Inspection on 13/12/05 for Hope House

This inspection was carried out on 13th December 2005.

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

Other inspections for this house

Hope House 04/09/08

Hope House 20/09/06

Hope House 27/04/06

Hope House 01/07/05

Hope House 28/01/05

Hope House 04/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Sandford House 5-7 Sandford Close Wivenhoe Colchester Essex CO7 8JN Lead Inspector Gaynor Elvin Unannounced Inspection 13th December 2005 10:00 Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 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 Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 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. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sandford House Address 5-7 Sandford Close Wivenhoe Colchester Essex CO7 8JN 01206 823647 01206 823647 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ashraf Hussain Ahmed Hussain, Aktar Hussain Manager post vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 5 persons) 1st July 2005 Date of last inspection Brief Description of the Service: Sandford House is located on a residential estate situated in the small quayside town of Wivenhoe. The home is within walking distance to shops, pubs and cafes and a regular bus route provides access to Colchester. The home provides accommodation for five service users of both sex. Single bedrooms and two communal bathrooms are located on the first floor. A lounge and dining room on the ground floor. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place one day in December 2005 and was the third inspection to be carried out during the current inspection year (April 2005 – March 2006). This report also refers to an unannounced visit carried out on 26th October 2005 as part of the inspection process to monitor the home’s progress in addressing an extensive agenda for action from the last unannounced inspection in July 2005. Also following the unannounced inspection in July, further concerns were raised for the health, safety and welfare of the service users by the sudden departure of the Registered Manager under suspicious circumstances at the beginning of September 2005, a notification received on 24th October 2005, by the Commission, from Essex County Fire and Rescue regarding Sandford House non-compliance with guidelines and regulations; and a notification received on 21st October by the Commission from the Environmental Health of a prohibition notice served to Sandford House, for a second time, on the use of the bath relating to the temperature of the hot water in excess of 50 degrees. The Inspector issued a Notice of Immediate Requirement at the time of the monitoring visit for the Responsible Persons to take immediate action to address the issues identified by the Fire and Rescue ensuring the safety of all persons in the service. Details of the action taken by the home in order to address the issues are included in this report. Of the 38 National Minimum Standards (NMS) and expected outcomes assessed on this occasion, 6 met NMS with no shortfalls and 32 did not meet with NMS; 16 were rated at level 2 with minor shortfalls and 16 were rated at level 1 with major shortfalls. One recommendation at the last inspection had been addressed. The outcome of this inspection indicates that a high proportion of National Minimum Standards continue to remain unmet. The CSCI continues to be seriously concerned with the standard of professional practice and care outcomes for service users living at Sandford Close and the service will continue to be closely monitored, with a view to seeking legal advice about possible enforcement action. Discussion regarding the shortfalls will be addressed with the Responsible Persons as a follow up to this report. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Overall this inspection continues to raise serious concerns in respect of increasing requirements and failure to take the home forward in ways expected to achieve quality care outcomes and meet National Minimum Standards. There is a lack of experienced, skilled and competent workers for effective care outcomes. Care practice is mostly intuitive and some carers are clearly attempting to provide care to the best of their ability. National Minimum Standards relating to recruitment, induction, deployment, supervision and training requirements were all unmet, placing the service users at risk. Individual care programmes had not been developed including risk assessment and risk management documentation. This is required in order for staff to understand and meet needs more appropriately and effectively. Care should be offered according to identified needs and in line with person centred care principles. The service does not provide ongoing opportunities to promote service users potential and development and a fulfilling lifestyle. There were not sufficient systems and robust procedures in place, nor appropriate staff training to protect service users from abuse. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 7 The home has yet to develop the required policies and protocols to inform and guide staff in professional care practice and promote and protect service users’ well being. 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. