Inspection on 13/07/06 for Glenroyd House

This inspection was carried out on 13th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenroyd House 22/01/08

Glenroyd House 15/02/07

Glenroyd House 25/03/06

Glenroyd House 10/05/05

Glenroyd House 14/03/05

Glenroyd House 16/09/04

Glenroyd House 10/02/04

Glenroyd House 21/05/03

Glenroyd House 17/12/02

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

CARE HOME ADULTS 18-65 Glenroyd House Glenroyd House 26 High Road North Laindon Basildon Essex SS15 4DP Lead Inspector Michelle Love Key Unannounced Inspection 13th July 2006 08:30 Glenroyd House DS0000032135.V301289.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 Glenroyd House DS0000032135.V301289.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. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenroyd House Address 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) Glenroyd House 26 High Road North Laindon Basildon Essex SS15 4DP 01268 541333 01268 541333 cushti@blueyonder.co.uk Glenroyd House Ltd Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th March 2006 Brief Description of the Service: Glenroyd House provides accommodation and personal care for eight adults over the age of eighteen with learning disabilities. The home is situated in a residential area, close to local amenities. Each resident is provided with their own single room within this two storey detached house. There is a large garden to the rear of the property, and a parking area for vehicles at the front. The home has its own mini bus which takes the residents to and from their community based activities and leisure pursuits. Residents also have the opportunity to attend college, and pursue hobbies if they so wish. The range of fees charged to individual residents ranges from £686.24 to £1191.70 per week. Additional charges incurred to residents, includes chiropody, personal toiletries, magazines, meals at fast food outlets and pursuing personal hobbies and interests. This information was not included within the homes pre inspection questionnaire, but obtained on the day of the site visit. The homes Statement of Purpose and Service Users Guide, is not readily accessible/displayed. A copy of both documents can be obtained from the office. Inspection reports are located within the office. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced `site visit` was undertaken by Michelle Love and Claire Brookes-Nandara, inspectors and lasted approximately 10.5 hours. On the day of the site visit some residents were observed to attend formal day care provision, however six residents were present during the day. As part of the `site visit` process a tour of the premises was undertaken and a number of records pertaining to care planning/associated documentation/healthcare records were examined. Additionally staff employment files, staff training records, medication systems and health and safety records were also inspected. The `site visit` was conducted with the assistance of one member of staff in the morning and with the acting manager in the afternoon. During the visit, inspectors spoke with both support staff, management and with individual residents. Prior to the `site visit` a number of surveys were forwarded to residents next of kin/representatives and visiting professionals i.e. care managers/advocates etc. The number of responses received was positive and many comments received have been incorporated into the main text of the report. What the service does well: What has improved since the last inspection? What they could do better: The findings from this `site visit` indicate that both the registered provider and acting manager have much work to do if the standard of care is to be improved for residents and requirements and recommendations as highlighted within this report are addressed. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 6 Following the last inspection, three Statutory Requirements were highlighted. It is of concern that at this `site visit` 18 Statutory Requirements and 8 Recommendations were highlighted for attention. The registered provider and acting manager must ensure that care plans for individual residents are detailed and comprehensive and more urgently ensure that all staff working within the care home understand and follow information recorded so that residents can have their needs met. It was evident at the `site visit` that residents needs within a number of areas are not being met and in some cases staff are `taking the easy option` by not adhering to documentation available. However in some instances it is also evident that there are no specific guidelines for support staff to follow and some staff are unclear as to how to care/provide support for some residents. It is concerning to note that the acting manager has only been in post for approximately five weeks and the above issues have not been addressed prior to her employment to the care home and these have been inherited. Failure to address the above issues will result in residents not having their needs met and support staff possibly providing incorrect care practices. A varied, innovative and more individualised programme of activities both `in house` and within the local community must be devised and implemented. The registered provider and acting manager must ensure that drivers are available on all shifts to enable residents to participate. Additionally all staff must ensure that residents are regularly consulted and have the opportunity to be part of the decision making processes within the home. The registered provider and acting manager must ensure that staffing levels within the home are appropriate for the needs and numbers of existing residents. Should staffing levels fall below those as previously agreed with the registration authority, the Commission for Social Care Inspection must be notified as part of Regulation 37 Notifications. Additionally urgent action is required to ensure that robust recruitment procedures are adopted at all times, that a training programme for both mandatory/specialist training is provided for all staff and that all newly appointed staff receive an induction in line with Skills for Care and that all staff receive regular supervision. The above will hopefully ensure that all staff working at the care home, work effectively and efficiently to meet the individual and collective needs of residents. Robust recruitment procedures will ensure that residents are protected. One of the negative aspects of feedback from visitors to the home and from discussions with staff was that many feel that the registered provider is not supportive enough and is partially to blame for the homes poor performance. The registered provider must as a matter of priority ensure that the care home fulfils its stated purpose and objectives and meets the needs of those people who live there. It is positive to note that an acting manager has been appointed who appears committed and enthusiastic to provide quality care and to raise the homes profile. The calibre of this person is critical to the quality of care provided and to the success of the home in achieving a high level of care for the future. