Inspection on 03/03/08 for Hartfield House

This inspection was carried out on 3rd March 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartfield House 16/12/08

Hartfield House 24/06/08

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Hartfield House 170 Roehampton Lane London SW15 4EU Lead Inspector Louise Phillips Key Unannounced Inspection 3rd March 2008 10:15a Hartfield House DS0000070866.V357503.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 Hartfield House DS0000070866.V357503.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. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartfield House Address 170 Roehampton Lane London SW15 4EU 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) 020 8780 0057 www.southsidepartnership.org.uk Southside Partnership vacant post Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 18 N/A Date of last inspection Brief Description of the Service: Hartfield House is a care home providing respite/ rota and emergency care for up to eighteen service users with a learning disability, five of whom may also have a physical disability. Accommodation is provided in bedrooms, double bedrooms and two semi-independent flat-lets. Since September 2007 the service has been owned and managed by Southside Partnership, having been previously run by Wandsworth Council. Hartfield House is located close to shops, pubs and other amenities. It has good access to public transport. A limited number of parking spaces are available outside the home. At the time of this inspection the weekly charge for respite/ rota care and emergency care is £1086.63 per week. Additional charges are made for some outings. Hartfield House DS0000070866.V357503.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 one day by two inspectors. Time was spent talking three staff, one service user and viewing paperwork. A tour of the premises was carried out and care records were inspected. Information has also been gained from the inspection record for the home and surveys received from five service users, six relatives and four staff. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 6 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 Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 7 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): 1, 2 and 3 Quality in this outcome area is adequate. There is up-to-date information about what service users can expect from the service. However, service users needs are not always assessed appropriately to ensure the service can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose reflects the recent change in service provider to that of Southside Partnership. It provides relevant information about what service users can expect from their stay, admission criteria and the relevant policies and details about the staff employed. It is recommended that the staff dates of birth are removed from the document, and consideration should also be given to producing the document into a user-friendly format. Most of the service users who stay at Hartfield House have done so over a number of years, staying for periods of one to seven days, on a rota basis, throughout the year. A Team Leader stated that when a new service user first comes to the service an assessment is carried out through meeting them, their carer and social worker. Referral and assessment information is obtained and the service user Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 8 is invited to stay for a trial visit, in which time the staff would carry out an assessment of their needs and abilities. Four care files were looked at during the inspection. One service user’s file did not contain an assessment by either the social worker or the home, whereas another file contained full assessment information, including likes/ dislikes, communication and behavioural needs. The assessment for one service user was dated 1994, and had not been updated since that time. The manager said that the home is not always provided with full assessments from social workers prior to new residents being admitted. One staff member also fedback that, “…sometimes clients come in on an emergency basis and very little information is available on arrival…”. A requirement has been made to ensure that current assessments by the social worker and service are in place to ensure that service users ongoing needs can be met. As the Statement of Purpose outlines, Hartfield House provides respite and emergency care for service users for a period of one to seven days. However some residents have been living at the service for a number of years, and no alternative long-term accommodation has been found for them. Hartfield House is a respite unit and not an appropriate setting for long term care and the manager must ensure that suitable accommodation is being sought for these service users. Hartfield House DS0000070866.V357503.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 and 9 Quality in this outcome area is adequate. There is little evidence to demonstrate that the needs of the service users have been planned for or are being met. Risk assessments do not ensure the safety of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from relatives is that they generally feel that their relative gets a good level of care during their stay at Hartfield House, though they would like to receive more information about issues affecting them or their relative. Most service users said they are involved in making decisions about their life at the home. They also said that they enjoy their time at the service, and that they feel well treated by the staff. The Team Leader said that they try and ensure consistency for service users frequently using the service, by allocating the same keyworker each time to oversee their care. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 10 The care files for four service users were looked at during the inspection. One file was found to contain a lot of information, however much of it needs to be re-organised and archived as the most up-to-date and important information about the service user was not easily accessible. For this service user there was a care plan called an ‘Individual Programme Plan’ which contained information such as cultural needs, likes and dislikes, dietary needs, what they like to do and places they would like to visit. However it was not person-centred and there was no evidence that the service user had been involved in drawing up the care plan. A risk assessment for them was dated April 2007 covered areas including: health, mobility, road safety, household safety and behaviour. For two service users there was only a basic information sheet in their file, containing contact details of relevant people involved in their care. There was no evidence of any care plan or risk assessment for either individual. The Team Leader also confirmed that this information was not in place. The care file for a third service user contained an Individual Programme Plan which provided information regarding their mobility, going out with staff and their cultural background. In this incidence information had been obtained from the relative of the service user, and this had been adapted into the care planning. However, there was no evidence of the service users involvement in this. The risk assessment was only partially completed for areas such as taking medication and travel skills, but not for issues around personal safety or behaviour. Hartfield House DS0000070866.V357503.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, 15, 16 and 17 Quality in this outcome area is good. Service users are supported to pursue activities and maintain community links. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Team Leader explained that the service users coming to stay for a week usually arrive around 4:30pm on a Monday from the day centre, where they are shown to their room and given time to settle in before joining the other service users for dinner. The following morning service users are assisted to get ready and go to the day centre, and that evening a meeting is held with all service users to discuss activities, menu ideas, and for them to raise any suggestions or complaints. Evidence was seen on a timetable that most service users attend a variety of day and college placements throughout the week. For those who do not attend these, one-to-one support is offered by the staff, and during the inspection one Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 12 individual was observed very happy to be going out with a staff member for lunch. In the evenings and at weekends service users can spend time in the games room, or go out to the pub, cinema or bowling with staff. Feedback from staff is that they feel the service is good at letting the service users choose what they want to do, where to go out and what they would like to eat. However, one service user did comment that they “…would like to be taken out more…” and a relative said the service could improve by “…ensuring that residents are taken out socially when they wish…”. One relative did say that the home is very supportive to their relative, and that “…(they) seem so happy which gives me peace of mind…”. Meals at the home are chosen by the service users and prepared by the cook. There was seen to be a wide range of foods, fresh, frozen, tinned and dry goods to ensure that balanced meals are provided by the service. The fridge contained a number of opened/ decanted foods, such as beans, yoghurt and salad that had not been labelled appropriately as to when they had been opened, and this must be carried out at all times. Hartfield House DS0000070866.V357503.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 and 20 Quality in this outcome area is poor. Service users receive support with personal care that meets their needs. The systems for storing and managing medication do not ensure the health and safety of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Team Leader explained that a number of service users need support with their personal care, and that staff support them with this. Service users said that they feel cared for by the staff and that their privacy is respected. In some of the care files there was evidence of input from specialist health services including the speech therapist and consultant medical professionals. However there was little evidence to demonstrate that review of service users care, and their use of Hartfield House takes place on an annual basis. The medication for all service users was looked at during the inspection. When service users come to Hartfield House on a Monday they bring their medication Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 14 with them from home, which is then put into the medicine cabinet and a Medication Administration Record (MAR chart) is implemented to record the administering of this by the staff. There is a list of staff who have completed medication training with Boots chemist in November 2007. Whilst inspecting the medication systems and storage a number of discrepancies were observed and outlined to the manager during the inspection. These are listed below: • • • In the envelope containing medication to be disposed of a bottle of folic acid tablets were found, dated to expire in January 2006. The name on the bottle was that of a staff member. Neither of the two medicine cupboards in use on the desks were secured to a wall, as they must be. The medication for one service user had a written label stuck over the original pharmacy label. The written label contained different prescribing information to that on the original label (could read this clearly through the label). An unopened packet of 84 tablets of Ibuprofen was not labelled. The Team Leader showed the inspector a detached label that was in the medicine cupboard and said that this should go on the box. However, the label stated a prescription for 100 tablets, not the 84 in the box. One cupboard contained an unlabelled packet of Sudafed congestion tablets. A packet of soluble Paracetamol tablets for one service user was not labelled, just the service users name written in this. On the MAR chart only the word ‘paraceto’ was written. The MAR chart for one service user states ‘Daktarin cream’, however there was only Daktarin powder available in the medicine cupboard. The MAR chart contained staff signatures that this had been given to date. Sudocream and savlon in office, not locked away One cupboard contains a packet of unlabelled Nurofen tablets. The Controlled Drugs (CD) cupboard is a single cupboard, not a cupboard within a cupboard, as it must be. The CD cupboard was found to contain found 12 x 20mg Temazepam tablets for a service user. These expired in April 2007. The Team Leader was unable to locate the CD record book. • • • • • • • The discrepancies listed above highlight a number of health and safety issues, staff training and management around the medication system, where requirements have been made to address these. It is also required that a weekly audit of medication administration, and checking of MAR charts is commenced to ensure that any discrepancies and errors are identified and managed appropriately. Hartfield House DS0000070866.V357503.