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. The home did not provide adequate information to current and prospective service users with regard to the facilities and services available. The home did not operate a thorough pre admission assessment process, giving care and attention to ensuring the home was admitting individuals whose entire assessed needs could be fully met. Service users admitted to the home had specialised needs, which fall outside the boundaries of the conditions of registration. EVIDENCE: The Statement of Purpose did not meet regulatory requirements and did not provide the appropriate information to enable prospective service users to make an informed choice about the suitability of the home to meet their needs. A Service User Guide was not provided to service users. No further action had been taken to address the content of the contracts of the terms and conditions of residency to reflect the care and support agreed between the home and the service user to meet assessed needs. A Care Management Assessment or a pre admission assessment was not evident in service users’ care files. The home had yet to develop a robust policy and procedure informing professional practice on the admission process. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 10 As highlighted in the previous inspection report, some service users’ primary need was their mental health problems; a service the home is not registered to provide. Staff did not have the experience, competencies and skills required to meet the specialised needs of the service users admitted to the home with regard to mental health. Since the previous inspection the home had one vacancy, a discussion was undertaken between the inspectors and the Acting Manager, regarding the admission process and the service the home is able to offer and provide within the boundaries of the homes registration category. One service user led a socially independent lifestyle and spent a lot of time away from the home. It was questionable as to whether a less dependent setting was more suited to meet their needs. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 There is no clear or consistent care planning system in place to adequately provide staff with the information they need to meet the service users assessed needs and care outcomes. Evidence of the care and support provided to the service users was minimal. EVIDENCE: A sample of service users’ records was examined. It was very concerning to find that no further action had been taken to address previous requirements with regard to implementing written care plans and risk management strategies. Discussion with the Acting Manager and staff, at the time of this inspection, provided no evidence that this was likely to be achieved without significant improvement to professional practice. With the lack of a clear understanding of the care planning process and an absence of an agreed planned approach to meeting care outcomes, staff relied heavily on their own intuitive practice. The Acting Manager indicated that the multi professional panel within a Care Programme Approach was reviewing service users and documentation was awaited from this process to implement individualised care plans. However, Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 12 two service users had recently had a review within the last two weeks and an agreed plan of care and support from this process was yet to be developed. The Acting Manager indicated that service users were supported in maximising their capacity to make financial decisions, however service users financial decision making abilities were not reflected within a risk management and care planning process, including the understanding of basic concepts relevant to finance. From discussions throughout the inspection it was apparent that some individuals, at times, displayed challenging behaviour. Risk assessments and structured risk management strategies for crisis prevention, intervention or diversion strategies were not documented to inform staff of how to manage behaviour appropriately, effectively and consistently. Staff had not received training with regard to this issue and again strategies were intuitive. A written policy or procedure on confidentiality incorporating the Data Protection Act 1998 was not evident and there seemed to be little understanding or adherence to this issue. A daily reporting/message book was examined. Some entries were in pencil, some unsigned, some undated and featured a combination of ‘diary’ type entries such as visits to GP’s; together with service users care related messages to some that were clearly confidential and should have been recorded within the service users file. Outpatient appointments for a service user’ on going treatment was displayed on the office notice board. Staff medical certificates (Med 3) were also pinned to the notice board in breach of security and confidentiality. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. The home did not demonstrate a commitment to offer opportunities and support to establish a structured and purposeful lifestyle. The meals are poor with little evidence that service users are offered a wellbalanced meal of good nutritional value. There are serious concerns relating to how and if the dietary and nutritional needs of some service users are being met. EVIDENCE: At the time of the inspection all four service users were at home. One service user welcomed the inspectors upon their arrival and kindly made them a cup of coffee. Throughout the inspection service users were not observed to be involved in any activity other than watching television or spend any time engaged in developing or maintaining any practical independent life skills. Staff need to explore various approaches to prompt and motivate as part of the service users’ support plan to build self esteem, social and life skills and Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 14 ability to participate in meaningful daytime activity and promote optimal independence. One service user was stated to be in bed and remained there throughout the inspection. Staff were hesitant in