 08/09/08 for Ernest Luff Home

This inspection was carried out on 8th September 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ernest Luff Home 06/09/07

Ernest Luff Home 23/11/05

Ernest Luff Home 22/07/05

Ernest Luff Home 02/06/04

Ernest Luff Home 18/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Ernest Luff Home 2-4 Luff Way Garden Road Walton On Naze Essex CO14 8SW Lead Inspector Francesca Halliday Unannounced Inspection 8th September 2008 09:00 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 Ernest Luff Home DS0000017812.V371250.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 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. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ernest Luff Home Address 2-4 Luff Way Garden Road Walton On Naze Essex CO14 8SW 01255 679212 01255 674414 eluff@tiscali.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) The Ernest Luff Homes Limited Mr Derek William Carpenter Care Home 64 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (53) of places Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2007 Brief Description of the Service: The Ernest Luff Home is situated in Walton-on-Naze, Essex and provides accommodation in two buildings. The home was originally established to run along Christian principles and still has a strong Christian ethos. The Ernest Luff House provides accommodation for 37 people over the age of 65 on two floors. Olive Luff House provides accommodation for 17 people over the age of 65 on the first floor and 11 people over the age of 65 who have dementia on the ground floor. Lifts and stairs provide access to the first floors of both buildings. Both houses have gardens. The two houses are situated on a site that also includes a sheltered housing scheme and a day care unit run by the same charitable foundation. There are shops within walking distance and churches and public transport is close by. There is ample parking in the grounds. Weekly charges at the time of inspection in September 2008 were between £370 and £440 for general care (depending on whether the bedroom had an en-suite facility) and £550 for dementia care. Additional charges were made for private chiropody, private audiology (for hearing tests), hairdressing, toiletries and newspapers. Respite care for residents with physical care needs was also available. Information about services provided by Ernest Luff Homes Ltd can be found in the home’s statement of purpose, service user guide and brochures. Ernest Luff Home DS0000017812.V371250.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 one star. This means that people who use this service experience adequate quality outcomes. This key inspection was carried out on 8th September 2008 and completed during a short visit on 10th September. The term resident is used throughout the report to refer to people who live in the home and the term “we” refers to the Commission for Social Care Inspection. All the key national minimum standards (NMS) for older people were assessed during the inspection. The report has been written using evidence accumulated since the last key inspection as well as that gathered during the site visits. The report includes views and comments from two relatives spoken with during the inspection, from eight surveys completed by residents, three completed by relatives and one completed by staff and returned to the commission. We also looked at some of the residents’ and relatives’ responses to surveys carried out by the home. We carried out a tour of parts of the premises and sampled the records held in the home. We also looked at the annual quality assurance assessment (AQAA) completed by the manager. Time was spent talking to the registered manager, the chief executive of the company and eight of the staff. We also had chats of various lengths with seven residents during the inspection. What the service does well: Residents told us that they were happy with the care and support provided in the home. One resident said “The home is comfortable and friendly” and another told us “It’s a good place to live”. A resident who responded to our survey told us “The home is very good and the staff are very caring and helpful”. A relative responding to our survey told us “If a survey was done on all the residential homes in Essex, Luff Homes would be very close to the top”. One resident told us that they could see the difference the activities made to residents in the home “in their liveliness and the way that their faces lit up”. The home was very clean and there were no unpleasant odours. One resident praised the “very high standard of cleanliness”. A relative described the home as “wonderful – it’s where I’d choose to live myself”. Another relative told us “The home is excellent and we are delighted to have a place here for my mum”. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 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 Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1, 3, 5 (standard 6 not applicable) Quality in this outcome area is good. Prospective residents can be confident that they will receive an assessment of their needs before making a decision about admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a range of information for prospective residents, their representatives and their families, which gave clear information about services provided. Prospective residents were encouraged to visit and spend time in the home before making a decision about admission. A month’s trial period was offered before a decision was made on taking up a permanent placement in the home. The home offered respite care for older people with physical care needs and a single room was kept solely for this