Inspection on 15/10/08 for Hertha House

This inspection was carried out on 15th October 2008.

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

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hertha House 22/10/09

Hertha House 06/02/08

Hertha House 04/10/07

Hertha House 24/04/07

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Hertha House 14a St Michael`s Square Gloucester GL1 1HX Lead Inspector Ms Lynne Bennett Unannounced Inspection 15 and 16 October 2008 14:30 th th Hertha House DS0000069133.V372818.R02.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 Hertha House DS0000069133.V372818.R02.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. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hertha House Address 14a St Michael`s Square Gloucester GL1 1HX 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) 01452 313113 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Margaret Kathleen Smith Care Home 11 Category(ies) of Physical disability (11) registration, with number of places Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Physical Disability - (Code PD) The maximum number of service users who can be accommodated is 11. 2. Date of last inspection Brief Description of the Service: Hertha House is a modern fully equipped Care Home which opened in early 2001 to provide accommodation for 11 service users with a physical disability. Some people living at the home also have a learning disability. It is located in a residential area very close to the centre of Gloucester. There are three selfcontained flats on the first floor that fall under a supported living scheme. Care being provided by other domiciliary care providers. Aspects and Milestones Ltd are the registered providers for the home. They have had delegated responsibility for managing the home since 2005. Gloucestershire Housing Association owns the building. Single en suite accommodation is provided on two floors with access to the upper floor via a shaft lift. Three flats are provided on the first floor for people independent of the home. Hertha House has a sensory room, an assisted bathroom with a hydro-massage bath and spacious communal facilities. There is also a small garden and upper balcony. The home has a mini-bus that is accessible to wheelchair users. Fee levels at Hertha House range from £660 to £1500 per week. Additional charges are made for day care, travel, holidays, chiropody and hairdressing. Each person living at the home has a copy of the Statement of Purpose and Service User Guide. Further copies are available in the office, where a copy of inspection reports can also be found. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place in October 2008 and included two visits to the home by one inspector and a visit by an expert by experience. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with us to help provide a picture of what it is like to live in the home. The registered manager completed the AQAA providing information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). This was given to us on the second visit to the home. We (The Commission for Social Care Inspection) spent time with all people living in the home, talking to them and observing the care provided. We talked to four staff about the support they provide. The registered manager was present on the second visit to the home. Feedback was received from visiting relatives and healthcare professionals. A range of documents were examined including care plans, medication and financial records, health and safety systems and quality assurance audits. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Hertha House provides purpose built accommodation for people with a physical disability, providing single rooms with en suite facilities and access to well maintained and accessible grounds. The home has a Jacuzzi and sensory room which people enjoy using. People have rooms that reflect their personalities and lifestyles, in some cases providing a sensory environment. People commented to the Expert by Experience that, “We’re “treated like adults, which is what we want” and “I feel safe living here and am happy.” Staff have access to a training programme to equip them with the knowledge and skills to support people living in the home. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hertha House DS0000069133.V372818.R02.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 Hertha House DS0000069133.V372818.R02.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): 1, 2 and 5. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People do not have access to current information about the home. Regularly reviewing the Statement of Purpose and Service User Guide will make sure this is available. Completion of the homes own admission assessment would complement assessments provided by others and make sure that people’s needs could be met. EVIDENCE: The Statement of Purpose and Service User Guide will need amending to include changes to the management of the home. These documents also refer to the home providing a service to people with a physical disability and/or a learning disability. This needs to be rephrased to reflect the registration of the home that states a service is provided to people with a physical disability (who may also have additional learning disabilities). Two people had moved into the home and both said they had settled in well. The registered manager confirmed that one person had visits pre-arranged although the second person had been admitted as an emergency placement. We had been contacted for advice about this admission and agreed that under the circumstances this was acceptable. Full admission information had been Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 9 obtained for each person including information from previous placements and a care plan and assessment from their placing authority. A copy of the home’s Community Services Assessment had not been completed for each person. Neither person had a copy of their terms and conditions on their files. A licence agreement produced by Aspects and Milestones was in place for another person who had moved into the home earlier in the year. This document had not however been filled in. Hertha House DS0000069133.V372818.