Inspection on 10/03/06 for Hft - Falstaff House

This inspection was carried out on 10th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hft - Falstaff House 06/10/08

Hft - Falstaff House 17/10/06

Hft - Falstaff House 26/08/05

Hft - Falstaff House 30/11/04

Hft - Falstaff House 21/07/04

Hft - Falstaff House 05/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hft - Falstaff House 12 Victoria Road Bidford On Avon Warwickshire B50 4AS Lead Inspector Catherine Mundy Unannounced Inspection 10th March 2006 01:00 Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 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 Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 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. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hft - Falstaff House Address 12 Victoria Road Bidford On Avon Warwickshire B50 4AS 01789 490526 01789 772790 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) www.hft.org.uk Home Farm Trust Mrs Carolyn Margaret Manktelow Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th August 2005 Brief Description of the Service: Falstaff House is situated in Bidford On Avon. It is part of the Home Farm Trust group, which owns 14 homes nationwide and provides a day service separate but close to this home. People who live here usually attend HFT day services. It is a large traditional, detached property with a large, wellmaintained garden. People who live here receive personal care, 24-hour supervision and accommodation. The home can accommodate 8 people in 2 ground floor and 6 upper floor single bedrooms. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection of this home in the 2005/06 inspection year. This inspection focuses on the key standards that were not inspected at the last inspection and the progress made towards meeting the requirements that were made. For a full overview of this service this report should be read alongside the report that was written following the last inspection of this home which took place on 26th August 2005. This inspection took place on 10th March 2006 between 1.20pm and 4pm. During the inspection records relating to the residents and the running of the home were examined, two residents and one staff member participated in the inspection. The inspection also included a tour of the communal areas of the home and one residents bedroom. The manager has completed a pre-inspection questionnaire and feedback cards have been received from 7 of the residents. What the service does well: What has improved since the last inspection? Behaviour management guidelines have been provided, with evidence in the residents files that these are implemented. Personal information relating to the residents is now stored securely. There is now sufficient storage for household waste and food items are stored safely. PAT (portable electrical appliance tests) have been completed. Thermostatic controls are available on hot water outlets and fire doors are no longer wedged open. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 6 The homes training and development plan provides the staff with the training that they require at appropriate intervals. Visits to the home, by a representative of the organisation are required to take place each month, under Regulation 26 of the Care Homes Regulations 2001. A copy of the report made following these visits is provided to the Commission for Social Care Inspection. Four reports have been provided to the Commission in the six month period 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. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 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 Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: The standards within this section were not assessed on this occasion other than to note that the requirement to provide each resident with a copy of the Service Users Guide to the home, Statement of Purpose and a contract detailing terms and conditions of residency has been met. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 A lack of care plans and incomplete needs assessments, combined with poor record keeping means that the residents do not have an individual plan of care that reflects their current needs; record keeping is insufficient to enable an accurate assessment of the residents changing needs to be made. The residents are supported to make decisions regarding their every day lives. EVIDENCE: The file relating to the resident who had most recently moved into the home was examined. This file was also examined at the last inspection. The requirement made, to provide each resident with a detailed plan of care that meets their identified needs, has not been met. Information in this residents file detailed that the resident has identified health needs. Written care plans were not available to detail how these needs are to be met. Records, maintained by the home, to monitor the residents health are not regularly completed. Pre-admission information, in the file, emphasised that an aim of the admission is to promote independence and teach skills. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 10 There is no evidence that this work has commenced. A skills assessment is available in the residents file. This has not been completed. Behaviour management guidelines are in place to support the staff to manage individual behaviours that are exhibited. A community learning disability nurse provided these to the home. Written records completed by the home confirm that these guidelines are implemented. Although the home has taken some action to identify risks and implement strategies to reduce these, a thorough and comprehensive assessment of risk has not been completed. Discussions with the staff member and observations during this and the previous inspection confirm that the residents are supported to make decisions regarding their every day lives. These include how they spend their time, personal appearance and layout and décor of their rooms. The residents are able to make their needs known to the staff, this is reliant upon the positive relationships that have been built, and the use of communication methods that are appropriate for individual residents. The residents personal preferences are recorded in their individual files. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The residents are supported to maintain relationships with relatives and friends. EVIDENCE: Standards 12, 13, 16 and 17 were met at the last inspection and so were not assessed on this occasion. Discussions with the staff and examination of records relating to family contact confirmed that the home continues to support the residents to maintain contacts with family and friends. The home supports the residents to make telephone calls and send letters, cards and gifts. Where necessary the home makes telephone calls on behalf of the residents. The residents are able to have family and friends visit them in the home and are supported to go and visit their families. The staff member confirmed in discussion that she is aware of the homes visitors policy, of the action she should take in the event of a resident not wishing to see a visitor and in the event of a visitor acting inappropriately. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Although the residents are supported in a sensitive way that promotes their privacy and dignity, the home cannot demonstrate that the level of support provided reflects the residents current needs or addresses the residents health, because of incomplete needs assessments and a lack of detailed recording. EVIDENCE: Standard 20 was met at the last inspection and was not assessed on this occasion. The file relating to the resident that has most recently moved into the home was examined, and observations made of the interactions between staff and residents. The residents preferred daily routine and level of support required to assist with personal care is recorded. The staff demonstrated in discussions that they are fully aware of the actions they should take to support the residents. Observations of the interactions between the staff and residents during this and the previous inspection confirmed that the residents are supported in a sensitive way that promotes their privacy and dignity. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 13 Details of medical appointments, routine health screening at the GP surgery, dentist and optician are also recorded. The records detail the purpose of the visit and the outcome for the resident. There is evidence in the residents file that a medical consultant, a consultant psychiatrist and a community nurse for people with a learning disability support the resident. There is a physiotherapy assessment, although there is no evidence that the recommendations made have been implemented. There is no evidence of involvement with a dietician or speech and language therapist, other than an incomplete speech therapy assessment form. Records maintained by the home are insufficient to demonstrate that the residents identified health needs are met, or to provide health care professionals with sufficient information for them to make an informed assessment of the residents current health. Please also refer to the ‘Individual needs and choices’ section of this report. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X EVIDENCE: These standards were assessed at the last inspection of this home. The requirements made could not be assessed on this occasion. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Whilst the home has taken action to provide a comfortable and homely environment, further action is required in order to ensure the safety of the residents and staff. Good hygiene continues to be compromised by the unnecessary use of the kitchen of a thoroughfare. EVIDENCE: Standard 24 was assessed at the last inspection of this home, when it was noted that the home has a plan in place to refurbish the bathroom. This work has been completed. The requirement made to provide automatic door closures to the residents bedroom doors and to the small lounge has been met. It is noted that a door closure has not been provided on the landing doorway, despite being recommended in a physiotherapists report, to enable one resident to mobilise independently around the home. A tour of the communal areas of the home confirmed that the residents continue to live in a clean, comfortable and homely environment; this is with the exception of the flooring in the hallway, which is damaged. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 16 The laundry facilities available are appropriate for the needs of the home. These are situated in a separate building adjacent to the home. The staff member confirmed that the staff and residents continue to walk through the kitchen to get to the laundry and rubbish bins, even though there is another route available. Hand washing facilities are available in the laundry and protective aprons can be worn if required. The homes cleaning materials are stored in a locked cupboard in the laundry, information sheets detailing the actions to be taken in the event of skin contact, inhalation, ingestion and spillage of these substances are not available. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35 The homes training and development plan provides the staff with the training that they require, at appropriate intervals. EVIDENCE: Standard 34 could not be assessed as the manager was not on duty at the time of the inspection. The records relating to the staff member on duty were examined. These together with discussions with the staff member confirmed that the staff have either training dates planned or have received training, that is appropriate to their role. Regular updates of mandatory training are planned. Information provided in the pre-inspection questionnaire stated that the home has an annual training and development plan. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Although the home has taken some action to maintain the health and safety of the residents and staff further action is required. EVIDENCE: Standard 37 could not be assessed in this inspection year, as the registered manager was not present during the inspections. Visits to the home, by a representative of the organisation are to take place each month, under Regulation 26 of the Care Homes Regulations 2001. A copy of the report made following these visits is to be provided to the Commission for Social Care Inspection. Four reports have been provided to the Commission in the six month period since the last inspection. The home continues to hold residents meetings. These allow the residents to express their opinions regarding the running of the home and to raise any concerns or complaints that they may have. The staff member confirmed that Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 19 minutes of these meeting are maintained, these were not examined during this inspection. The staff member on duty was not sure if the views of the residents and their relatives had been sought with regard to the quality of the service that is provided or if this feedback is given anonymously. The staff member confirmed that whilst staff views are sought in supervision meetings she had not been given the opportunity to provide feedback anonymously. The staff member was not aware of any other quality monitoring that is undertaken by the registered manager or the organisation. Standard 42 was assessed at the last inspection. Eight requirements were made. Five of these have been met in full, two could not be assessed on this occasion and one is outstanding. There is now sufficient storage for household waste and food items are stored safely. PAT (portable electrical appliance tests) have been completed, thermostatic controls are available on hot water outlets and fire doors are no longer wedged open, however the lack of automatic door closing devices has caused difficulties for one resident. Please refer to the ‘environment’ section of this report. Records relating to the fire risk assessment and electrical wiring safety checks were not examined on this occasion. The requirement made at the last inspection to stop using the kitchen door to access the laundry and rubbish bins has not been addressed. Observations during the inspection and discussions with the staff confirmed that the kitchen door continues to be used as a main doorway. The practice of carrying laundry and waste through the kitchen and using the kitchen door as a main doorway increases the risk of cross infection. This is unacceptable in view of the fact that there is another doorway into the home adjacent to the kitchen door. Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 20 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 X X X X 2 X X 2 X Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 21 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 Regulation 14 Requirement The Registered Manager must complete her own assessment as to whether the identified needs of a prospective resident can be met, prior to offering a placement in the home. Timescale for action 30/06/06 2 3 YA6 YA9YA6 14 12,13,15 Progress towards meeting this requirement could not be assessed at the time of this inspection. The provider must ensure that 30/04/06 each residents needs are assessed. The provider must ensure that 30/04/06 each resident has an individual plan of care that addresses their identified needs. This requirement was made at the last inspection and remains outstanding. Risk assessments and risk management strategies must be completed to address the residents identified needs. This requirement was 4 YA9 12 13(4)(c) 30/04/06 Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 22 5 YA6YA9YA19 17 6 YA18YA19YA24 13(1)(b) made at the last inspection and remains outstanding. The provider must ensure that 06/04/06 the quality of record keeping is improved to enable an accurate assessment of the residents changing needs to be made. The provider must ensure that 30/04/06 referrals are made to the relevant health care professionals. This requirement was made at the last inspection and remains outstanding. The home must cooperate fully with the referral process and act upon the advice/treatment prescribed. 7 YA22 17(2) Sch 4.11 A complaints log is to be retained by the home. This requirement was made at the last inspection. Compliance could not be assessed on this occasion. Full details of the arrangements in place for external audit of the residents monies are to be made available to the Commission. This requirement has been made at previous inspections. Compliance could not be assessed on this occasion. The provider must repair or replace the flooring in the hallway. A door closure device is to be fitted on the landing door, as detailed in a physiotherapists report. DS0000004243.V286195.R01.S.doc 06/04/06 8 YA23 13(6) 20(3) 30/04/06 9 10 YA24 23(2)(b) 06/04/06 06/04/06 YA18YA19YA24 23(2)(n) Hft - Falstaff House Version 5.1 Page 23 11 12 YA30YA42 YA39 13(4)(b) 26 The provider must ensure that 31/03/06 COSHH data sheets are available in the home. Visits to the home under 30/03/06 Regulation 26 are to be made each month. Copies of the reports made following each visit are to be provided to the Commission. 13 YA39 14 YA42 This requirement was made at the last inspection and is part met. 24 The provider must ensure that 30/06/06 the quality of the service provided is monitored, seeking the views of the residents, their relatives or representatives, staff and other stakeholders, providing opportunity for these views to be expressed anonymously. A report detailing the outcomes of this monitoring is to be produced and the homes annual development plan reviewed. 13(3)(4)a The provider must ensure that 31/03/06 23(2)a (5) the external door to the kitchen must not be used as a main access to the laundry or rubbish bins. This requirement was made at the last inspection and remains outstanding. The fire risk assessment must be reviewed and updated annually. This requirement was made at the last inspection. Compliance could not be assessed on this occasion. Electrical wiring safety checks are to be completed. This requirement has been DS0000004243.V286195.R01.S.doc 15 YA42 23(4) 30/04/06 16 YA42 13(4)(a) 30/04/06 Hft - Falstaff House Version 5.1 Page 24 made at previous inspections. Compliance could not be assessed on this occasion. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hft - Falstaff House DS0000004243.V286195.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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