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 7 As a result of the Commissions concerns additional random `site visits` will be undertaken to check compliance to the National Minimum Standards and Care Homes Regulations for Younger Adults (18-65). 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. Glenroyd House DS0000032135.V301289.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 Glenroyd House DS0000032135.V301289.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. The Statement of Purpose/Service Users Guide does not include all information as required. No new residents have been admitted to the care home since the last inspection. All residents are issued with a contract of residency. EVIDENCE: Following the last inspection to the home, the newly appointed acting manager has devised a new Statement of Purpose/Service Users Guide. The document has been devised in a written and pictorial format. The document needs to be reviewed to include information relating to a summary of the purpose of the home, description of the accommodation provided, number of places provided, relevant qualifications/experience of the registered provider and the manager/support staff. Additionally it was noted that the document makes reference to another service (Primrose Lodge). Once updated a copy of the completed document must be forwarded to the Commission. Evidence was available to indicate that residents are issued with an individual contract, setting out the terms and conditions of the home. Of those contracts inspected, all were seen to be signed and dated. Since the last inspection no new residents have been admitted to Glenroyd House. This was confirmed by the homes pre inspection questionnaire and from discussions with support staff and the acting manager. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A plan of care is available for all residents residing at the care home, however some lack detail and comprehensive information. Care plans are not always followed and resident’s needs are not consistently met. EVIDENCE: On the day of the site visit two individual plans of care were inspected. In general terms these were seen to contain some detailed information relating to residents social, physical, healthcare and emotional care needs. Both care plans were noted to require additional information i.e. one resident’s care plan made reference to them on occasions displaying aggressive and inappropriate behaviours. No information was recorded relating to the specific nature of the resident’s behaviours, possible triggers and guidance for staff as to how to provide relevant interventions and support. The daily care records for one resident record on a regular basis that the resident becomes frustrated and aggressive as a result of their obsessive behaviour pertaining to tea, coffee (wish to frequent Macdonald’s fast food outlet) and their craving for cigarettes. The care plan details that cigarettes are rationed to once hourly and Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 11 coffee and tea must be limited as a result of the resident’s obsessive behaviours and a tendency to become constipated. It is of concern and very evident that the resident’s care needs relating to the latter, are not being met by support staff. Records indicate that on a regular basis the resident is being taken to Macdonald’s. Following discussions with staff and from daily care records it is evident that the frequency of visits is as a direct result of support staff not knowing how to deal effectively with the resident and/or his demanding behaviours and so therefore `give in` to limit his possible outbursts. It was evident that this person’s plan of care did not detail restrictions imposed/limitations agreed between the care home and the resident/their representative. Additionally the care plan made no reference to the resident absconding or leaving the home environment unaccompanied. Records (ABC charts) detailed that the resident went missing from a local college for a short period of time. The acting manager advised the inspector that since her appointment she has instigated advice and support from the local behaviour therapy team and that guidelines for staff on how to deal with the resident’s behaviours are in the process of being devised and implemented. Another care plan stated that the resident can become distressed and anxious if daily routines are altered. No clear guidelines were devised pertaining to their specific daily routines i.e. morning/evening etc. It was positive to note that there were clear detailed guidelines relating to their shower/personal care routine. The care plan is explicit that the resident should be encouraged to drink water instead of coke and fizzy drinks and should also have their weight monitored. It was evident during the inspection that the resident’s healthcare needs are not being met i.e. the resident’s diet is not being monitored closely and they are not eating/being encouraged and supported by staff to eat a reasonably balanced healthy diet i.e. on 27.6.06 menu records indicate that the resident had a fizzy drink (coke) for both breakfast and lunch, however they did eat a main meal in the evening. On the 8.7.06 menu records indicated that the resident did not eat breakfast, had noodles for lunch and for dinner had a `Big Mac` meal and a fizzy