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Greater consistency in care planning and risk assessment will ensure that the assessed and changing needs of people are identified and they are safeguarded from possible harm. EVIDENCE: The care of three people was case tracked, including two people who had recently moved into the home. This included reading their care plans and other related documents, examining medication and financial records and observing the care provided to them during the visits. All other care plans were sampled. No assessments or care plans had been developed for the two people who had moved into the home in May and July 2008. Essential information had been recorded and each person had a pen picture which had been drawn up with them providing information about the way in which they would like to be Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 11 supported. They had signed these documents. They also had a risk assessment in place providing guidance about how to ensure their safety when using the mini bus. Care plans must be developed from their assessed need and further risk assessments must be put in place. The registered manager said that a proforma had been selected to assess each person’s needs but that this was still to be completed for all people living in the home. Care plans for other people living in the home provided evidence of regular review by key workers. Amendments had been made to some documents and the deputy manager stated these would be retyped in due course. Plans provided a holistic analysis about people’s needs covering such areas as personal care, mobility, communication, social and leisure, nutrition and finance. There was evidence that annual reviews were being held involving relatives and representatives from placing authorities. Key workers were drawing up preliminary agendas for review meetings with people living in the home. A reassessment of needs and new care plans from placing authorities were in place for some people. Staff spoken with had a good understanding of the needs of the people they support. A number of agency staff were being employed and they had been provided with a handbook containing pen pictures about each person, care plans and risk assessments. Communication profiles were in place for each person providing a guide to how people prefer to communicate and how to interpret non-verbal behaviour. The Expert by Experience was given a communication profile for one person they talked to and they said that this had helped them. One person living in the home discussed ways in which they were advocating for others who were unable to express themselves verbally. A notice board in the entrance hall provided people with information about which staff were on duty including a display of their photographs. A newsletter had been produced in the summer that made good use of photographs to illustrate the text. There was evidence the photographs were being collected for future use. The deputy manager had plans to illustrate house-meeting minutes in this way. Any restrictions to people’s freedoms or movement such as use of bed rails and using an electric chair in manual were documented including the rationale for this clearly noted. Where people needed support to manage their personal finances, this was noted in their care plans. Robust systems were in place for checking financial balances. Receipts for purchases were obtained and could be cross-referenced with entries on the records. During the first visit one person had a meal out which was paid for out of their own money. This meal replaced their evening meal. The home’s policy and procedure did not make reference to how this should be funded. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 12 Some people had advocates with whom they had regular contact. Information was also available in the home about the Mental Capacity Act and use of Independent Mental Capacity Advocates. Risk assessments had been drawn up for most people with evidence of regular review. After a recent incident the Regulation 37 notification and an entry in the home’s diary indicated that a risk assessment had been changed to reflect that two staff were needed to attend to a person’s personal care needs at all times. This risk assessment was not in place. Hertha House DS0000069133.V372818.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels continue to impact on the quality of life available to people who at times are unable to access educational, social and leisure opportunities. Improvements need to be made to ensure that people have a nutritional diet with meals served at regular intervals. EVIDENCE: Each person had an individual schedule of activities on their files. A notice board in the office was being used to identify people’s activities for the week with activities being entered daily. Dairies and the handover file were sampled for two weeks in October indicating that there was some difficulty during that period supporting people to attend activities outside the home. People living in the home and visitors confirmed this. One person said that they had been unable to go to their day centre because there had been no driver. Staff said that there were three members of staff who were able to drive the minibus and Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 14 two had been absent during this period. Current recruitment problems were also having an effect on access to activities. (See Standard 33) Dairies also indicated that the staff were unable to support people regularly at church. Three people like to attend a local church each Sunday but in September/October they had not been able to attend each week. However some people had continued to attend colleges, their day centre and the Guildhall in Gloucester. During the visits people were observed being supported to go into town shopping or for a meal. People told the Expert by Experience that they had been to the cinema and ten-pin bowling and