purpose. Residents confirmed that they had received a contract. One relative who responded to our survey told us “staff have been very supportive helping us through the adjustments to Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 9 residential care. We were given a draft contract to look at prior to completing a full contract, to give us time to fully understand the detail of the contract”. The care officers carried out the pre-admission assessments. The assessments we sampled covered residents’ preferred routines, care needs, diet and preferences in detail. A social services assessment also provided information for those being funded by social services. Prospective residents who were selffunding completed self-assessment forms, which enabled them (or their relatives) to give their view on their needs and expectations. The preadmission assessment form had limited detail on prospective residents’ psychological health. This area needed to be expanded when assessing prospective residents for the dementia care unit and also to ensure that the home could meet potential residents’ needs when considering admission to the other two units. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area is adequate. Residents consider that they receive good care but limited care documentation does not encourage consistency of care practices. Improvements in medicines management are needed to ensure residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents we spoke with and those who responded to our survey told us that they were happy with the standards of care and the attention they received from care staff. One resident told us “The staff are gentle, kind, understanding and considerate. They always ask how I would like help and give me full support”. A relative told us “staff are very friendly and caring”. Residents we spoke with said that staff respected their privacy and always knocked before entering their bedroom. One female resident said that they did not want a male carer to provide their personal care and said that staff respected this. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 11 Discussions with a number of staff demonstrated that they had a good understanding of residents’ individual care needs, however, the care records did not always provide evidence of this. We sampled the care documentation for five residents across the three units. The care plans did not cover all needs identified in the daily care records and from discussions with staff. The care plans had some detail about residents’ preferences but needed to be developed and to be more focused on the individual resident’s wishes in relation to the support and care they needed, their abilities, their current condition and their needs. Some care plans contained statements such as “full assistance needed”, without specifying the actual assistance needed and whether this could vary at different times. This could result in staff providing care in an inconsistent manner. A resident in the main unit, whose condition had deteriorated and who exhibited some challenging behaviour, did not have a care plan that included information on how staff supported them and monitored their psychological health. The care plans for residents on the dementia unit did not include a section on their psychological health. There was no information in the care plan on the management of one resident’s severe allergic reactions. The home had a strong Christian ethos, however, there were no information on how staff would support residents to meet their spiritual needs. Detailed evaluations were seen in one resident’s records on the dementia unit, the others seen had frequent statements such as “no change to care plan” rather than an evaluation of care and care needs. The home did not have a tool for monitoring residents’ psychological health, for example monitoring changes in condition or challenging behaviour, reaction to medication or gathering evidence of the need for reassessment. The manager said that he would check whether the handover books, that had information on all residents together, complied with the Data Protection Act. He said that he would also ensure that staff entered all information used at handovers, in the individual residents’ care folder. One member of staff who responded to our survey considered that information about residents’ needs was not always passed on to staff after they had been off duty. The daily care records we looked at varied in the detail recorded. Some gave a good indication of residents’ healthcare needs and how they had spent their day, others were very brief. The home did not carry out risk assessments for malnutrition or for the development of pressure sores. Staff on one unit that had residents of a higher dependency were only monitoring residents’ weight on a three monthly basis and therefore were not picking up significant weight loss. One resident on this unit, who was already underweight, had lost over 11 kg in three months. Staff contacted district nurses once this resident had developed signs of pressure sores but did not have the risk assessments to alert them to a need for district nursing input at an earlier stage. However, one resident who responded to our survey said that staff arranged for them to see the district nurse soon after their admission so that they could be provided Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 12 with an air mattress “to help my back”. The manager stated in the annual quality assurance assessment (AQAA) that the home had introduced a body map. However, staff told us that they were only using them for injuries and were not recording pressure sores on the map. Staff told us that the home had good