Inspection on 20/05/08 for Foxmead

This inspection was carried out on 20th May 2008.

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

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

Foxmead 21/05/07

Foxmead 30/05/06

Foxmead 29/09/05

Foxmead 08/04/05

Foxmead 12/10/04

Foxmead 12/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Foxmead Foxmead Horsham Road South Holmwood Dorking Surrey RH5 4JX Lead Inspector Marion Weller Key Unannounced Inspection 20th May 2008 10:30 20/05/08 10:30 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 Foxmead DS0000013645.V363258.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. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxmead Address Foxmead Horsham Road South Holmwood Dorking Surrey RH5 4JX 01306 888053 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) aisah@hotmail.com Mrs Evelyn Ramdass Mrs Aisah Talip Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14) Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: Over 65 years of age 21st May 2007 Date of last inspection Brief Description of the Service: Foxmead is a Victorian property situated four miles south of the town of Dorking. It overlooks a church, and used to be the vicarage. The service provides accommodation and care for up to fourteen older people who have a past or present mental illness and/or dementia. There are ten single occupancy bedrooms and two shared bedrooms on the ground and first floor of the home. None of the bedrooms are en-suite, however, all have a washbasin. Communal toilet and bathing facilities are located close to all bedrooms. The first floor accommodation can be reached by the main staircase, which has a chair lift fitted. There is a break in the chair lift track across the landing between the ground and first floor. There is no shaft lift fitted and therefore the home is not suitable for those with very limited mobility. There are two large lounges and a dining room, which overlook the garden. The garden is large and has wheelchair access via a ramp. There is ample parking to the front of the property for visitors and a regular bus service operates to Dorking, which stops outside the home. The weekly fees range from £500 to £650. Foxmead DS0000013645.V363258.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 key unannounced inspection was conducted by Marion Weller, Regulatory Inspector, who was in Foxmead from 10:30 a.m. until 5.00 pm. During that time the inspector spoke with some residents, one visitor, the registered manager, the registered owner and some staff. Parts of the home and some records were inspected and care practices observed. Residents were seen to be appropriately cared for, with staff attending to and supporting individuals as and when required. A number of survey forms were received prior to the inspection. Survey forms had been completed by care staff on behalf of service users. No free hand comments were therefore received from people actually using the service. Tick box responses to questions asked in surveys, illustrated that service users were largely very satisfied with the service they received at Foxmead. There have been improvements both in practice and administration since the last inspection in line with statutory requirements and good practice recommendations made. However, there is still no clear evidence of management being proactive and addressing issues before they become a problem, especially in relation to risk management, infection control, the use of the garden and the surrounding land and the use and safe storage of chemicals covered by the COSHH Regulations. There is no evidence that the recent improvements made will be sustained. Until this sustainability is in place, good outcomes for service users cannot be demonstrated, which will impact on the home’s overall quality rating judgment using KLORRA. From the evidence seen the inspector considers that this service would be able to meet the needs of individuals of various religious, racial or cultural needs. At the time of writing this report there were no outstanding complaints about the service held by the Commission. The Manager and staff gave their full co-operation and help throughout the inspection. Feedback was provided to the registered persons at the end of this site visit. What the service does well: A full assessment process and written documentation is in place to ensure the individual needs of service users are clearly identified prior to admission, which Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 6 ensures the home can fully meet their needs. Prospective service users and/or their representatives are encouraged to visit the home before making a firm decision to move in. Service users physical and mental health needs are well met with access to relevant health professionals. People living in the home enjoy a lifestyle, which largely matches their needs and preferences. Where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a healthy balanced diet. The overall cleanliness of the home is of a very good standard. What has improved since the last inspection? What they could do better: Improvements to the organisation, lay out and timely archive of service users care documentation would ensure care plans and risk assessments were always up to date to appropriately guide and direct staff and to avoid any confusion which may place service users at risk. Care plans must evidence the signature of the individual receiving care, both to show their involvement with the drawing up of the plan and their agreement to its content. If this is not achievable then the reasons why the individual is not being involved should be clearly recorded. The home’s medication procedures are basically sound but some improvements to the home’s administration records would ensure that people are fully protected. People living in the home would benefit from