that they enjoy using the home’s Jacuzzi. The Annual Quality Assurance Assessment stated, “Service users have all had a holiday away from the home, increased activities and social events. We are planning to explore the use of volunteers and activity co-ordinator. Purchase more games etc for in house entertainment.” Since the last inspection an activity co-ordinator had been seconded to work with staff to promote a range of activities that could be introduced in the home. An example of this was the newsletter that was to be carried on by another member of staff. A computer had been put into the lounge for people’s use. People said that they help around the home cleaning their rooms, doing laundry and helping with the gardening. One person said they like to help with the cooking or baking. House meetings were being held regularly and minutes produced. Examples of people’s artwork and personal photographs were displayed around the home. Families and friends continue to visit people at the home. Visitors said they were made to feel welcome and can meet relatives in private if they wish. A person who had recently moved into the home was impressed with the family atmosphere in the home and that visitors spent time with everyone living there. Records indicated that people keep contact using a variety of methods, telephone, email and visits. One person commented that they wished visitors could stay over but there were no facilities for this at the home. The home no longer employed a cook to prepare meals. Care staff do this as part of their duties which impacts on staffing ratios to support people doing their chosen activities. People living in the home commented that the quality of the food could also be inconsistent. They were involved in deciding the menus choosing a range of freshly produced meals including fresh vegetables. The Expert by Experience commented that no salad or fresh fruit had been provided with a lunch of sandwiches. Fresh fruit was available in the kitchen but not accessible to most people. One person commented that the timing of meals was more erratic with lunches often being served in the early afternoon. One person’s care plan indicated they needed a high protein diet. Staff were observed providing a breakfast of eggs and they confirmed that they often had Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 15 fish. Their care plan however did not provide staff with specific guidelines about what should be offered. The registered manager said that advice had been received from a dietician. A record of this guidance needs to be in their care plan. Hertha House DS0000069133.V372818.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal care support is offered in a way that responds to people’s needs and preferences, promoting people’s dignity. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. EVIDENCE: The AQAA stated, “Health care action plans are in place. Care plans show the level of support needed by individuals. Staff receive appropriate training to care for the needs of the service users.” The way in which people would like to be supported was clearly recorded in their care plans and staff were observed following these. For instance people who use wheelchairs need to spend time out of their chairs and people were observed spending time lying on their bed or using personalised easy chairs. The deputy manager said that physiotherapy exercises were being completed for people during the day. The physiotherapist had attended a staff meeting to discuss exercises with staff. Clear guidelines illustrated with photographs were in place. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 17 Observations of the staff team during the visit indicated that they treat people with dignity and respect, ensuring personal care was provided sensitively and in privacy. People’s care plans noted their preferences for the gender of carers providing personal care. One person living in the home commented that at times there was only one female carer on duty and they had concerns about how the personal care for women living in the home was being provided. The registered manager and deputy manager both stated that when this was the case, the rota would provide for an overlap of female staff for times when personal care was being delivered, such as between 14.00 and 16.00 and 20.00 hours. During one of the visits there were four male carers and one female carer on shift until 18.00 with arrangements for two female night staff to come on duty at 20.00 hours. Health action plans were in place although some of the records were not being kept up to date. For some people it looked as though they had not visited their dentist although appointments had been recorded in daily diaries. Other healthcare records for Doctor and hospital appointments were being recorded with a summary of the outcome of the appointment. During the visit medication was observed being given to a relative in a sealed pot. The deputy manager stated that when people go on social leave for a short period of time, staff were secondary dispensing medication into a pot for them to take with them. This could lead to error and advice was given about the use of an appropriately labelled container. The home must make sure the following is in place: • A risk assessment alongside a written procedure, this should include which staff are permitted to put medication into a compliance aid/labelled container, what containers are to be used, how the containers are to be labelled and what other information is to be given • a clear record of all staff involved in each stage of the procedure and the actions taken. During the second visit the medication system was being audited and changes made to levels of stock kept and records being kept. Creams and liquids were labelled with the date of opening and the medication administration records were satisfactory. The temperature of the cupboard was being monitored and an additional ventilation grill had been installed to keep the temperature below 25°C. There were plans to relocate the medication cupboard. Protocols for the use of “as necessary” medication were in place and staff had received training in its use. Correct storage was in place for this medication and the appropriate records were being reviewed to ensure they were in line with current legislation. Hertha House DS0000069133.V372818.