support from local GP surgeries and district nurses. There were good records, with information on any changes needed, following visits from GPs or district nurses. These were written in red to highlight them in the daily records. Residents told us that they saw the chiropodist on a regular basis and had optical checks once a year. They said that staff arranged for them to have dental checkups and hearing tests when necessary. The manager told us that some residents made their own arrangements for checkups. The manager said that there were very long waits for NHS hearing tests and so if residents agreed they could arrange for a private audiologist to carry out the tests at a reasonable cost. The medicine administration records (MAR) were generally well completed but there were a few gaps in recordings and times when it was not clear why medicines had not been administered or had been crossed out. It was not possible to audit the medicines that were not in the monitored dosage systems (MDS) as the medicines left over from the previous month were not recorded and added to the amount delivered. This meant that it was not always possible to establish what doses of prescribed medicines residents had received. A handwritten change to the MAR was seen that was not signed or dated and did not state the frequency that the medicine was to be given. The temperature of the rooms where medication was stored were not being monitored regularly to ensure medicines were kept at the appropriate temperature to maintain their quality. Staff were not taking action when the drugs fridge temperatures were outside the safe limits for the storage of refrigerated medicines. This could potentially result in medicines being given to residents when they were no longer fit for use. Some medicines with a limited shelf life on opening did not have a date of opening on first use, which could alert staff to the date at which medicines should be disposed of when they were beyond their usable life. Some medicines that were still in use did not have prescription labels on them. This could potentially result in residents being given the wrong medicines. Some prescription only topical creams were seen in residents’ rooms. This did not meet the requirements of the Misuse of Drugs Regulations and also did not ensure that the medicines were kept safe for residents with dementia who could potentially misuse them. The home did not have a system for recording the administration of all topical creams. This meant that there was no clear system of assessing residents’ response to treatment. Resident who were prescribed sedatives or anti-psychotic medication on an “as required” basis did not have care plans to provide guidance to staff on their use and the actions to take before giving medication. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 13 Staff regularly checked the balances of all controlled drugs (CDs) and those we looked at were correct. There were two cupboards provided for the storage of CDs but they did not comply with the Misuse of Drugs (Safe Custody) Regulations since they were not fixed to an outside wall with rag or rawl bolts. A register was used to record the use of controlled drugs but there was a need to clearly record the name and address of the supplier (or recipient on disposal). The manager told us that all senior carers had completed in-house training in the administration of medicines and that this included an assessment of competence. He told us that he was arranging additional external training for some of the senior care staff. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area is good. Residents benefit from a wide range of activities and good links with the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had three activity coordinators, two of whom worked part time. There was a good range of activities for both residents who were more independent and those who were more frail or dependent. Staff held regular exercise sessions including movement to music and various physical games. There were also poetry sessions, flower arranging, music sessions with various instruments, sing-along sessions, quizzes, word games and bingo. Residents generally said that they enjoyed the activities, although a couple of residents told us that some of the activities were “a bit childish”. The dementia unit had memory boxes for the residents, with photographs and personal mementoes that staff used for chats and reminiscence on a one to one basis. Staff who carried out activities had a good understanding of how they could provide stimulation and activities for residents in the later stages of dementia. Residents on the dementia unit had grown plants from seeds and Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 15 grown some vegetables. They also regularly did baking and soup making. On the day of inspection the residents were making a chocolate cake. Staff told us that the dementia unit had activities at the weekend but that no activities were arranged at weekends on the other two units. We looked at the activity records for five residents. We saw some good assessments but we saw no social care plans and there was limited detail about how the residents’ responded to the activities and the benefits they gained from them. The home had open visiting and relatives told us that they were always made to feel very welcome when they came to the home. The home had good links with local churches and some of the local schools. Transport was provided to Connaught Avenue in Frinton (the main shopping area) once a week from the home. There was a weekly women’s fellowship meeting at one of the local churches that a few residents attended. A pianist came to the home