Inspection on 29/11/06 for Hambleton House

This inspection was carried out on 29th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hambleton House 05/08/07

Hambleton House 28/12/05

Hambleton House 08/09/05

Hambleton House 01/02/05

Hambleton House 10/11/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Hambleton House 337 Scraptoft Lane Leicester Leicestershire LE5 2HU Lead Inspector Ruth Wood Unannounced Inspection 29th November 2006 12:40a Hambleton House DS0000006374.V320438.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 Hambleton House DS0000006374.V320438.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. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hambleton House Address 337 Scraptoft Lane Leicester Leicestershire LE5 2HU 0116 2433806 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) Mr Suresh Advani Mrs Maureen Barbara Baines Care Home 18 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (3) Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Hambleton House is registered to provide personal care and accommodation to both male and female service users in the following categories: Learning disability (LD) 15 Learning disability (LD(E)) 2 MD Mental disorder 18 - 65 years (MD) 3 To be able to admit the named person of category LD(E) named in the variation application number 53629 dated 22nd September 2003. To be able to admit the named person of category LD(E) named in the variation application number 57627 dated 15th October 2003. The maximum number of service users to be accommodated in Hambleton House is 18 28th December 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Hambleton House provides a service for eighteen people who have either a learning disability or a mental disorder. It is situated within large grounds in a residential area close to the village of Scraptoft. It is close to many amenities, including shops, pubs and sports facilities as well regular bus routes to Leicester. The house is spread over three floors with all communal areas and some bedrooms being situated on the ground floor and remaining bedrooms being on the first and second floors. A recent extension has provided four bedrooms with en-suite facilities and there are sufficient communal bathrooms and showers on all floors to meet residents’ needs. Current fee levels at the home are £372 per week. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three weekdays, the first between 12:40 and 18:10 the second between 09:50 and 13:00 and the third between 10:20 and 11:50. The total length of the inspection was ten hours ten minutes. During this time discussion was held with six residents, the registered manager and three staff members. Various records were examined including those relating to medication, care, staff recruitment, menus and health and safety. All communal areas of the building were seen and two residents’ bedrooms. Staff interaction with residents was also observed. On the second day of inspection a letter was given to the registered person informing him of serious concerns with regards to staff recruitment practices. These are outlined in the final section of this summary. What the service does well: What has improved since the last inspection? What they could do better: Several things need improving. Firstly the registered person hadn’t arranged criminal records bureau checks for more than half of the staff members, neither had their names been checked against the vulnerable adults register. The registered person was asked to take prompt action to remedy this and checks have now been requested and agency staff are working at the home until this has been done. Two written references were not in place for three of the staff members and these must also be obtained. On the first day of Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 6 inspection staffing levels were below those that the registered person had said would be provided when the application to increase the numbers in the home was made. On the second day of the inspection the staffing levels had been increased and these should be monitored to ensure that they are sufficient to meet people’s needs. Some staff had not had sufficient training in supporting people with mental health needs – again this should be arranged. Significant improvement is needed in how medication is managed. There was no record of some medication received into the home and no instructions on the medication record as to how it should be given. Some medication that had been given was not recorded on the medication record’ and some medication had been given in a different way to what was instructed on the record. Staff members administering medication had not received sufficient training or demonstrated their competence in this area. On the first day of inspection one staff member and the deputy manager gave out medication without using the medication record. These problems were brought to the attention of the manager on the first day and are being addressed. Training has been arranged for staff and health professionals are being consulted for guidance on record keeping. Four residents living in the home did not have suitable support plans or risk assessments in place and these must be completed. Improvements are also needed to the way in which people are assessed before they come to live in the home to make sure that the home can meet their needs. Menu records showed that food served, lacked variety and nutritional balance and that there was no hot meal available on two days of the week. The deputy manager acknowledged that there were problems with the menus and they intended to change these. Some staff preparing food did not have training in basic food hygiene. This has now been arranged. Finally there is no clear quality monitoring system in place to ensure that residents’ views inform the way the home is run. 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. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 7 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 Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 Quality in this outcome area is adequate Residents’ needs must be assessed by the Registered Manager prior to admission, to ensure that they can be met. Good systems are in place to enable residents to ‘test drive’ the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Social workers’ assessments, together with an assessment completed by the registered manager were in place for two residents who had lived at the home for some time. The assessment included information about the residents’ likes and dislikes and their aspirations for the future. There were no in-house assessments or care plans in place for the four residents who had moved into the home over the last four weeks. Two of these residents fell into the home’s new registration category of mental disorder. One of the issues discussed prior to the extension of registration was that careful assessment would be needed to ensure that the residents would ‘fit in’ with those people with learning disabilities currently living in the home. Discussion with one resident indicated that they had received written information about the home and had been given ample opportunity to meet with residents and staff prior to making a decision to live there. This included having meals at the home and making overnight stays. The four residents who moved into the home during the last four weeks had also been given opportunities to look around the home and make visits, prior to moving in. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. Not all residents have support plans and risk assessments that accurately reflect their needs or guide staff in how to meet those needs. Residents are involved in making decisions and good systems are in place to support them in managing their finances. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Support plans and risk assessments were in place for two of the three residents selected for case tracking. No support plan or risk assessment was available for the resident who had moved into the home three weeks ago despite them having clear risks identified by their care manger’s assessment. No support plans or risk assessments were in place for the remaining three residents who had moved into the home during the last four weeks. It should be noted however that care manager’s comprehensive assessments were in place and therefore it was judged that no one was being placed at immediate risk. The two support plans in place were well structured and there was evidence of regular review involving the resident. However information in one support plan was inaccurate with regards to ‘as required’ medication; this plan had Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 10 been reviewed by the key worker and the inaccuracy was still evident. The registered manager agreed that she had not monitored the plans to ensure the accuracy of the information and that staff were able to complete them correctly (See also Standard 38). The daily notes of the three case tracked residents contained some inappropriate use of language (judgement rather than objective recording). There was also discrepancy between the manager’s description of one of the resident’s needs and the information conveyed by daily records. These indicated that on occasion the resident’s behaviour had been intimidating to both residents and staff. The manager said that she had been unaware of this and has subsequently spoken to the resident’s Community Nurse to seek advice and support on this issue. Residents have the opportunity to be involved in making choices and this is facilitated by formal residents’ meetings and in making decisions about social outings and holidays. Good arrangements are in place to manage residents’ finances and detailed records were available for all transactions; the balances and financial records of three residents were checked and found to be accurate. The Registered Manager stated that she reluctantly acted as appointee for six residents and it is strongly recommended that she negotiate with their placing authorities to see if alternative arrangements can be made. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate Residents have opportunities to engage in vocational, leisure and community activities and are given good support in maintaining links with family and friends. The variety and nutrional content of food served is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are engaged in a variety of daytime activities including voluntary work, college, specialist day centres and a gardening project. One resident spoke enthusiastically about the latter which they attended three days per week, travelling there independently by bus. The registered manager had ensured that two residents recently admitted to the home had been able to continue with their existing college courses. One resident said that they did not want to attend any daytime activities at present as they had tried this in the past “and it didn’t go too well”. Residents make good use of local facilities such as the pubs, shops and hairdressers and also access Leicester either independently or with staff support. At the beginning of the inspection a group of residents were arranging to go late night Christmas shopping that evening with staff. Various Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 12 activities are arranged throughout the year including boat trips and annual holidays. Residents spoke enthusiastically about visits earlier in the year to the Isle of Wight and Torquay. Discussion with residents, the registered manager and examination of support plans showed that residents are supported by their key worker to maintain contact with their friends and family. Good interaction was observed between residents and staff and in particular between residents and the registered manager. Residents open their own mail, and can make telephone calls in private. The menus submitted with the pre-inspection questionnaire and those seen on the first day of the inspection indicated that food served, lacked variety, offered limited choice, and did not have a high nutritional content (it did not offer the recommended five portions of fruit and vegetables per day). It was noted particularly that on two weekdays there was no hot meal served at either the afternoon or evening meal. Residents, whether in or out of the home, were offered sandwiches for lunch and a choice of salad for the evening meal. The evening meal served on the first day of inspection was mushy peas, potato waffles and fish cakes. Residents asked directly about their views of the food said that it was “very nice” and that they had “no complaints”. The deputy manager stated that they were aware that the variety and nutritional content of the food needs to be improved and that they were working towards introducing new menus. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. Residents receive appropriate personal support and their health needs are well met. Current poor practice in medication administration does not protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of support plans, discussion with residents and observation of their physical appearance indicated that appropriate personal support is offered to people, dependent on their wishes and level of independence. Detailed records were in place for all healthcare appointments and staff support residents at medical appointments again dependent on their wishes and level of independence. Information about residents’ medical conditions was available and there was evidence that they had access to optical, chiropody, dental and GP services as well as ongoing support from consultant psychiatrists and community nurses. Issues of concern were found in relation to medication training and staff competence, medication administration and recording. There were also particular issues identified in relation to ‘as required medication’. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 14 Daily records indicated that ‘as required’ pain relief had been given to one resident but this was not recorded on the medication administration record (MAR). ‘As required’ medication (Lorazepam) was stored in the medication cabinet for four residents but was not recorded on the MAR or the record of medication received into the home. The pharmacy labels indicated that the medication had been dispensed prior to the residents moving into the home and that only one tablet was unaccounted for. The staff member on duty was asked about the ‘as required’ medication for one resident and stated that it was to “calm them down but only when the manager says so”. The registered manager had earlier stated that no residents took ‘as required’ medication with the exception of pain relief. There were no protocols in place stating under what circumstances ‘as required medication’ should be given, and who had authorised/prescribed this. The MAR for a resident who had recently moved into the home stated that they should use a Ventolin Evohaler ‘as required’. The MAR indicated that has been signed as being given every day. When this was raised with the registered manager they immediately contacted their dispensing pharmacist who reassured them that this would not have caused the resident undue harm. Later consultation with the resident and their GP (by the deputy manager) indicated that they had always used the inhaler on this basis and that the prescription would be changed to reflect this. On the first day of the inspection, the deputy manager and another staff member undertook the medication round without using the MAR. The staff member said that they had not received any formal, external training in medication but had been shown what to do by the registered manager. They said they were aware that they should not give out medication without referring first to the medication record and signing it after the medication had been given. Other residents’ administration records appeared accurate and medication appeared to be stored appropriately. Medication received from the current pharmacist was appropriately recorded, as was medication being received directly into the home from the hospital. On the third day of the inspection visit evidence was seen that training on the safe handling of medication had been arranged for 14 December delivered by Stamford Training, which all staff were being asked to attend. The registered manager also stated that she had contacted residents’ community nurses to discuss protocols for ‘as required’ medication. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate Residents are listened to but poor recruitment practices and lack of knowledge about existing guidance means they are not fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a formal written complaints procedure and residents spoken with said that if they weren’t happy with anything in the home they would tell Maureen (the registered manager) or “any of the staff as they would sort things out”. Residents also have the opportunity to raise concerns at the residents’ meetings, which are facilitated by a ‘friend of the home’ who is a member of the local church. No complaints have been made about the service either directly to the home or the Commission. Procedures are in place covering whistleblowing, protecting residents from abuse and dealing with behaviour that may challenge. Staff records indicated that staff had received training in these areas but this information was not checked with staff. There was some discrepancy in the response to one resident who was recorded as exhibiting some behaviour that residents and/or staff may find challenging. This was brought to the attention of the registered manager who subsequently contacted the residents’ community nurse for guidance. The registered manager demonstrated an understanding of local safeguarding adults procedures and protocols although was unclear as to her responsibilities with regards to the vulnerable adults register. This was later confirmed during further examination of staff records when seven of the home’s twelve staff were found to be working without a valid Criminal Records Bureau check, neither had their names been checked against the Vulnerable Adults Register (see also Standard 34). Urgent action was required and complied with immediately. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate Residents live in a clean and comfortable environment but specific improvements are needed to ensure residents’ safety in all areas This judgement has been made using available evidence including a visit to this service. EVIDENCE: All communal areas appeared comfortable, clean and appropriately decorated. There were no offensive odours and laundry facilities were appropriately sited away from food preparation areas. Two residents showed the inspector their bedrooms; these were decorated and furnished to their personal taste. Radiator temperatures in two of the bathrooms were excessive and presented a potential safety risk. The deputy manager stated that all residents were supported to some degree in the bathroom and that it was the registered person’s intention to cover the radiators “soon”. Examination of the home’s health and safety records found that a health and safety at work inspection had been conducted by the City Council’s Environmental Health Department on 20/12/05. Arising from this the home was recommended to cover all radiators in rooms where residents were unsupervised. The agreed date for completion Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 17 of this work was 28/02/06. This work has not been completed and the Commission have informed the Environmental Health Department of this. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is poor Residents are not effectively supported or protected due to very poor recruitment practices, inadequate staffing levels and, in certain areas inadequate training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A recent registration variation increased the numbers of people from fourteen to eighteen to include up to three people with a mental disorder. As part of this application the registered person stated that there would be three people on duty at all times in the care home during the day. Examination of the current week’s rota on the first day of inspection showed that there were several periods during weekdays when only two members of staff were on duty; notably between 7.30 and 9am and between 4pm and 6pm when people required support either preparing or returning from their daytime activities. There are no cleaners or cooks and support workers are expected to undertake domestic duties in addition to their general support role. Four residents had recently moved into the home, two of which were in the home’s new registration category. The level of staffing would seem to offer little opportunity for more intensive support or assessment while these residents settled in. The registered manager stated that she was unhappy with the current level of staffing in the home and was in negotiation with the registered provider to increase levels. On the second and third inspection dates it was Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 19 noted that the rota had been modified to ensure that there were three members of staff on duty during the daytime but staffing levels should be constantly monitored to ensure that the needs of all residents can be met. Four staff members have attained National Vocational Qualifications (NVQ) in care at level 2 or above and three staff members are currently undertaking Learning Disability Awards Framework (LDAF) induction training. There are some areas however where staff require additional training. As part of the variation application, the registered provider stated that all staff would be provided with training in working with people with mental health needs. Discussion with a staff member, the registered manager and examination of training records indicated that training undertaken by some (not all) staff had been a one day introduction to mental health. Given the home’s new registration category more training in this area should be provided for staff, to ensure that they can meet these residents’ needs effectively. Recruitment practices urgently require significant improvement. Seven staff had been employed without ensuring Criminal Records Bureau checks had been completed or that their names had been checked against the Protection of Vulnerable Adults register. Two written references had also not been obtained for three of these staff. The registered person’s representative was made aware of the seriousness of these issues when they were discovered on the second day of inspection. The registered person was subsequently contacted and a letter of urgent concern given to him on the same day. This made three requirements (12-14) in relation to obtaining checks against the Protection of Vulnerable Adults register and obtaining Criminal Records Bureau checks. A Requirement restricting the staff members’ working until such checks had been completed was also made. At the final day of the inspection (05/12/06) it was noted that the requirements had been complied with, the staff members were no longer working in the home and the necessary checks had been applied for. Agency staff had been engaged to ensure sufficient staffing levels. A requirement relating to obtaining two written references for all staff members is made in the inspection report. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is adequate Current management and Quality Assurance systems do not ensure residents’ welfare and protection in all areas or that their views underpin and actively inform the delivery of the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager holds the Registered Manger’s Award, NVQ in care at level 4 and updates her training by attending relevant courses. Management practice in the home is somewhat erratic however, primarily because of a lack of clarity regarding the respective roles of the registered manager and the deputy. As the registered person the manager must ensure that management practices and responsibilities within the home are clear and that practice within the home conforms to the Care Home Regulations 2001. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 21 Some attention had been given to Quality Assurance within the home with questionnaires left over from previous CSCI inspections being used to canvas the views of visitors, relatives and residents. However there is no structured approach to quality monitoring and this must be addressed to ensure that shortfalls in practice are addressed and that the quality of the overall service is improved. Health and safety records were examined and fire records were in good order. An updated fire risk assessment was in place, there was evidence of regular testing and servicing of systems and equipment. Fire drills were recorded and information corroborated by discussion with one resident about their recent experience of being involved in a fire drill. There was evidence that gas and electrical systems had been appropriately maintained. Some staff that prepare meals had not received training in basic food hygiene. This was raised with the manager on the first day of inspection and a course was arranged for all staff to take place before the end of the year. It has already been noted (in Standard 24) that the Environmental Health Officer’s recommendation to cover radiators has not yet been met (See Requirement 9) Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 22 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 X 2 X 3 2 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 2 2 X X 2 X Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 (1) Requirement ‘The registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met.’ The registered person must ensure that such a plan is in place for all residents. ‘The registered person shallafter consultation with the service user or a representative of his, revise the service user’s plan’ The identified resident’s plan must be revised so that it is an accurate reflection of their needs. ‘The registered person shall ensure that- any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and unnecessary risks to the health or safety of series users are identified and so far as possible eliminated.’ The registered person must ensure that appropriate risk DS0000006374.V320438.R01.S.doc Timescale for action 12/01/07 2. YA6 15 (2) (c) 12/01/07 3 YA6 13 (4) (b) (c) 12/01/07 Hambleton House Version 5.2 Page 24 4 YA17 16 (2) (i) 5 YA20 13 (2) 6 YA20 13 (2) assessments are in place for all residents. The registered person must 31/12/06 ‘provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably be required by service users’ ‘The registered person shall 31/12/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.’ An accurate record must be made of all medication received into the home. ‘The registered person shall 31/12/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.’ All medication administered must be accurately recorded on the medication administration record ‘The registered person shall 12/01/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.’ Arrangements for the administration of ‘as required’ medication must be clearly documented and communicated to all staff. This information must include under what circumstances this medication is to be given, who has the authority to give it, the name of the person prescribing it and the arrangements for review. ‘The registered person shall 15/12/06 make arrangements for the DS0000006374.V320438.R01.S.doc Version 5.2 Page 25 7 YA20 13 (2) 8 YA20 13 (2) Hambleton House 9 YA24 13 (4) (a) 10 YA32 18 (1) (c) (i) 11 YA33 18 (1) (a) 12 YA34 19 (1) (9) (10) 13 YA34 19 (1) (9) (10) 14 YA34 19 (1) (9) recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.’ All support staff that administer medication must be competent and trained to do so. ‘The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free form hazards to their safety’ Radiators in areas where residents are routinely unsupervised must be covered to reduce the risk of residents being burnt. ‘The registered person shall ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform’ All staff working at the home must receive adequate training in working with people with mental health needs. ‘The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users’ The registered person must ensure that the identified members of staff do not work in the home until a POVA First check has been obtained Requirement met The registered provider must apply for a POVA First check in respect of the identified members of staff. Requirement met When POVA First checks have DS0000006374.V320438.R01.S.doc 31/12/06 31/01/07 31/12/06 30/11/06 01/12/06 31/12/06 Page 26 Hambleton House Version 5.2 (10) 15 YA34 19 (1) (b) 16 YA39 24 (1) been obtained the registered provider must review staffing arrangements at the home to ensure that at all times the identified members of staff do not work unsupervised until an Enhanced Criminal Records Bureau check has been obtained. ‘The registered person shall not 31/12/06 employ a person to work at the care home unless he has obtained in respect of that person two written reference, including, where applicable, a reference relating to the person’s last period of employment, which involved work with children or vulnerable adults, of not less than three months duration’ Two written references must be obtained for all staff members before they start work at the home. ‘The registered person shall 28/02/07 establish and maintain a system for evaluating the quality of the services provided at the care home’ 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 YA3 Good Practice Recommendations The registered person should undertake and document an assessment of need for all residents before they come to live in the home to ensure that their needs can be met and that their needs do not impact adversely on the existing resident group. It is strongly recommended that the registered person negotiate with placing authorities to see if alternative appointeeship arrangements can be made for the identified residents. DS0000006374.V320438.R01.S.doc Version 5.2 Page 27 2 YA7 Hambleton House 3 4 5 YA6 YA23 YA32 6 YA38 The registered person should arrange training for staff in the appropriate way to write care records. The registered person should become familiar with the Department of Health Guidance on the Protection of Vulnerable Adults Scheme in England and Wales. Progress should be made in enrolling staff on NVQ courses, in order to ensure that residents’ care needs are met by trained staff consistent with the National Minimum Standards. The registered person must ensure that management practices and responsibilities within the home are clear and that practice within the home conforms to the Care Home Regulations 2001. Hambleton House DS0000006374.V320438.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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