drink. On 5.7.06 menu records indicated that the resident did not eat breakfast, had 2x fried eggs with onions plus 2x bread/butter and for dinner they had fish cakes/chips and peas. The resident’s weight had not been monitored since February 2006. Risk assessments are not devised for all areas of assessed risk i.e. The care plan for one resident detailed that they can become isolated if they do not go out/socialise with other people/peers, can display verbal aggression/bouts of frustration and need to have their dietary needs monitored. No risk assessments were devised in these areas. Some elements of both care plans had not been reviewed or updated for some considerable time. On inspection of care plan documentation for two residents, it was evident that one resident had received a formal review involving the resident, the care home, advocacy services and the resident’s placing authority. It was disappointing to note that many issues highlighted for Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 12 `action` had not been addressed or a reason for them not being dealt with recorded. Of the two care files examined no photograph was available for one resident. It was unclear when examining both files as to whether or not these had been compiled in conjunction with either resident and/or their representative. Glenroyd House DS0000032135.V301289.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A limited programme of meaningful activities and occupation is available for residents. Residents community presence and participation care needs are not being met. Residents are not offered a healthy balanced diet and this is in contrast to their specific care needs/care plans. EVIDENCE: None of the care plans inspected had a weekly programme of activities recorded. The one consistent activity, which was readily available and as far as one can see appears to be enjoyed by all residents, is `Wednesday Club. It was apparent following discussions with the acting manager and support staff that frequently there are insufficient drivers available to enable residents to pursue leisure activities and to participate within the local community. Although the care home has access to a mini-bus, on the day of the site visit no member of staff was actually able to drive the vehicle (1x member of staff on sick leave and 1x member of staff on paternity leave). The acting manger advised the inspector that some staff are able to use their own private vehicle as they have business insurance cover. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 14 The care plan for one resident detailed that they require specific support from staff to access the community and require a structured day care programme to be implemented. Records evidenced that up until recently they had attended adult education classes 3 days a week. It was disappointing and of concern that no alternative activity had been sought to fill the gaps. The acting manager advised that one formal day care placement has been pursued and the resident is now attending. However transport issues are problematic as a result of previous comments. This often results in resident’s either being collected early or late, much to the annoyance of the day care placements. The other care plan inspected detailed that the resident requires a more structured day instead of spending their time in front of the television and enjoys going out shopping and out for a meal. Records further indicate that the resident did not wish to attend adult education classes until quite recently. There is no evidence to indicate at all that a structured range of activities has been offered or attempted for the resident. On the day of the site visit the resident was observed to spend most of their day in front of the television. Records also detail that the resident needs encouragement to leave Glenroyd House. No information was recorded as to what steps are being taken to address the issue by support staff or the reasoning behind the resident’s rational. Records indicate that some residents receive formal day care i.e. Hadleigh Centre, Walter Boyce Centre and during term time there is access to adult education classes. On the day of the site visit, support staff appeared confused and unaware of the menu week number i.e. 2 or 3. The home operates a four weekly menu, however it was evident that food offered to residents is not always in line with the week’s menu. Residents were observed to be offered choices, however it is clearly evident that items offered are not always in the best interests of the individual or in line with their plan of care e.g. one residents care plan makes reference to them having their fizzy drink intake monitored/encouragement to drink water/healthy diet. The resident was noted to have copious amounts of fizzy drinks in their fridge and a further box of 24 cans of coke in their wardrobe. Additionally the fridge contained chocolate mousses and packet/microwavable rice and in their bedroom there were boxes of coco pops cereal. Not all residents are empowered or encouraged to actively participate in meal preparation. During the lunchtime meal five residents sat in the dining area with the inspector. No members of support staff were on hand to assist residents throughout the lunchtime period and tensions surfaced between two residents. The inspector felt obliged to provide a level of intervention but should never have been placed in this situation in the first place or left with residents who can display aggression and/or inappropriate behaviours. The Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 15 registered provider must ensure that at mealtimes residents are adequately supported. The evening meal was prepared by support staff and looked plentiful and appetising (spaghetti bolognaise). One resident was overheard to state that they did not like the meal prepared. Staff appeared somewhat unsympathetic and stated “that’s all there is”. No alternative as far as the inspector was aware was offered to the resident. This is unacceptable and the registered provider is reminded that it has a duty of care to ensure that all residents residing at the care home are offered a healthy diet, that they enjoy their meals and mealtimes, that residents are actively supported to help plan and prepare meals where appropriate and residents are offered a choice of suitable menus which respect their individual preferences. On the day of the site visit support staff purchased the home’s food shopping. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to a range of healthcare professionals as and when required. Records are inconsistently completed, as some are more detailed than others. The healthcare needs of individual residents are not always met. Medication storage facilities and records were generally seen to be appropriate. EVIDENCE: From inspection of care files for residents and from discussions with support staff and the acting manager, it was evident that residents have access to a range of healthcare professionals i.e. Community Nurse Services, Behaviour Therapy, Consultant Psychiatry, GP’s, Care Managers, Dentists etc. As stated previously it is clear that in some instances resident’s healthcare needs are not being met and issues highlighted within individual plans of care are not being followed and reviewed regularly. It is of concern to note that visiting professionals have commented that support staff, do not appear to demonstrate a clear understanding of resident’s needs and that they feel dissatisfied with the overall care provided to individual resident’s that are placed at Glenroyd House. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 17 On inspection of the homes medication storage facilities and records, these were seen to be appropriate and satisfactory. It was positive to note that medication profiles are available for all residents. The acting manager was advised to devise PRN (as and when required medication) protocols for those residents who receive this medication. The home was observed to have a copy of the Royal Pharmaceutical Guidelines for the Safe Administration of Medication in Care Homes. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a complaints procedure/log book. Residents residing at the care home are not safeguarded and protected from abuse and self-harm. EVIDENCE: On the day of the site visit no complaints procedure or complaints log book, was readily available. There is no evidence that residents are aware of how to report incidents or make a complaint/raise concerns. The acting manager advised that since the last inspection, one complaint has been placed by the previous acting manager to the home. This complaint was in relation to no keypad system being installed for the front door and the risks this posed to residents (one resident in particular). The Commission for Social Care Inspection is in receipt of several items of correspondence between the previous acting manager and Beacon Care pertaining to their concerns (keypad system). The Commission is concerned that the registered provider has not dealt with this issue within a reasonable time frame and that it has not safeguarded residents. Additionally there are no records to indicate that the registered provider took the previous managers concerns seriously, investigated the issues or took appropriate action. The home was noted to have a Protection of Vulnerable Adults policy and procedure. No staff within the care home have, received training relating to challenging behaviour. This is of concern as there are some residents within the care home environment who can display aggressive/inappropriate behaviours on occasions. The review records for one resident stated that training relating to this area is being considered by the registered provider. This is unacceptable and must be provided and acted upon as a matter of Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 19 urgency by the registered provider. Following discussions with the acting manger and support staff it is evident that some staff are frightened of working with certain named resident’s and that inappropriate interventions and `avoidance` techniques are being adopted. The registered provider should consider the purchase of suitable equipment, which enables staff to summon help and assistance quickly as and when required. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a comfortable and safe environment. EVIDENCE: All residents have a single bedroom with en-suite facilities. Individual residents bedrooms were noted to be personalised and individualised with many personal effects. The bedrooms appear to be suitable for their individual needs and lifestyles and promote some independence. The pre inspection questionnaire forwarded to the Commission details that since the last inspection some changes have occurred to the premises. This refers specifically to one shower being altered/lowered and redecoration of the premises and new flooring purchased and placed. On the day of the site visit the home was observed to be clean, tidy and odour free. It was disappointing to note that the homes gardens to the front and rear of the property are not well maintained and were observed to be untidy and overgrown. It was positive to note that the acting manager has initiated the Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 21 use of a gardener and on the day of the site visit they were attending to the homes front garden. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels at the care home are not always appropriate to meet resident’s needs. The home’s recruitment practices are not robust and do not protect residents. Training records indicate gaps pertaining to both mandatory and specialist courses. Some staff have received formal staff supervision, however this is not in line with National Minimum Standards recommendations. EVIDENCE: On inspection of four weeks staff rosters it was evident that these do not include the full names of staff on duty and there is no `key` depicting actual hours worked by individual staff i.e. E=/L=/N= etc. The acting manager was advised that the use of tippex/white correction fluid on the statutory roster should be discouraged. The rosters indicate that some staff are consistently working long days/excessive hours i.e. the staff roster for week commencing 10.7.06 indicated that one member of agency staff was scheduled to work a total of 69.5 hours and to complete 3x sleepover shifts and another member of staff was scheduled to work 62.5 hours. The staff roster detailed that one member of staff was scheduled to not leave the homes premises for two days completing an early/late and sleepover shift on 10.7.06 and 11.7.06 inclusive. The staff roster indicates that on 4.7.06 one member of staff worked a total of 16 hours between 14.00 and 06.00 hours. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 23 Staff rosters detail on occasions there have been insufficient numbers of staff on duty for the numbers and needs of current residents i.e. on 5.7.06 and 12.7.06 there were only 2x staff on duty during the early shift. On the 6.7.06 it was unclear as to who the waking night person had been. The staff rosters indicate that at least on two occasions there were insufficient senior staff on shift to administer medication to residents and a senior member of staff had to return to the home. The acting manager advised that some issues are as a result of 1x senior member of staff is on sick leave, 1x senior staff member is on paternity leave and 2x support staff are on long term sick leave. Of five staff recruitment files requested, no staff recruitment file was evident for the acting manager. On inspection of the four remaining files it was evident that the previous acting manager had not adopted and implemented robust recruitment procedures in line with regulatory requirements i.e. for one employee there was no photograph, no health declaration, only 1x reference (personal reference and not from last employer), no proof of identification, no job description, no record/evidence of training and qualifications and no record of induction. Additionally there was no evidence that this person has received formal staff supervision (start date 6.3.06). Of the other files inspected proof of identification were not available for two staff. One person’s application detailed that they suffered with back problems, however there was no evidence to indicate that this had been explored or discussed further. A record of induction was only partially completed within a further two files. The home does not have confirmation from the agency, which supplies additional staff to the care home as and when required, confirming that all necessary recruitment checks have been undertaken. Although there was no staff file for the acting manager, her training records were evident. A training matrix was forwarded to the Commission with the homes pre inspection questionnaire. This indicated that not all staff have attained mandatory training pertaining to fire awareness, food hygiene, manual handling, health and safety and protection of vulnerable adults. As stated already within the main text of this report, no staff have undertaken and attained training relating to challenging behaviour/dealing with aggression. It is concerning to note that very little specialist training has been provided to support staff which caters for those needs associated with adults who have learning disabilities i.e. autism, total communication, learning disabilities, epilepsy etc. The training matrix indicates that 2x staff have attained NVQ Level 2 and 3x staff have attained NVQ Level 3. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 24 Some staff had received formal staff supervision, but these are not in line with the Commissions recommendations. The acting manager is fully aware of the need to implement staff supervisions as soon as possible. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appointed a new acting manager. It is unclear and difficult to decipher at present as to whether or not the home is well run. Records as required by regulation were readily available and these ensure that the health and safety of residents are promoted. EVIDENCE: The acting manager advised the inspector that she has worked within a care field setting for approximately 17 years (older people, adults with learning disabilities, children and supporting young people in the community). Training records for the acting manager indicate that she has attained a BTEC NVQ Level 3 in Care and NVQ Level 4 in Management. Additionally she has undertaken training relating to first aid, person centred planning, food hygiene, protection of vulnerable adults, infection control, relationships and business workshop and coaching session. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 26 The acting manager stated that upon commencement of employment, she spent a total of between 2-4 days with the homes manager as part of her induction, going through various elements i.e. petty cash, staff rosters, residents monies etc. As part of her induction she also spent time at another local Beacon Care home. At the time of the site visit the acting manager had been in post for approximately five weeks. It was evident at this visit that there are many issues which require urgent attention and addressing. Many issues have been inherited, however there are some matters which should have been dealt with from the start i.e. staffing levels, staff care practices and interaction with residents, staff following individual resident’s care plans etc. Although the Commission is concerned following the site visit of its findings, hopefully the acting manager once given the time will be able to raise the home’s existing profile and standards. It was very apparent at the site visit and from correspondence received that the general feeling is that the registered provider does not provide or offer sufficient support. This imbalance must be corrected if the acting manager/care home is going to have any chance of improving the current situation. Staff spoken with were very complimentary regarding the newly appointed acting manager and felt that in the last five weeks she was having a positive impact on the running of the care home and making changes for the better. A random sample of records were inspected relating to fire procedures, emergency lighting, portable appliance testing, hot water temperatures, the homes risk assessments, employers liability and residents monies. The home was observed to have a reviewed fire safety policy and appropriate fire evacuation procedures. A record of fire drills were evident and these indicated that up until May 06 these were being conducted monthly. The homes emergency lighting and alarms were