disturbing and motivating this individual due to his earlier reported mood and he was only called for lunch. It was clear from discussion that this service user led a full socially independent lifestyle outside of the home and spent a lot of time away from the home with friends living in the Community. Another service user spoke of visits made to her family. Following discussion with inspectors, the Acting Manager recognised that person centred planning had not been the centre for decision making for the individuals, taking into account wishes and aspirations and providing individually tailored support. At a recent Care Programme Approach review, one service user had identified various activities and interests they would like to take up and the Acting Manager indicated the service user would be supported in pursuing these. The Acting Manager indicated that the service users accompanied the staff to do the shopping. The menu was probably reflective of service users wishes and choices but could have reflected a more balanced approach. The menu for the current week was brief; meals planned were mostly convenience processed foods with chips and fish planned for two occasions and a ‘roast’ for another day, vegetables were only identified for two days, there was no other detail. On inspection food stocks were poor; the freezer was full of processed foods and there was not an available supply of fresh vegetables, fruit or salad. The inspectors were informed that approximately £100.00 per week was budgeted for housekeeping for the four service users with an additional float of £20 £30 for additional items. A record of food served to the service users was not adequate in that not all meals had been recorded. There was no information available regarding menu planning, food consumed, support strategies or monitoring in relation to one service user with a known eating disorder. During the inspection service users were asked what they would like for lunch and this was prepared and served by a member of staff, later when the service user with an eating disorder was asked by the inspector if she enjoyed her lunch, she said she did not have any. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Appropriate care planning with associated risk management strategies were not in place and physical and emotional healthcare needs were not reflected within the individual care planning system to evidence the care being provided. Self-medication assessment and management plans were not evident for service users where appropriate and necessary. EVIDENCE: Healthcare monitoring remains poor. No progress had been made to adequately record and monitor physical and emotional healthcare needs within a care planning process and there continued to be a lack of planned risk management strategies informing staff of how to reduce the risk and/or manage a significant event, particularly in relation to mental health problems, eating disorders, asthma and epilepsy. One service user had recently required an urgent medication adjustment and review and was receiving additional emotional support from the NHS Mental Health Intensive Support Team however there were no clear structured care plan objectives for this individual. With an absence of care management practice staff had little understanding of the need to carefully monitor and record the mental health of the service users particularly with regard to mental health medication. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 16 Visits to GPs and other healthcare professionals were recorded inappropriately in the staff communication book, calling into question confidentiality. Policies and procedures for the safe management and administration of medication were not evident. A thorough review of the medication system was not undertaken on this occasion. Staff practice was observed and satisfactory with the exception of service users being called to a central point to receive their medication rather than receiving individual attention. This process was institutional and clearly not an encouraging or supportive approach. Assessments and support management plans with regard to the more independent service users retaining, administering and controlling their own medication where appropriate were not in place. Individually prescribed creams were observed open and stored in the kitchen fridge along with the service users food. Since the last inspection staff had received further training in the administration of medication and the use of the Monitored Dose System and related Medication Administration Records from the local pharmacist. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. The complaints process in the home was poor with no information available to service users. Adult protection in the home is poor with the lack of staff training and policies and procedures to guide staff. EVIDENCE: The home has still to develop a complaints policy and procedure in line with National Minimal Standards, to include all the appropriate information required for service users, representatives or stakeholders to make a complaint and know that their concerns would be acted on efficiently and effectively. The Acting Manager indicated that the need for effective consultation with the service users had been recognised and meetings had commenced, however records and outcomes of the meetings were not evident. The previous two inspection reports had raised concerns in respect of the homes culture and practice in promoting and protecting the safety of vulnerable adults from abuse. Staff had not received any training in this area and there was a lack of robust policies and procedures, including local policy, to guide staff of the steps to be taken in the event of an allegation or suspicion of abuse being reported. Since the last inspection an allegation of possible financial abuse has been made and the police and Social Services are currently investigating this. The home demonstrated a lack of clarity and understanding in dealing with this level of allegation and robust procedures and local guidelines were not followed to immediately initiate a POVA alert to Social Services when the allegation was first brought to their attention. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 18 No further action had been taken to address these areas with regard to developing a policy and procedure or accessing staff training. The Acting Manager was advised during the monitoring visit to access Local policy guidelines and training opportunities from the Essex Vulnerable Adults Committee (EVAC); guidelines and booklets have now been received and distributed to members of staff. Individual lockable security boxes had been provided for service users to store personal money, bankcards and valuables and the acting manager stated that individuals had their own bank accounts. However financial management and recording systems were still inadequate to enable an accurate audit trail to be carried out for those service users who require support in managing their own finances. Staff are managing challenging behaviour without appropriate training, which has the potential to be harmful to service users health, safety and welfare. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 19 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, 25, 27, 28 & 30. The home did not fully present a homely, comfortable and safe environment. EVIDENCE: Some financial investment had been placed into some improvements within the home, which included an additional bathroom with shower facilities, and redecoration and new carpeting in the lounge. The games room, which was not previously used had been cleared of clutter and made into a dining room, thus achieving additional space in the lounge by the removal of the dining table and chairs. The remainder of the environment remained rather shabby and dismal although another phase of improvement was said to commence in the New Year. The dining room had fluorescent light fittings unprotected from mechanical damage and potentially a hazard, especially where service users have behavioural disturbances. An offensive odour was noted in one bedroom. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36. The procedure carried out for the recruitment of staff was not robust and did not provide the safeguards to offer protection to people living in the home. The home was unable to evidence that all staff are adequately trained and competent to do their jobs. Service users did not always benefit from a cohesive effective staff team deployed in adequate numbers to meet all their assessed needs. EVIDENCE: When the inspection commenced at 9.30am, two members of staff were on duty, one was giving out medication and the other was hoovering. The acting manager arrived later. The staff roster identified two members of staff on duty between the hours of 08.00am to 10.00pm and one member of staff at night on a sleeping duty. The home was currently experiencing a high percentage of sick leave within the staff team and this situation has a detrimental impact on the standard and consistency of care offered within the home. The acting manager indicated she was also covering shifts and this took her away from the managerial duties of the home. The ratio of staff deployment had not been calculated according to the service users assessed needs and the weekly staffing hours was considerably lower than expected for the purpose of the service, taking into consideration the absence of domestic staff and a cook. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 21 The practice of staff recruitment did not meet with National Minimum Standards or regulatory requirements at the previous inspection and little progress had been made on this occasion, potentially placing service users at risk. A sample of three staff files were examined and shortfalls were found in relation to two written references, previous employment record, CRB disclosure checks and terms and conditions. The acting manager indicated contracts were in existence but not held at the home. Original copies of Criminal Record Bureau (CRB) disclosures were not held on file for inspection. A CRB disclosure or POVA First clearance had not been obtained prior to the commencement of a new member of staff employed as bank relief. There were no records of induction. The manager was advised that staff must not commence employment until the required documentation is in place including the receipt of a satisfactory CRB for any person employed within the home in a care position that enables them regular contact with resident in the course of their duties. The home did not have an annual training and development plan for future planning. The sample of staff files examined did not contain an individual training and development assessment and profile to identify any training needs or gaps in knowledge and skills, and did not provide evidence of relevant qualifications or mandatory training. The acting manager indicated that all staff had recently received fire safety awareness and the certificates of attendance were still awaited. Staff meetings had commenced to inform future planning and raise awareness in areas such as the Care Standards Act 2000, the National Minimal Standards and the General Social Care Council Code of Conduct. The sample of staff files did not contain any record of formal supervisions being received within the last year. The acting manager was advised that a regular formal supervision approach must be taken to support staff to assess their own levels of skill and competence, focusing on residents and care outcomes. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 22 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): 38, 39, 40, 41, 42 & 43. Sufficient investment has not been put towards essential elements of management, structured training, individualised care programmes and related documentation. Service users are placed at risk by poor record keeping and the lack of policies and procedures. The home is not managed efficiently and the acting manager is not receiving the support required by the Responsible Individuals. There are concerns in respect of increasing requirements and failure to take the home forward in ways expected by the National Minimum standards and in the best interests of service users. EVIDENCE: Since the last inspection the Registered Managers position has become vacant. An application for the proposed Registered Manager has been received by the Commission but was incomplete; the required information to complete the application is still outstanding. Meanwhile a temporary acting manager supplied from an agency has been in post for three months. Staff spoken with were positive regarding the temporary management arrangements and supportive of the changes taking Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 23 place in the home with regard to new systems and structures. However they indicated there was a divided staff group and some were resistant to change and the new management approach. The acting manager stated this had an impact on the service users and the atmosphere in the home and was a contributing factor to the slow progress being made, particularly with the high levels of sick leave. With an absence of systems, structures and care management, the acting manager has had to start from basics in her approach to addressing the extensive agenda for action in attaining the National Minimum Standards. Following an Immediate Requirement notice issues of serious concern were addressed relating to fire safety. The fire alarm panel, emergency lighting and self-closing doors and fire extinguishers were serviced and staff were instructed on how to carry out checks. A fire safety logbook was commenced detailing records of weekly checks and fire drills carried out. Staff received training in fire safety awareness, although certification of attendance was still awaited. Risk assessments had been carried out to identify and reduce hazards although associated risk management strategies were brief. Clutter had been removed from the communal areas. The home had yet to review and further develop the homes fire policy and procedure. Risk assessments with regard to health and safety in the workplace had not been carried out. Water temperature from hot water outlets was tested and found to be 46 degrees. The temperature was previously raised by a staff member turning up the water thermostat on the boiler instead of the heating thermostat. A risk assessment and risk management strategy addressing this issue was not evident. There was no evidence of compliance with relevant legislation relating to service, maintenance and installation with regard to gas and electric, with the exception of Electrical Personal Appliance Testing carried out in June 2005. Core staff training needs with regard to protecting and promoting health, safety and welfare of service users remained unmet, such as First Aid, Food Hygiene, Health and Safety and Infection Control. There is an absence of required written policies and procedures to inform professional practice. There is an absence of records required by regulation for the protection of service users, recording practices was very poor overall, disorganised and difficult to follow. The acting manager struggled to find anything. The home had not progressed in addressing quality assurance and quality monitoring systems, an essential process for measuring the quality of the service provided and service user outcomes. Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 24 Only one report has been received from the registered Provider on the conduct of the home in the last three months by the CSCI (Regulation 26). Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 1 1 X 1 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 2 2 1 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 3 3 N/A 3 LIFESTYLES Standard No Score 11 1 12 2 13 2 14 2 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 2 1 2 1 1 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sandford House Score 2 2 2 X Standard No 37 38 39 40 41 42 43 Score X 3 1 1 2 2 1 DS0000017926.V273181.R01.S.doc Version 5.0 Page 26 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 YA1YA8 Regulation 4,5,6,24 & Sch 1. Timescale for action The Responsible Person must 01/04/06 ensure that a Statement of Purpose and Service User Guide is produced that complies with regulatory requirements and NMS and service users are provided with accessible, comprehensive and up to date information. A third repeat requirement not met within the previous given timescales,30th May 2005 & 1st October 2005. The Registered Manager must 01/04/06 demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. A repeat requirement not addressed within the given timescale of 1st October 2005. The Registered Manager must 01/04/06 demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. A repeat requirement not addressed within the given timescale of 1st October 2005. DS0000017926.V273181.R01.S.doc Version 5.0 Page 27 Requirement 2 YA2YA3 12 3 YA2YA3 12 Sandford House 4 YA5 5( c ) 5 YA2YA6YA 18Y YA19YA41 12,16,13, 