further improvements being made to the premises and to the exterior grounds to ensure they continue to live in a safe and comfortable environment that is fit for purpose. Despite the manager maintaining a COSHH register and developing risk assessments for all substances, which may prove hazardous to health in the home, procedures for ensuring chemicals are locked away when not in use Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 7 were not being adhered to. Such practices may seriously compromise the safety of vulnerable individuals living in the home. Communal bathrooms and toilets in the home had paper towels but lacked the provision of liquid soap. The home’s infection control procedures, designed to safeguard service users and staff, were therefore being compromised. Despite recent improvements to the home’s recruitment procedures the registered persons must ensure that all aspects of procedure are sufficiently robust to ensure the safety and protection of people living in the home and to enable them to evidence the home’s good practice. Service users would benefit from the home formulating a training matrix that gives a clear overview of staff training needs and evidences their good practice in the area of staff development. 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. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 356 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using this service benefit from comprehensive assessments, which ensure their needs are identified and they can be met by the home. Either they or their representatives are encouraged to visit the home prior to making a firm decision to move in. EVIDENCE: Three service users care files were looked at in detail. All contained preadmission assessments undertaken by the manager. Additional information was also available from care and health professionals involved with the care of the individual prior to them moving in. The home has an admission and referral policy and procedure that is followed when referrals are made to them. Since the last inspection the manager has revised the policy document in line with a good practice advice to include a statement that prospective service users and/or their relatives and Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 10 representatives are encouraged to visit the home prior to admission to assess the quality, facilities and suitability of the home. The manager informed the Inspector that the home does not offer intermediate care. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 11 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): 7 8 9 10 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have their health, personal and social care needs set out in an individual plan of care and their health needs are clearly being met. They would further benefit from improvements to the organisation and management of their care and medication administration records. EVIDENCE: Three service users were resident in the home on the day of the site visit. Each service user had a care plan. All three care plans were looked at in detail. They were found to contain comprehensive information about service users individual needs and aspirations and provided necessary direction for care staff on how the health, personal and social care needs of service users was to be met. All three care plans had been regularly reviewed. It was evident from discussion with the manager, staff and a relative that the health care needs of residents are closely monitored and acted upon without delay. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 12 The visits and outcome of health care professionals consultations with service users were clearly recorded and records were signed and dated. The likes and dislikes of individual residents were recorded and daily records detailed how resident’s needs were met and gave an account of the state of their well being throughout the shift. It was however discussed with the manager that care documentation is currently not well-organised and laid out for ease of reference. Some information is old and has been superseded and yet it is retained in current records. To avoid any confusion and to eliminate any potential risk to service users, a timely review and archive of care files would ensure care plans and risk assessments were always up to date to appropriately guide and direct staff and to better evidence that service uses needs are being met. Daily records should not be maintained separately from other care documentation as this fragments the information held and maintained by the home about individual service users. Care plans inspected did not always evidence the signature of the individual receiving care. It was discussed with the manager that care plans must be signed by service users to show their involvement with the drawing up of the plan and their agreement to its content. If this is not achievable then the reasons why the individual is not being involved should be clearly recorded in future. The manager stated her intention to address this issue. Risk assessments for service users were in evidence and those seen provided clear guidance and direction to staff. Risk assessments were largely in relation to service users moving and handling needs. It was discussed with the manager that generic risk assessments should be further developed to cover other potential risks to service users and thus eliminate all avoidable hazards. For instance, service user had no individual fire evacuation risk assessments, even though some individuals are known to lack capacity and would need careful management and support to evacuate the building in an emergency. There were no written risk assessments that explained how service users access the home’s gardens, even though the manager spoke of allowing accompanied access only due to hazards such as a pond, steps and a disused swimming pool and tennis courts. The arrangements for the safe receipt and disposal of medication were largely robust. The home has a policy and procedure in regard to the administration of medicines and uses a monitored dosage system provided by a local pharmacy. Medicine Administration Record sheets (MAR’s) were evidenced for recording medicines given to service users. The MAR records for residents were being accurately maintained except where hand written entries had been made. The person making the entry had not signed it, neither was the entry signed by a second person to confirm accuracy of transcription. This practice potentially places service users at risk of a medication error/ wrong medication being given. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 13 At the front of the MAR records there is a list of names and full signatures to confirm that designated medication administrators had seen the home’s medication policy, however, there were no examples of how the individuals initial the MAR records, which makes auditing administration records difficult. A requirement will be issued for the manager to address the current shortfalls. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. This is permantly fitted to the service users dining room wall. The manager informed the Inspector that no resident is capable of selfadministering his or her medication and that staff designated to administer medicines have attended training. The local pharmacist undertakes an annual audit of the home’s medication systems During the tour of the premises the manager was noted to knock on all bedrooms doors before entering even when she knew the occupant was elsewhere in the home. Service users were addressed using their preferred name and title. Issues of privacy and dignity are included as part of staff induction training. The use of plastic beakers at mealtimes was discussed with the manager. There was clear evidence to suggest these are being provided to all service users regardless of individual capacity. The manager stated that ‘some service users couldn’t hold heavy glasses and others drop them’. It was further discussed that the practice should be risk assessed to ensure that people’s dignity is not compromised by the provision of inappropriate aids at meals times. Foxmead DS0000013645.V363258.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): 12 13 14 15 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles largely match their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a healthy balanced diet. EVIDENCE: During the site visit three service users were observed to be taking part in a numbers quiz. This mainly consisted of mental arithmetic questions. The member of staff asking the questions said that activities are provided in the morning and afternoon for service users to take part in if they wish. The home has an activity programme, which is displayed where people living in the home can read it. Activities offered were said to include word/number games, exercise with music and traditional board games. Service users preferences in relation to their interests and hobbies are recorded in individual care files. From observation it was clear that service users are able to choose what they do and the activities they wish to take part in. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 15 The manager said that the religion of all but one resident is Church of England, and all residents attend the local church every Sunday. This provides them with the opportunity to continue supporting their faith and to meet other people outside of the home. One resident is a Roman Catholic, and receives Holy Communion every week from a religious representative of that faith. There are no restrictions to visitors at the home, and residents are able to meet with their relatives in any of the home’s communal areas or use their bedrooms if they wish. On the day of the visit it was observed that a visitor was able to use the home’s large entrance hall to speak with a relative in private. The area is large, pleasant and provides comfortable chairs away from communal lounges. The home uses a three-week rolling menu that offers healthy diet options and choice to service users. Lunch was observed during this site visit. Service users were enjoying the meal, which was a relaxed and unhurried occasion. There was sufficient staff on duty to offer sensitive support to those that required it. Surveys returned by service users showed that people living in the home liked the meals provided. Since the last inspection the home’s occupancy has fallen to four permanent service users. The manager stated that from time to time they do also admit individuals who are referred to them for respite or short-term care. Due to the falling activity levels, staff rosters had been revised. The manager stated that they were being kept under review however and staff deployed were always in direct relation the dependency needs of the service users in residence. At the previous inspection the manager stated that the home was in the process of recruiting a cook. On this visit the plan to recruit a cook had been shelved. Care staff were covering food preparation and cooking duties as well as the direct care of residents. Evidence of training in food hygiene was observed in staff training files sampled. The home’s kitchen was viewed. Food was appropriately stored and daily records of fridge/freezer temperatures were observed. The kitchen was seen to be scrupulously clean. The manager said that the home had an inspection by the Environmental Health Officer in May 2008. No recommendations for improvement were made as a result of the visit. Two staff are on duty in the home and the manager during daytime hours. Staff are deployed to be either with service users or undertaking other noncaring tasks. It was observed that service users were never left unsupervised or unsupported due to their mental health needs. The manager steps in and covers if care staff are busy elsewhere. There was sufficient staff seen to meet the needs of service users on the day of the site visit. A relative spoken with stated that there were always sufficient staff available to care properly for Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 16 people and made a point that “if they were personally not satisfied and didn’t feel that their loved one was safe at all times, they would most certainly not still be there.” Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 17 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): 16 18 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know their complaints and concerns are listened to and acted on. There are systems in place to protect residents from abuse. EVIDENCE: The complaints procedure is readily available to people living in the home and their relatives. People spoken with felt confident that their concerns would be listened to and any necessary action would be taken. It was observed that the home’s written procedure now requires revision. The contact details for The CSCI are no longer current and the document fails to provide details of the local Social Service Department who hold the statutory power to investigate complaints. The manager stated her intention to revise the home’s complaints and concerns procedure. A visitor said: “The home is good and I have no major concerns, minor issues of concern have been speedily addressed by the manager and staff here” The Commission has not received any complaints about the home neither have there been any safeguarding alerts in the last twelve months. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 18 The home has a Protection of Vulnerable Adults Policy and Procedure and was able to evidence an up to date copy of the Surrey Multi-Agency Protection of Vulnerable Adults Procedures. The home’s safeguarding policy and procedure has been revised by the manager since the last inspection to ensure the content provides sufficient detail in regard to what constitutes abuse and directs staff as to the procedures to be followed if they suspect abuse has taken place. The last report issued a requirement that the home’s Protection of Vulnerable Adults policy and procedure must be reviewed, to ensure it is written in line with the Surrey Multi-Agency guidelines. This has now been resolved and will be removed from this report. The staff induction and NVQ training programme have elements of adult protection training and there has been POVA training for staff. Those spoken with have a sound understanding of adult abuse and protection procedures. The Manager stated any allegation of abuse would be referred to the concerned agencies without delay. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 19 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): 19 26 Service users experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable and homely environment that meets their needs. They would benefit further from some areas of the property and grounds being repaired and refurbished to ensure the home continues to offer them a safe and comfortable place to live in. EVIDENCE: A tour of the premises was undertaken with the manager. Service user bedroom accommodation is provided on two floors of the property. The ground floor consists of one double bedroom, large entrance hall and stairs, a communal lounge, common room with library books, a communal dining room, laundry and kitchen. The first floor accommodates further bedrooms for single occupancy, communal bathrooms and toilets. Bedrooms viewed were appropriately furnished and kept very clean. Rooms that were occupied evidenced that service users are encouraged to bring some of their own Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 20 personal possessions with them and that they were provided with lockable facilities. At the last inspection two service user bedrooms on the first floor required some attention. One bedroom needed a repair to the sink unit; the side panel edge had begun to warp. The radiator cover required attention to the paintwork, and a malodour was apparent in the room. This room was inspected on this site visit. The previous issues of concern have now been addressed. A further bedroom required a repair to the sash cord on one of the windows, which had broken. This remains in the same condition. The manager and the registered owner of Foxmead confirmed that some windows and doors are to be replaced in a rolling refurbishment programme. The window in this bedroom is to be included in the refurbishment plan and has priority. The doorframe which previously required repair in the dining room has been repaired and the matter is now resolved. The manager stated that all communal areas are accessible to residents. The home has a large and attractive garden to the rear and side of the property. There are also steps leading down to an ornamental pond. Service users, particularly in good weather, access the garden area regularly according to the manager. Some of the flagstones on the patio area were seen at the last inspection to have become loose. The manager stated on this visit that the home’s gardener has since resolved this issue. There is a disused tennis court to the rear of the garden. The surface has become overgrown with weeds and requires attention. The gate allowing access to the tennis courts was left open. It was discussed with the manager and the registered owner that the potential hazard to people accessing the garden should be risk assessed. It is the responsibility of the registered persons to ensure the home and its layout is suitable for its stated purpose. The manager stated that the current service users do not access the garden, without the support of a member of staff. No written