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure that was produced in a format appropriate to people’s needs using a mixture of text and picture. Copies of this document were kept in the registered manager’s office so it was difficult to assess how accessible it was to people. Those spoken with said they would talk through any concerns with staff or the manager. The AQAA stated that three complaints had been received by the home. A complaints folder was kept in the registered manager’s office providing a summary of the outcome of the complaint. A copy of the most recent complaint was not on file. External managers to the home were dealing this with. Appropriate action had been taken by the home involving the local police, adult protection unit and notification to us. The investigation into the allegation was ongoing at the time of the inspection. Staff confirmed that they had completed training in the safeguarding of adults and those spoken with had a satisfactory understanding of the home’s procedures. The deputy manager had attended training in the Mental Capacity Act and information was available for staff within the home. Staff had completed training in the “Reporting of Malpractice”. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 19 Systems for the administration of people’s personal finances were satisfactory. Security of financial systems had been reviewed and there were plans in place to relocate the safe to further enhance these. Hertha House DS0000069133.V372818.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. EVIDENCE: The home was purpose built for people with a physical disability. Each room on the ground floor had overhead tracking that was also provided in the bathroom. All rooms have en suite showers. Corridors on the ground floor were showing signs of wear and tear. The registered manager stated that there were plans to redecorate the entrance hall and people living in the home had been involved in discussions about the colour scheme. The appearance of the first floor was significantly improved now that people had moved into rooms. Corridors, the laundry and lounge were tidy and a snooker and football table had been installed in the annexe. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 21 People’s rooms had been individualised to reflect their lifestyles and interests. Some people’s rooms provided a sensory environment with good use made of lighting and equipment. One person who had recently moved into the home said they had been involved in plans to redecorate their room. The home had a sensory room that was going to be relocated to a smaller room to provide a more intimate environment. There were also plans to move the office to another location. The home had reviewed its security systems and was in the process of installing keypads on the first floor to provide greater security to people living there. Specialist equipment and adaptations had been provided with input from healthcare professionals. Servicing of equipment was in place. Some bath chairs were beginning to rust around the frame/wheels and this needs to be monitored. At the time of the visits the home was clean and tidy. Good infection control measures were observed to be in place in the laundry. Hazardous substances had been moved to a new cupboard and were stored securely. Hertha House DS0000069133.V372818.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. The impact of staff vacancies and use of agency staff is affecting the ability of the home to meet people’s needs and putting a strain on the staff team. EVIDENCE: People living at the home said that the permanent staff team “are great and work very hard.” They were observed being open and approachable with people and those spoken with had a good understanding of the needs of people living in the home. In contrast some agency staff were observed not interacting with people and appeared unsure of what they should be doing. The Expert by Experience commented that he had observed a person living in the home requesting help from an agency member of staff four times before the agency staff understood them and provided the support needed. The Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 23 registered manager said that they try to make sure the same agency staff were being employed to ensure consistency but this was not always possible. A new member of staff confirmed that they had completed their induction programme. A copy of this was available for inspection confirming that it was equivalent to the Skills for Care standards. Staff also had access to the Learning Disability Award Framework and the new Learning Disability Qualification. Staff complained that the National Vocational Qualification programme that had been put in place at the time of the last inspection had not materialised. The registered manager said that the assessor had left and that they were looking to establish a programme with local colleges. The AQAA indicated that 20 of the team have a NVQ qualification. The home had two full time and two part time vacancies at the time of the inspection. Recruitment to these posts was taking place but in the interim staff were doing additional hours and agency staff were being used. This was putting significant strain on the team to ensure staff levels of a minimum of four care staff per shift were maintained and that the gender mix of staff was appropriate to the needs of people living in the home. During two weeks in October there were 10 shifts when staffing levels had fallen below this minimum. Under Regulation 37 the registered manager must inform us when this happens. Recruitment and selection files for two staff were inspected and found to be satisfactory. A reference missing at the last inspection had been requested. No new staff had been appointed since the last inspection. Agency staff were recruited from one agency who had completed recruitment and selection checks. A training matrix was in place confirming that staff had access to a range of mandatory training and refresher courses. Staff had completed first aid, fire, food hygiene, moving and handling, safeguarding adults and epilepsy training. Copies of certificates were on file. The registered manager confirmed that staff would be attending equality and diversity training in the future. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 24 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 and 42. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff vacancies are impacting on the quality of service provided. Effective quality assurance systems are in place involving people. The health, safety and welfare of people are being put at risk by inconsistent practices in the monitoring of some systems. EVIDENCE: The manager was recently registered with us to manage the home. She will be retiring in December 2008. She is a qualified nurse and has considerable experience in care. Since the last inspection a deputy manager has been appointed to support her to manage the home. An extension had been Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 25 granted for the return of the AQAA but this had not been returned to us on time. Training for staff had significantly improved and the registered manager was looking at alternative ways in which staff could access their NVQ Awards. Staff vacancies were again impacting on the quality of the service being provided to people living in the home. The registered manager was trying to be creative with the rota to make sure that the right gender mix and sufficient drivers were on duty. A quality assurance system had been put in place and a report produced with outcomes and actions for the home to complete. It was evident that a start had been made on this such as producing a newsletter and finding a volunteer to help with the gardening. People living in the home were involved in the quality assurance audit that was conducted by a manager external to the home. Regulation 26 visits to the home were being completed and a copy of the report being forwarded to us. Systems for the monitoring of health and safety were in place. However there appeared to be some gaps in the records for fire equipment checks between June and September and with water temperatures being checked every three months rather than monthly. Fridge and freezer temperatures were being checked daily but hot food temperatures were not being recorded as regularly. Opened food in fridges was labelled with the date of opening. Dry goods were stored in containers that had been labelled with the use by date but these labels were now out of date. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 2 X Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 27 Yes 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 YA1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be reviewed to ensure that people have access to up to date information about the home. Each person must have a copy of the statement of terms and conditions providing them with information about the service they are to receive. Assessments of people living at the home must be regularly reviewed to reflect their changing needs. This is to ensure that the home can continue to meet their needs. (This was being put in place) Care plans must be put in place for new people who have moved into the home so that their individual needs can be met. Risk assessments must be put in place to minimize hazards for new people living in the home. Where a new risk assessment is needed as a result of an incident this must be put in place as soon as possible. This is to safeguard people from further harm. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 28 Timescale for action 31/01/09 2. YA5 5(1)(ba) 30/11/08 3. YA6 14(2) 30/11/08 4. YA6 15 30/11/08 5. YA9 13(4) 30/11/08 6. YA17 16(2)(i) 7. YA20 13(2) 8. YA33 37 People must have access to a nutritional diet at regular times during the day. This is to make sure that people’s health and wellbeing is promoted. Where a compliance aid (pot) is used to provide medication to people on social leave, procedures, risk assessments and labelling of the compliance aid must be in place. This is to safeguard people from possible harm due to medication error. When staffing levels fall below the home’s minimum of 4 for the whole shift, a notification must be sent to the Commission. 30/11/08 31/10/08 31/10/08 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. 4. 5. 6. 7. 8. 9. Refer to Standard YA2 YA5 YA7 YA14 YA17 YA17 YA18 YA19 YA29 Good Practice Recommendations The home should complete their Community Services Assessment for new admissions to the home. Licence agreements should be completed, signed and dated. Clear guidance should be in place about the funding of replacement meals whether the home or the person should pay for this. Continue to expand and explore opportunities for people to have a range of social, leisure and recreational activities. Guidance for the person on a high protein diet should be recorded in their care plan. Consideration should be given to re-employing a cook to prepare nutritional and healthy meals. Continue to make sure that arrangements are in place to provide adequate levels of female staff to provide personal care to people. Records should be completed providing evidence that people have access to dental appointments. Monitor the condition of bath chairs and refurbish or replace where necessary. DS0000069133.V372818.R02.S.doc Version 5.2 Page 29 Hertha House 10. 11. 12. 13. YA32 YA42 YA42 YA42 Staff should have access to a National Vocational Qualification programme. Fire records should be maintained in line with the fire risk assessment. Dry good containers should indicate the current use by date. Temperatures should be recorded for hot meals. Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Hertha House DS0000069133.V372818.R02.S.doc Version 5.2 Page 31 - 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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