last tested at the beginning of June 06. A certificate of inspection for fire safety equipment was available and was dated November 05. It was positive to note that a fire risk assessment for the home had been completed in March 06. Portable appliance testing for electrical equipment within the home was conducted in November 05. A limited number of records were evident pertaining to hot water temperatures. The homes COSHH (Control of Substances Hazardous to Health) policy and procedures were readily available and included product data sheets for a variety of products used in the home. The homes employers liability insurance certificate was in date. The home was noted to have a missing persons and visitors policy and procedure. The inspector was advised that no surveys have been carried out since the last inspection in relation to the homes quality assurance. Previously the home has Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 27 sent questionnaires to residents, relatives/representatives, staff and other professionals. Records relating to individual resident’s monies (records/receipts) were seen to be satisfactory. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 28 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 2 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 1 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 2 1 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 1 15 2 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 2 2 2 X X 3 X Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 29 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 YA1 Regulation 4 and 5 Requirement The registered provider must produce a Statement of Purpose and Service Users Guide, which includes all elements as required by regulation. The registered provider must ensure that all care plans are detailed and comprehensive and clearly identify individual residents needs and include information depicting how these will be met by support staff. The registered provider must ensure that individual resident’s plan of care are kept under regular review. The registered provider must record any limitations and/or restrictions for residents and record on this on their care plan. The registered provider must ensure that risk assessments are devised for all areas of assessed risk. The registered provider must ensure that all residents participate within a meaningful DS0000032135.V301289.R01.S.doc Timescale for action 01/10/06 2. YA6 15(1) 01/09/06 3. YA6 15(2) 01/09/06 4. YA7 17(1)(a), Sch 3(q) 01/09/06 5. YA9 13(4)(c) 01/09/06 6. YA13 16(2)(m)(n) 14/08/06 Glenroyd House Version 5.2 Page 30 7. YA17 8. YA19 9. YA22 10. YA22 11. YA23 12. YA23 13. YA33 14. YA34 and stimulating programme of activities. 16(2)(i) The registered provider must ensure that all residents receive a balanced diet in accordance to their individual care needs. 12(1)(a) The registered provider must ensure that proper provision is made for the health and welfare of all residents. This refers specifically to residents healthcare needs/care plans not being followed by support staff. 22(1)(2) The registered provider must devise a complaints procedure and this must be appropriate for the needs of residents. 22(3) The registered provider must ensure that any complaints received into the home are fully investigated and that records relating to the issue, investigation and action taken are readily available. 13(6) The registered provider must ensure that appropriate arrangements are made for staff to receive training pertaining to challenging behaviour. 13(4)(c) The registered provider must ensure that unnecessary risks to the health and safety of residents are identified and eliminated. This refers specifically to the purchase of appropriate equipment, which enables staff to summon assistance and help. 18(1)(a) The registered provider must ensure that at all times there are sufficient numbers of staff on duty for the numbers and needs of residents. 17(2),19(1), The registered provider must Sch2&4 ensure that robust recruitment DS0000032135.V301289.R01.S.doc 14/08/06 14/08/06 21/08/06 14/08/06 01/11/06 01/09/06 14/08/06 14/08/06 Page 31 Glenroyd House Version 5.2 15. YA35 18(1)(c) 16. YA36 18(2) 17. YA38 10(1) 18. YA39 24 procedures are adopted at all times and that records as required by regulation are sought and available. The registered provider must ensure that all staff receive appropriate training relating to both mandatory and specialist training courses. The registered provider must ensure that all staff receive formal staff supervision on a regular basis. The registered provider must ensure that it manages the care home in accordance with the homes Statement of Purpose and the number and needs of residents residing currently. The registered provider must ensure that a quality assurance system is implemented and that the views of residents, their representatives and visiting professionals are sought and a report compiled and made available. 01/12/06 14/08/06 14/08/06 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA8 YA14 YA15 YA20 Good Practice Recommendations Ensure that residents are consulted at all times and that they are empowered to make decisions. Ensure that there are sufficient drivers available on each shift to enable residents to access the local community and to participate and pursue leisure interests and hobbies. Ensure that all visitors are made to feel welcome and are offered refreshments where appropriate. PRN (as and when required medication) protocols are devised and implemented for individual residents. DS0000032135.V301289.R01.S.doc Version 5.2 Page 32 Glenroyd House 5. 6. 7. 8. YA24 YA31 YA32 YA37 Ensure that the home’s gardens and grounds are well maintained and attended to on a regular basis. Ensure that all staff are issued with an up to date job description depicting their roles and lines of responsibility. 50 of staff should attain NVQ Level 2 or above. The registered provider should ensure that sufficient support is provided to the manager and support staff. Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenroyd House DS0000032135.V301289.R01.S.doc Version 5.2 Page 34 - 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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