risk assessments were seen in service users care files to support this statement, although staff confirmed this to be the case. The home has a small laundry that has a washing machine with a sluicing facility. Despite the manager maintaining a COSHH register and developing risk assessments for substances, which may prove hazardous to health in the home, procedures for ensuring chemicals were being locked away when not in use were not being adhered to. Soap powder and bleach were evidenced behind a curtain in the laundry. The door to the laundry was left open. The room is sited near to the service users dining room. It was discussed with the manager that such practices may seriously compromise the safety of vulnerable individuals living in the home and must be addressed. The Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 21 chemicals seen were immediately removed by the manager and locked securely away. Training files sampled during the site visit provided evidence that staff had attended training in regard to Infection Control and the home has a policy on infection control to secure the health and welfare of residents and staff. Despite this, bathrooms and toilets evidenced paper towels and communal bars of soap. The manager understood that the communal soap compromises good practice in relation to infection control. Action was taken to provide liquid soap to these areas immediately. Some areas of the building internally and externally are aged and in need of refurbishment. The registered owner has begun to organise re-decoration of some of the internal parts of the home and spoke of a rolling programme of refurbishment and renewal to address other issues of concern. For instance, renewal of some doors and windows in the home was mentioned. It was also stated that a firm plan is in place to repair the access driveway by the end of May 2008. Currently there are large and quite dangerous potholes evident to the surface finish. Repairs are also scheduled to the property’s perimeter fence. A work confirmation sheet from a contractor was seen to confirm this work is now organised. New chairs are on order for service users. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 22 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): 27 28 29 30 Service users experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The number of staff deployed is meeting service users needs and they are in safe hands. Staff recruitment procedures have clearly improved but service users are not yet fully protected. Service users would further benefit from the home formulating a training matrix that gives a clear overview of staff training needs and evidences their good practice. EVIDENCE: The manager revised the home’s staff duty roster in January 2008 due to falling occupancy and activity levels in the home. There is now a minimum of two care staff on each shift together with the manager during day time/ weekday hours. There is one waking night staff and one carer ‘on call’ to meet the needs of three service users at night. The manager also explained that some staff live on the premises and can be called upon to help in an emergency or at weekends. Care staff undertake both the cooking and domestic duties in the home. Cooking and domestic duties should not be carried out to the detriment of providing personal to service users who require it. Proportionally however, this is now a small service and the staff member on duty is viewed more as a support worker required to multi task, rather then providing personal care only. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 23 Staff spoken with explained that if they are either cooking or cleaning, one of them on each shift ensures they are available only to support and meet service users needs when they require it. The manager stated that staffing would be increased if the home’s activity and occupancy levels increased, in line with service user dependency needs. There was sufficient staff on duty during the day of the site visit to meet the needs of the 3 service users in residence. The manager informed the Inspector that all care staff are either qualified at NVQ level 2 and level 3 or they are undertaking their qualification. Upon completion, the home will exceed the National Minimum Standard in regard to 50 of staff holding the minimum of NVQ level two or above. At the last inspection the manager was strongly recommended to produce and follow a robust recruitment policy and procedure to ensure the service users health, safety and welfare was fully protected. On sampling the staff files during this visit it was evident that recruitment procedures have been improved. They are however still not robust enough to fully protect service users. Staff files inspected lacked the provision of two references for new staff employed via an employment agency that provides care workers from abroad. The agency had recorded on documentation sent to the manager that references had been obtained, however they were not available to evidence the suitability of the individual appointed to the post or the home’s good practice. The manager stated her firm intention to resolve this issue. Staffs training certificates were seen. There covered subjects such as Induction, Dementia, Protection of Vulnerable Adults, Equality, Diversity and Rights, Nutrition, Infection Control, Food Hygiene and Medication Administration training. The manager had a list of training dates for the next twelve months that included refresher training on the above and mandatory training for new staff. It would be useful and help the manager to evidence the home’s good practice if she developed a training matrix that provides a clear and ready overview of all staff training completed, booked and updates due. This will be recommended in this report. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 24 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): 31 33 35 38 Service users experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered owner and manager are responding to the need for improvements to be made to the service. The home’s policy and procedure documents have been reviewed to ensure residents’ rights and best interests are safeguard. Some safe working practices require further development to ensure that the safety and welfare of service users is promoted and protected. EVIDENCE: The registered manager said that she has been working at the care home since 2003. It is recorded that she has a Masters Degree in Social and Healthcare and completed the Registered Managers Award (RMA) in 2005. The manager continues to update her skills and spoke of several training courses she has attended this year. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 25 There have been improvements both in practice and administration since the last inspection in line with statutory requirements and good practice recommendations made. The manager has reviewed some policies and procedures and the home is reporting incidences to the Commission appropriately via Regulation 37 notifications. There have been Regulation 26 visits made by the Registered Owner. Supervision of staff by the manager is more regular and the home’s Quality Assurance system is being developed to ensure service users views are sought and acted upon. However, there is still no clear evidence of management being proactive and addressing issues before they become a problem, especially in relation to risk management, infection control, the use of the garden and the surrounding land and the use and safe storage of chemicals covered by the COSHH Regulations. There is no evidence that the recent improvements made will be sustained. Until this sustainability is in place, good outcomes for service users cannot be demonstrated, which will impact on the home’s overall quality rating judgment using KLORA. The manager said that the home sends out surveys to service users, their relatives and other associated professionals annually. The manager informed the Inspector that a summary of the findings would be collated and produced together with an action plan. No current quality assurance returns were available to view on this visit and it was discussed that the manager needs to further develop the homes quality assurance processes and business planning cycle. The manager stated that residents and their relatives handle their own finances; the home does not have any dealings in regard to this. Sampling of staff training records provided evidence that staff are receiving the mandatory training as required. Completion certificates are maintained together in one file, it is therefore difficult to gain a clear overview of staff training courses completed, planned and updates due for each staff member. The homes AQQA (Annual Quality Assurance Assessment) records that health and safety records are appropriately maintained and up to date. Records sampled during this site visit included fire risk assessments, dated July 2006, and records of fire drills. Fire extinguishers had been serviced in November 2007 and a current employers liability insurance certificate was on display. The home’s AQAA returned prior to the site visit was simplistically completed and requires further development. Possible improvements to content were discussed with the manager that she may wish to consider. Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 26 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 3 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 27 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 13 (2) Requirement The registered persons must: • Ensure that when hand written entries are made in service users MAR charts, the entry is signed by the person making it, and by a second person to witness the accuracy of the transcription. This is to avoid the risk of a medication error/ wrong medication being given. For reference and audit purposes, examples must be provided of how each designated medication administrator initials service users MAR records. Timescale for action 01/07/08 • Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations To avoid confusion and to eliminate any potential risk to service users it is strongly recommended that a review and archive of care files takes place to ensure they are current and in an appropriate format to guide and direct staff and to better evidence service uses needs are being met. It is recommended that service users daily records are not maintained separately from their other care documentation. This practice fragments information held and maintained about individual service users and compromises Data Protection. The reasons as to why care plans have not been signed by the resident should be recorded. Generic risk assessments should be further developed to cover the potential risks to service users in the home and grounds thus eliminate all avoidable hazards. It is recommended that the provision of plastic beakers to all service users at meal times be reviewed. It is strongly recommended that as part of the registered persons risk assessment for bedrooms, where windows are currently in a state of disrepair /broken, new admissions should not be accommodated in them until the planned refurbishment of that room takes place. It is recommended that the registered person further develop the home’s quality assurance and monitoring systems based on a systematic cycle of planning –action and review. This will assist the home to better evidence good outcomes for people living there. 2 OP7 3. 4 5 OP7 OP7 OP10 6. OP19 7. OP33 Foxmead DS0000013645.V363258.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Foxmead DS0000013645.V363258.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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