14,15 6 16,20,Sch 4 7 YA9 14 8 YA10 17 9 YA11 YA12 YA13 YA14YA16 16 The Responsible Person must ensure a contract is agreed specifying all arrangements as detailed in NMS 5.2 and provide the individual wth a copy. A repeat requirement not met within the given timescale 1st October 2005. The Responsible Person must ensure an individualised care plan is developed and agreed with each service user, setting out how all assessed needs will be met through positive planned interventions and programmes, reviewed within the agreed times and updated to reflect changing needs and/or outcomes for the service user. A repeat requirement not met within previous given th timescales of 30 May 2005 st and 1 September 2005. The Responsible Person must ensure service users decision making abilities, particularly with regard to financial management and the level and manner of support provided is documented and reveiwed within the individuals care/support plan. The Responsible Person must ensure that the service operates within a clear risk management framework approach. The Responsible Person must ensure all information relating to service users is confidential, appropriately recorded and stored securely. The Responsible Person must ensure that opportunities and support is provided to develop social and life skills and service users participate in a valued and fulfilling lifestyle. A repeat requirement not met within given timescale 1st Sept 2005. DS0000017926.V273181.R01.S.doc 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 Sandford House Version 5.0 Page 28 10 YA17 13,16,Sch 3(3m) Sch413 11 12 YA22 YA23 22 13 The Responsible Person must 01/04/06 ensure that the home can demonstrate that wholesome nutritious food in adequate quantities is provided at all times to promote well-being. The Responsible Person must 01/04/06 develop a clear and informative complaints procedure. The Registered Manager must 01/04/06 safeguard service users from all types of abuse by ensuring robust policies and procedures are in place and carried out. The Registered Person must ensure staff receive appropriate training in the areas of protecting vulnerable adults. This is a second repeat requirement not met within timescales 30th April 2005 & 1st Sept 2005. The Responsible Person must ensure the premises are safe and well maintained, and suitable for its stated purpose. A repeat requirement not met within given timescale 1st Sept. 2005 The Responsible Person must ensure that all staff have the knowledge, skills and experience necessary for supporting and meeting the needs of the service users particularly with regard to NVQ and mental health awareness. A repeat requirement not met within given timescale 1st October 2005. The Responsible Person must ensure that the home has an effective staff team, with sufficient numbers to support the service users assessed needs at all times. The Responsible Person must operate a robust and thorough recruitment procedure in accordance with regulatory requirements. This is a third DS0000017926.V273181.R01.S.doc 13 YA24 YA30 16 13 01/04/06 14 YA32 18, 19. 01/04/06 15 YA33 YA13 18 01/04/06 16 YA34 YA23 YA41 19 01/04/06 Sandford House Version 5.0 Page 29 17 YA35 18 18 YA36 12, 18 19 YA39 24 repeat requirement not met within given timescales 31st April 2005 & 1st Sept. 2005 The Responsible Person must 01/04/06 ensure that the home has a training and development plan, and that all staff receive at least five paid training and development days. The Registered Person must ensure staff receive structured induction and foundation training to Sector Skills specification. A repeat requirement not met within timescale of 1st October 2005. The Responsible Person must 01/04/06 ensure that staff receive regular and formal supervision to support and inform care practice and receive feedback on their conduct and performance. The Registered Person must 01/04/06 establish and maintain a system for reviewing the care within the home. This is a second repeat requirement not met within given timescales of 30th April and 1st September 2005. The Responsible Person must 01/04/06 ensure that records required by regulation are appropriately maintained and available for inspection purposes. The Registered Person must 01/04/06 ensure that unecessary risks to service users are identified and so far as possible eliminated. The Registered Persn must ensure suitable training is provided for staff to ensure the health, safety and welfare of service users. This is a repeat requirement not met within given timescale of 1st October 2005. The Responsible Person must 01/04/06 ensure the overall management of DS0000017926.V273181.R01.S.doc Version 5.0 Page 30 20 YA41 17 21 YA42 12,13, 23 22 YA43 25 Sandford House the service ensures effectiveness and accountability of the home and meets all statutory requirements within given timescales. 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 Refer to Standard YA20 YA31 Good Practice Recommendations The Responsible Person should ensure that the practice of medication administration is individualised promoting independence and dignity. The Responsible Person should ensure staff have clearly defined job descriptions and know, understand and implement policies and procedures to support the main aims of the service. The Responsible Person should ensure policies and procedures are developed covering the topics set out in Appendix 2 of NMS YA, which comply with current legislation and professional guidelines. 3 YA40 Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandford House DS0000017926.V273181.R01.S.doc Version 5.0 Page 32 - 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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