each week and the local school and playgroup visited the home at Christmas. The manager told us that the Gospel Chapel had performed a play at Easter for the residents. A library van visited the home. The activity coordinators said that they tried to order books that would appeal to residents’ particular interests and hobbies when they were not able to visit the library van themselves. A few residents attended the separate day care unit on the site. A number of residents attended the local church on Sundays and a service was held in the home every Tuesday. This service was open to residents in all parts of the home and was in part used as a residents’ meeting when residents could raise any issues or concerns. Sales of shoes and clothes are also held periodically in the home. Residents told us that they were encouraged to retain their independence, had choices about how and where they spent their day and the times that they got up and went to bed. A varied menu was offered in the home. Choices were available at each mealtime and these included a vegetarian option. Residents told us that they could have alternatives if they did not like what was on the menu. Residents we spoke with said that the food was generally good. Although one resident said that the cooks relied too heavily on frozen vegetables. They said that they would like more fresh vegetables and told us that “the tinned mushrooms are horrible”. Two residents told us that they were put off eating by the large portions and said that a lot of food was wasted but one told us that the portions were right for them as they had a big appetite. Two residents told us that they would like the chance to speak to the catering manager on a regular basis about choices on the menu. The catering manager told us that they would go to see all the residents following the inspection. The home catered for a range of diets. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18 Quality in this outcome area is adequate. Residents can be confident that they will be protected from abuse but cannot be assured that their concerns will always be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was in the statement of purpose but was not on display in the home. The procedure needed to be updated to reflect the current role of the commission and social services in reviewing and investigating complaints. The manager said that he would place a copy of the procedure in a prominent position so that everyone had access to it without having to ask. The majority of residents and relatives who responded to our survey said that they knew how to make a complaint and said that they would speak to senior staff if they had any concerns. Two residents told us that they had “never had cause to make a complaint about anything”. One relative and five residents told us that staff “always” responded appropriately if they raised concerns, one relative and one resident told us that staff “usually” responded appropriately and one resident considered that staff only responded appropriately “sometimes”. Verbal concerns were not recorded. One resident told us that concerns had been raised on a number of occasions with individual staff but Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 17 that they did not pass it on and so this resulted in the issues not being resolved. The manager said that staff had been issued with the brief leaflet on safeguarding vulnerable adults from Essex County Council and told us that he would also order the more detailed booklet for all staff. Initial safeguarding training was carried out during staff induction and additional formal training was also given. Staff had access to a policy on safeguarding vulnerable adults and on whistle blowing (the reporting of suspected abuse or poor care). A number of staff still required the training but the manager confirmed that two further training sessions on safeguarding vulnerable adults had been booked for September 2008. One member of staff we spoke with had a good understanding of the different types of abuse that could occur and the actions to take if abuse or poor practices was suspected or observed. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26 Quality in this outcome area is poor. Residents benefit from a clean and well maintained home but hazards in the environment put some residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We found the home to be very clean with good odour control. The parts of the home we inspected were in good condition and well maintained. Residents’ rooms were personalised with some of their own furniture and demonstrated their tastes and preferences. There were ramps where necessary for residents with more limited mobility or for those in wheelchairs. The gardens were well laid out with attractive plantings. There were chairs, tables and parasols available when residents wished to sit outside. The garden for residents with dementia contained some raised beds where residents were growing vegetables. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 19 The dementia unit had secure premises and a secure garden. The main home was accommodating a number of residents who had developed dementia since admission, however, this was not a safe or secure environment for them. Staff told us that one of the residents with dementia regularly left the home and there was evidence of this in the care records. The front door was kept open and a number of side doors were seen to be open, with the alarms disabled during the inspection. There were numerous hazards in the kitchen and laundry for residents with dementia, however, the rooms were not locked when a member of staff was not present. Hazardous chemicals were not being stored in locked cupboards and were seen unattended in corridors during the inspection. The windows had restrictors that could be disabled very easily and the majority of first floor windows seen on the day of inspection did not have restrictors in place. Risk assessments of the premises and its suitability for current residents had not been carried out. The provider told us that steps were being taken to address all the safety issues in the environment. A number of residents and relatives told us that clothes were regularly lost and not put in the correct rooms. The laundry room had washing machines with a sluice cycle but staff were hand sluicing soiled laundry and were not using the dissolvable bags for handling soiled linen. This could put staff and potentially residents at risk of cross infection. The home had a supply of protective equipment such as gloves and aprons. Residents’ who needed support with personal care did not have a supply of liquid soap and paper hand towels in their bedrooms. This would mean that staff could not carry out good infection control procedures when they gave personal care. Laundry staff did not have information on the chemical products used in the laundry with guidance on the actions to take in case of accidental contamination. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 Quality in this outcome area is adequate. Residents are supported by an adequate number of staff but the lack of some training means that their safety cannot be assured. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three care units were staffed separately and staffing levels reflected the dependency of residents on the different units. Staffing was highest on the dementia care unit and lowest on the main unit where the majority of residents were independent and largely self-caring. The staffing levels were generally satisfactory, although a number of residents in the main unit stated that the home could do with more staff on some of the afternoon shifts. One resident told us that the main home needed more staff “as there are people with dementia who need watching as they leave the home”. Three staff we spoke with during the inspection considered that the staffing levels were appropriate for the dependency of residents although one member of staff who responded to our survey told us “It is sometimes difficult to get adequate staffing levels when staff go off sick”. We looked at the records of two staff who had been recruited since the last inspection. The home had sound systems for recruiting new staff. There was evidence of checks with the criminal records bureau (CRB) and protection of Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 21 vulnerable adults (POVA) list. Two references had been obtained and there was evidence that the identification of new staff had been checked. The home used their own induction and orientation to the home for all new staff. The skills for care induction was then used for care staff. Over 50 of care staff had completed national vocational qualification (NVQ) at level 2 or above, which met the national minimum standards. The manager told us that a number of staff were undertaking the course and he was hoping that sixteen staff would be starting NVQ level 2 in the near future. The manager said that senior staff had completed a first aid course and that they were due for an update in the near future and that all staff had attended fire safety training. According to the training records we looked at a number of staff were in need of training in moving and handling, food hygiene, infection control, heath and safety and the control of substances hazardous to health (COSHH). Twenty-nine of the care staff had not attended training on dementia care and none of the staff had received training in the management of challenging behaviour or in the Mental Capacity Act. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 38 Quality in this outcome area is adequate. Residents generally live in a well managed home but potential risks to their health, safety and wellbeing are not always identified and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager managed the whole site, which included the three units that were part of the care home, the sheltered accommodation and the day care centre. Two care officers managed the day-to-day care in the care home. The manager had a background in nursing and had completed the national vocational qualification at level 4. He had also completed the D32/33 assessor’s award. Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 23 The chief executive of the company told us that he was in the home approximately four days each week and was responsible for quality assurance. He said that he spoke to residents on a regular basis and visited all areas of the home. However, the home did not have a system for internal quality assurance and it needed to provide more evidence that individual audits were carried out at regular intervals and that there were action plans to remedy any deficiencies identified. This inspection identified shortfalls in care documentation, medicines management, infection control and the safety of the environment (see the sections of the report on health and personal care and the environment). The manager said that the home had a monthly residents’ meeting that was linked to a prayer meeting. The chief executive told us that he was planning to start formal residents’ meeting in the near future. The home carried out periodic surveys of residents. One relative responding to the home’s recent survey said “I have been extremely satisfied. The level of tender loving care throughout the home has been exceptional and the staff should be