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 and 23 Quality in this outcome area is adequate. Service users know who to talk to if they are unhappy about anything. The lack of staff training in abuse issues does not help to reduce risks to the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are two complaints logs in use at the service. One is an external complaints log that documents complaints received from any person other than the service users who stay at the home. The log does not have an ‘outcome section’ and this should be added to the log to record the final outcome of any complaint received. There is also a service user complaints log for use. Service users and their relatives said that if they were unhappy they would raise concerns with the keyworker or manager of the service. There are policies and procedures in place for the Protection of Vulnerable Adults. The manager reported that only two staff members have attended Safeguarding of Vulnerable Adults training recently. There was no evidence to show that all staff were up-to-date with this training and this must be organised to ensure that staff are aware of what constitutes abuse and what action to take in the event of suspected abuse. Hartfield House DS0000070866.V357503.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, 25, 27 and 30 Quality in this outcome area is poor. A lot of work is needed to improve the environment to bring this up to a good standard for the comfort of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Overall there was a light and airy feel to many of the communal spaces and the bedrooms. The downstairs lounge was large and bright and contained a large, clean fish tank, widescreen TV, DVD player and comfortable sofas. The ground floor dining room has recently been decorated and is bright and clean, looking out over a large attractive garden. The manager said that steps are being taken to address a number of environmental issues, such as the re-decoration of the ground floor areas and regular shampooing of carpets. The manager said that this work is ongoing and it is planned that re-decoration will continue throughout the rest of the home. Some of the re-decoration work in the corridors did not look completed Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 17 to a satisfactory standard. Some of the skirting boards had just been painted over the existing cracked paint, and looked as though no effort had been made to prepare the surfaces prior to painting. The manager agreed that the standard of the finish was not very good. During this inspection areas observed as requiring attention are listed below: • • Room 2 – curtains need replacing. Ground floor bathroom, opposite room 2 – need to cover up exposed pipe-work under the sink and where the shelf is along the back wall. Also need to replace flooring to make this more homely for the service users. The manager said that this room had been recently re-decorated, however attention must be given to the areas addressed above. Games room – in need of re-decoration where the paint is cracked and peeling off the wall. Consideration should be given to carpeting the ground floor hallway. First floor bathroom – the vanity unit is damaged, old and worn, and in need of replacing. This also needs re-painting where the existing paint has cracked. Room 6 – re-painting needs to occur on the stained walls. The hole in the carpet that exposes floorboards needs to be repaired, or the carpet replaced. A number of chairs throughout the building have holes in and need replacing. The lounge on the first floor did not present as very homely. It contained four sofas. Two of these had no covers on the foam seating and the foam had chunks missing from them. Another sofa had a torn seating cover whilst a cover was coming off the seating on another sofa. The sofas in this area must be replaced. During the inspection the service user accommodated in room 12 was observed having to walk through the lounge area to go to bathroom, whilst in their nightclothes. Consideration should be given to situating a bathroom near this room so that they do not have to walk through the lounge. Room 11 – needs net curtains and cleaning, as dirt was observed around the skirting boards and inside the vanity unit. Room 14 – picture on the wall needs cleaning or removing, as it has stain marks on it. The shower room – needs to have curtains installed on the windows. The shower unit has mould around the sealant and this needs to be made good. On the door there is a smaller door at bottom. The Team Leader said that this “…is for staff to get in if a service user is in difficulty…”. The use of this is must be detailed in each service users risk assessment. Consideration should also be given to installing a workable bolt on the door, which can be unlocked from the outside. • • • • • • • • • • Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 18 • • • • A door was seen in the wall of the stairwell near room 13. It was marked ‘keep locked shut’ but was open, and not able to be locked. Behind it was a large dark attic space and the floorboards on this area had holes in places. This must be kept locked shut for the safety of the service users. On the top floor the toilet had a stained cistern and there was black mould growing on the ceiling. The walls had chipped and cracked paintwork. The team leader informed us that the roof is leaking and needs to be replaced. This must be done. The shower room on the top floor was observed to have water stains on the ceiling. Fungus was also observed growing on ceiling. There was also stained flooring and broken window. The Team Leader said that this bathroom was not currently in use, however the door was unlocked and there was no sign on the door. These actions must be implemented to ensure that service users do not access this area. Consideration should be given to covering up all the exposed pipe work observed throughout the building. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 19 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, 34, 35 and 36 Quality in this outcome area is adequate. Staff do not receive enough support for their role and improvements are needed to information held about staff at the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Surveys were received from four staff who work at the service, and three staff were spoken to during the inspection. The staff team have worked at the service for varying periods of time, and the current vacancies are filled by agency staff who have worked at the home for a number of years. Feedback regarding each person’s recruitment to the service was positive, with all stating that they had been interviewed and received an induction to their role. However the home does not maintain appropriate staff files at the home, with little and varying information held about each member of staff, with the files being very disorganised. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 20 For example, some staff files did not contain a photo, new contract (regarding Southside Partnership), or evidence of references or Criminal Records Bureau (CRB) check having been carried out. There was no evidence to demonstrate that thorough recruitment checks are carried out at the service. The staff files show that most staff have achieved the NVQ level 2 or 3 in care. There is no log or matrix in place to show what training the staff have undertaken. The manager reported that he is going to address training needs with the staff and that he has had difficulty accessing training since the registered provider has changed. Evidence must be kept to show that staff are up-to-date with mandatory training. The training certificates in staff files indicate that some staff have had recent training in food hygiene, manual handling, fire safety and first aid. Some staff commented that the service could improve by increasing support to them, whereas other staff said that they generally feel supported by the manager. The records evidencing one-to-one supervision sessions with between staff and the manager were sporadic, with one member of staff only having received four supervision sessions over a fifteen month period, whereas another member of staff had received three over the past two months. The manager must provide a minimum of six supervision sessions a year, at regular intervals. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 21 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, 39, 41 and 42 Quality in this outcome area is adequate. Some health and safety checks are carried out by the service. There are a number of areas of improvement needed to be managed and addressed by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the manager indicated that he has an awareness of some of the areas of improvement needed for the service. However the requirements from this inspection demonstrate that the manager needs to be supported more by Southside Partnership to ensure that Hartfield House progresses in a positive direction. The manager must also submit an application to the CSCI to become the registered manager of Hartfield House. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 22 One relative commented that an area of the service that could be improved was the “…health and safety…”. It was found that the service carries out some health and safety checks, where evidence was seen to demonstrate that hot water temperature checks are carried out. However, it was observed that there were recordings of very low water temperatures dating back to at least 1st November 2007, eg. bathroom wash-hand basin 33.3C, bath 31.6C. The maintenance log did not show evidence that these had been reported to be fixed. The Team Leader also confirmed that these had not been reported. Fire extinguisher testing had taken place in February 2008. Records are kept to show that fire drills have taken place, however, there are no lists of names kept of those who attended these. Also, on the last fire drill it is noted that ‘one client refused to respond’ however there is no evidence to suggest that a risk assessment was drawn up as a consequence of this. Checks regarding gas safety, electrical installation and legionella testing were in date at the time of the inspection. The Portable Appliance Testing (PAT) certificate was out of date, with no evidence to show that this had been carried out since March 2006. It was also noted that a number of ‘stand alone’ heaters were in use throughout the home, without a PAT sticker on them. These must be removed until confirmed safe to use following PAT testing. As highlighted throughout this report, record-keeping at the service needs to be improved, such as assessments, care planning, risk assessment, complaints and health and safety checks. The entries in the service users progress reports were also seen to be recorded erratically. For one service user, no records had been written about their stay for six of the seven days they had been at the service, whereas another service user had three entries for one day, and two for the following, despite no significant event occurring during this time, which would warrant a number of entries in comparison to the other service user. The service carries out some quality assurance monitoring through regular service user and staff meetings, and new pictorial forms have been devised to get their service users views about the running of the home. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 1 26 X 27 1 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 2 X 3 X 2 2 X Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA2 Regulation 14 Requirement The Registered Persons must ensure that up-to-date, written assessment information from the social worker is received prior to the admission of any service user. This must be used by the service to inform their own assessment, to ensure the ongoing needs of the service users are met. The Registered Persons must ensure that suitable accommodation is being sought for the service users who have been living at the home for a number of years. The Registered Persons must ensure each service user has an up-to-date care plan that details all their needs. The service user must be involved in planning their care, and this must be evidenced. The Registered Persons must ensure that a person-centred approach is implemented at the service, and that this is used to DS0000070866.V357503.R01.S.doc Timescale for action 30/04/08 2. YA6 14(2) 30/04/08 3. YA6 15 30/04/08 4. YA6 12(4), 15 30/06/08 Hartfield House Version 5.2 Page 25 enhance the care planning and record-keeping. 5. YA9 13(4) The Registered Persons must ensure that an individualised risk assessment is completed and in place for all activities and areas of risk identified for each service user. The Registered Persons must ensure that all foods opened or decanted into another container are appropriately labelled with the date opened, and date to be disposed of. The Registered Persons must ensure that a review of each service users care, and their use of Hartfield House takes place on an annual basis. The Registered Persons must ensure all staff receive up-todate training in medication handling, storage and administration. 30/04/08 6. YA17 13(4)(c) 30/04/08 7. YA19 15(2) 30/04/08 8. YA20 13(2), (6) 30/04/08 9. YA20 13(2) The Registered Persons must 30/04/08 ensure that: - only medication for service users currently accommodated is stored at the service. - staff do not use the medication cabinets to store their own medication. - only medication with a pharmacy label, detailing the service user, medication, dose and frequency to be given is administered to service users. - any medication without a pharmacy label must be disposed of. - only medication prescribed for service users is administered. - all medication no longer in use DS0000070866.V357503.R01.S.doc Version 5.2 Page 26 Hartfield House is disposed of monthly, and that a record is kept of this. - medication to be disposed of must be kept in a separately labelled container in the medication cupboard prior to disposal. 10. YA20 13(2) The Registered Persons must ensure that: - all medication cupboards in use are secured to a wall - the Controlled Drugs cupboard is a lockable cabinet within a cupboard, both of which are secured to a wall. - all prescribed medicines and creams are stored securely in the medication cupboard. The Registered Persons must ensure that: - the MAR chart contains all information relating to the medication to be given to the service user, the dose and frequency of this. - a Controlled Drugs record is maintained for all Controlled Drugs stored at the service. 30/04/08 11. YA20 13(2) 30/04/08 12. YA20 13(2) The Registered Persons must 30/04/08 ensure that a weekly audit of medication administration, storage and checking of MAR charts is commenced to ensure that any discrepancies and errors are identified and managed appropriately. The Registered Persons must ensure that the outcome of complaints are recorded in the complaints log. The Registered Persons must ensure that all staff are trained in Safeguarding of Vulnerable DS0000070866.V357503.R01.S.doc 13. YA22 22(4) 30/04/08 14. YA23 YA35 13(4), 18(1) (c) 30/05/08 Hartfield House Version 5.2 Page 27 Adults. 15. YA24, YA25, YA27, YA30 YA34 13(3)(4), 16(c),23 The Registered Persons must address all environmental issues as detailed on pages 19 – 21 of this report. The Registered Persons must ensure that records relating to the recruitment of staff are held at the home to demonstrate that appropriate recruitment checks have been carried out prior to employment. The Registered Persons must ensure that a Criminal Records Bureau check has been carried out on all staff prior to their commencing employment. Evidence of this must be held at the service. The Registered Persons must ensure that all staff receive upto-date training in basic first aid, basic food hygiene, health and safety and fire safety. A log must be maintained of all training undertaken and of future training planned for each individual staff member. 19. YA36 18(2) The Registered Persons must ensure that staff receive a minimum of six one-to-one supervision sessions a year, at regular intervals. The manager must submit an application to the CSCI to be the registered manager. The Registered Persons must ensure that all staff working at the service receive training in good record keeping techniques. DS0000070866.V357503.R01.S.doc 31/03/09 16. 17(2) Sched 2 30/04/08 17. YA34 19, Sched 2 30/04/08 18. YA35 13(4), 18(1) (c) 30/06/08 30/04/08 20. YA37 9 30/05/08 21. YA41 17 31/05/08 Hartfield House Version 5.2 Page 28 22. YA42 13(4) The Registered Person must ensure that water dispersed around the service does not fall below 42 centigrade. Action must be taken to address this if it does. The Registered Person must ensure that full details are maintained of all persons who attend fire drills, and the actions taken where a service user refuses to take part. The Registered Persons must ensure that Portable Appliance Testing (PAT) is carried out at least annually, and that only PAT certified equipment is used at the service. 30/04/08 23. YA42 13(4) 30/04/08 24. YA42 13(4) 30/04/08 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. Refer to Standard YA1 YA1 YA6 & YA34 Good Practice Recommendations It is recommended that the staff dates of birth are removed from the Statement of Purpose. Consideration should be given to producing the Statement of Purpose into a more user-friendly format. It is recommended that the care files and staff recruitment files are re-organised to a more easily-accessible format. Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hartfield House DS0000070866.V357503.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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