complimented on this”. The home held a small amount of money for residents’ personal expenses. Receipts were available for all purchases and for services such as hairdressing and chiropody. However, they were not in date order so it were not easy to check. Two balances were checked and were found to be correct. The home did not always use a double signature system and no audits of the system were carried out, which would have improved the safeguards for residents’ monies. The accident records seen were well completed. The manager told us that he was aware of the need to start auditing the accidents to identify trends and identify whether particular residents needed additional support. There were systems in place for the maintenance and servicing of equipment in order to keep it in a safe condition for residents. The manager said that two new hoist slings had been purchased due to wear that had been identified. The manager confirmed that all water outlets used by residents had thermostatically controlled valves to regulate water temperature. There was evidence that the water temperatures were checked periodically and the manager was aware that the checks should be more frequent. External consultants undertook the home’s health and safety and fire risk assessments and produced their health and safety manual. However, this inspection identified a number of heath and safety issues relating to the environment. Ernest Luff Home DS0000017812.V371250.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 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (2)(b) Requirement Residents must have up to date care plans that reflect all their current needs and give clear guidance for staff on how their care should be delivered. Residents must be involved in drawing up the care plans, wherever possible, so that the plans reflect their individual wishes, interests, preferences and priorities. Timescale for action 01/12/08 2. OP8 14 Nutritional and pressure sore risk 01/12/08 assessments must be developed, used and acted upon when needed in order to protect residents in the home. Residents’ with dementia must have their mental health needs monitored on a regular basis in order that appropriate and timely support and treatment can be given to them. In order to protect and safeguard residents during the management and administration of medicines the following must DS0000017812.V371250.R01.S.doc 3. OP8 12(1)(a) 01/11/08 4. OP9 13(2) 10/09/08 Ernest Luff Home Version 5.2 Page 26 be done: Keep accurate records of all medicines administered. Monitor the temperature in all medicine storage areas. Date medicines with a limited shelf life on first use. Only use medicines with a prescription label. Record the administration of topical creams. Keep “prescription only” medicines locked up when not in use. Develop a care plan when residents are prescribed sedative or antipsychotic medication on an “as required” basis. 5. OP9 13(2) Controlled drugs must be stored in accordance with the Misuse of Drugs Act and associated Regulations. Risk assessments of the premises must be carried out on a regular basis and action taken to ensure that the environment is safe and meets the needs of current residents. Staff who handle hazardous chemicals must be provided with guidance on the actions to take in case of accidental contamination of themselves or residents. Staff must be supplied with the appropriate equipment to enable them to carry out good infection control procedures and reduce the risk of cross infection to themselves and to residents. This refers to the supply of dissolvable bags for handling soiled linen and the supply of liquid soap and paper hand DS0000017812.V371250.R01.S.doc 01/12/08 6. OP19 13(4) 01/11/08 7. OP26 13(4) 01/11/08 8. OP26 13(3) 01/11/08 Ernest Luff Home Version 5.2 Page 27 towels in all areas that staff carry out personal care. 9. OP30 18 Staff must be provided with the 01/04/09 training and skills to enable them to meet residents’ needs. This refers to training in moving and handling, food hygiene, infection control, heath and safety, the control of substances hazardous to health (COSHH), dementia care, the management of challenging behaviour and the Mental Capacity Act. The provider must ensure that 01/01/09 there is an effective audit system to monitor standards in for example care plans, medicines, infection control and the safety of the environment. 10. OP33 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The mental health aspects of the preadmission assessment should be expanded in order to ensure that the home can meet all the care needs of potential residents. Hand-written changes or additions to medication records should be signed and dated by the person making the change and checked for accuracy by a second person. Staff should ensure that verbal complaints and concerns are recorded as part of good quality assurance and communication within the home and in order to ensure that staff take consistent action in response to the issues raised. 2. OP9 3. OP16 Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 28 4. OP26 The home should review the systems for handling residents’ clothes in order to reduce the frequency of clothes being lost or put in other residents’ rooms. The home should put in systems to regularly audit the monies held on behalf of residents and use a double signature system in order to increase the safeguards for residents. 5. OP35 Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 29 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 Ernest Luff Home DS0000017812.V371250.R01.S.doc Version 5.2 Page 30 - 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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