Inspection on 04/09/08 for Hope House

This inspection was carried out on 4th September 2008.

CSCI found this care home to be providing an Poor 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 36 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hope House 20/09/06

Hope House 27/04/06

Hope House 13/12/05

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 08/11/2008.

CARE HOME ADULTS 18-65 Hope House 5-7 Sandford Close Wivenhoe Colchester Essex CO7 8JN Lead Inspector Sara Naylor-Wild Unannounced Inspection 4th September 2008 10:00 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hope House Address 5-7 Sandford Close Wivenhoe Colchester Essex CO7 8JN 01206 823647 F/P 01206 823647 jimohare147@btinternet.com 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 Mr James Patrick O`Hare Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Hope House DS0000017926.V371189.R01.S.doc Version 5.2 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) 2nd May 2008 Date of last inspection Brief Description of the Service: Hope 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 is registered to provide accommodation for five service users of either sex. Single bedrooms and two communal bathrooms are located on the first floor. A lounge and dining room on the ground floor. Information was not readily available regarding fees and additional charges during the inspection process. The service has been unoccupied since December 2006. Hope House DS0000017926.V371189.R01.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 0 star. This means the people who use this service experience poor quality outcomes. This unannounced key inspection was carried out on the 4th September 2008. Hope House has been unoccupied since December 2006. Since that time the proprietors have appointed a registered manager who was contracted to work at the home on two days a week. Prior to the inspection visit efforts were made to contact the manager and proprietors to arrange an announced visit to the home. The registered manager advised that he was on long-term sick leave following an accident in June 2008, and was not aware of any management arrangements that had been made to cover his post. Attempts to contact the provider proved impossible as the contact numbers held by the Commission were not active and the number for Hope House itself did not accept incoming calls. Nobody was present at the service on the day of the inspection and it was not possible to gain entrance to the premises of Hope House to carry out the key inspection visit. Limited evidence was available when compiling this report. An Annual Quality Assurance Assessment (AQAA) was returned to us on 31st April 2008. This was not properly completed and contained very limited information about the service. Due to lack of access to Hope House we were not able to confirm any of the information provided in the AQAA. No documentary evidence such as assessment forms, care planning documents, staff rotas and policies, were available to assess their compliance. The inspector was not able to gain access to carry out a tour of the premises. What the service does well: What has improved since the last inspection? Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 6 On the day of the inspection access to Hope House was not possible, so we were not able to confirm if any changes or improvements have been made since the last full key inspection on 2nd May 2008, therefore we are unable to say whether the service has improved. 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. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as adequate, and judged that “Prospective service users or their representatives would be provided with the necessary information to enable them to decide upon the home’s ability to meet their needs. The service would carry out an assessment but this would not be consistently applied to determine the suitability of the proposed admission “ The evidence considered for this was; “The service has a Statement of Purpose and Service Users Guide that provide sufficient information for the reader to understand what the service aims to provide and what in broad terms should be expected if someone chose to live there. The Statement of Purpose included the home’s philosophy, qualifications of the registered manager, services and facilities provided, the organisations structure and lines of accountability, terms of residency, and a copy of the home’s complaints procedure. The document also set out the service’s admission policy. This states that as well as an invitation to introductory visits to the home the person’s needs would be fully assessed before a decision is taken to offer residency for an Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 9 initial three-month probationary stay. Overall the policy meets the expectations of the National Minimum Standard. However the documentation required to fulfil the assessment process was not fully present. There is an initial referral information sheet that the manager stated is used to determine whether the initial enquiry is within the service’s criteria, this contains brief details of the person, their disabilities, behaviour and health needs. The format does not ask for a fuller detailed assessment in which the person’s abilities, aspirations and support needs are identified in each area of their daily living. So although the service would be aware that someone had a sensory loss, it would not be clear how this impacted upon their daily life and how they would require support to be provided to minimise this. The lack of detail in the document does not support the evidence of a planned admission process where the home fully understand what the persons needs and aspirations will be in order to consider if the service has the skills, resources and equipment to meet these. The manager did discuss recent enquiries made by prospective residents to the service, although these had not been progressed to full assessments, and in the absence of admissions to the home it was not possible to determine further how the successful the admission process would be. The Service Users Guide also referred to the home as Sandford House in the text.’” There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.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 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as poor, and judged that “People considering living at the home could not be assured that staff would understand how to consistently meet their needs and aspirations in a way they would prefer. They would not be able to see an agreement in how their support would be delivered. “ The evidence considered for this was; “In the initial discussions with the manager about care planning he said that the service did not have a formally written care plan and that he had thought from previous experience that the document would be a free flowing layout that was developed as the individual was assessed. He had not thought that a document that led you through the areas of needs was required. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 11 However after some exploration on the home’s computer a sample of a format was found. This format asks a series of questions of the person the plan is centred on. The questions are all issues relating to the persons abilities and preferences for daily living and include, which members of your family or friends do you want to see regularly, what do you like to eat, how do you talk and how do you want other people to talk to you, things you do regularly outside of the home (with a calendar). It includes the outcomes of risk assessments and the agreements made as a result, and how the person manages their anger. At the end of the document there is a page that asks about the future and leaves a space for the persons aspirations to be documented. This is a very open form that puts the individual at the centre of the information gathering. The way in which this information is translated into action that staff should follow was not included in the document. For example, in the section about who the person wanted to be in contact with, there is not a conclusion that tells staff what specific steps they will need to take to support this and how frequently they should do so. Without this information staff cannot consistently provide support in a way that ensures this need or aspiration will be met. The document does not therefore provide the key elements of care planning and may well serve as an initial assessment format better than a care plan. People entering the home may be in need of support from advocates to ensure their views are represented in consultation about their care and the way the home operates. At the time of the inspection advocacy groups had not been identified and the manager stated that he had not made contact with local advocacy groups. Whilst this is not an immediate need in the absence of people living at the home, the relationships with advocacy services in preparation for admissions would be a proactive development in readiness for admissions to the service. Risk assessment forms are on file for general risks and individual behaviour needs. The first of the two formats identify areas in which there may need to be consideration of risks such as a person’s aggression, eating disorders, refusal of medication etc. The second form is a risk assessment format that identifies individual issues, the reason for the assessment, the benefits in taking the risk, what steps are being taken to reduce risk and decision made with signatures of people involved in assessment and review dates. The risk taking policy informs the reader that risk is a reasonable part of life and independence and the intention of the risk assessment is to provide opportunity to exercise balanced judgements. The policy and documents support positive approach to risk as part of the individuals daily life at the service and would support staff in determining a balanced reaction to risks that are part of a fulfilled life. However, because the service’s care plan document does not set out how staff should take action in response to identified needs, Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 12 the issues identified in the individuals risk assessment could not be consistently managed by staff.” There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.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): 12, 13, 15, 16 and 17 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as poor, and judged that,” People considering moving to the service would not be able to be confident that the service knew how to access a full range of community life for them to participate in.” The evidence considered for this was; “The service’s statement of purpose includes amongst its objectives to “enable residents to live as members of a local community and be accepted and treated as ordinary citizens and to foster relationships with the local community, to provide special help, support, guidance and sometimes protection to enable residents to enjoy the benefits of community life including memberships of organisations and clubs. To provide the opportunity for appropriate leisure time activities and pursuits.” Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 14 The outcomes for these standards are difficult to assess without the participation of people living at the home. However people choosing to live at the home should have information available which tells them about the opportunities for engagement in daily living and activities that they may be able to access. From discussion with the manager at this visit there no connections made with organisations in the area has been made. Whilst the outcomes for these standards are difficult to assess without the participation of people living at the home, we were not provided with evidence that the manager has made preliminary enquiries about the opportunities for engagement in daily living and activities that prospective residents may be able to access. Evidence prior to people moving into the home should include information about what is available in the area for staff to draw from in order for them to support any new residents in choices in this area of their life. As expected where there is no one in residence there were not any food stores or ingredients to provide for meals in place. The menu on display in the kitchen related to Sandford House and was dated for 2006. The budget allowance for food, choice of suppliers and development of a balanced menu was not in place.” There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as poor, and judged that “It is not possible to fully assess the outcomes of these standards, although evidence available indicates that people living at the service can expect some understanding of how to protect their rights, but this is not fully upheld in all aspects of their support.” The evidence considered for this was; “The service has a policy and procedure statement in the Service Users Guide and Statement of Purpose. This sets out the way in which the service will operate to uphold the rights to privacy, dignity and respect of individuals living there. So for example it states that people living at the home will have their privacy respected by the provision of locks to single bedrooms where they hold the key and the key to the front door of the building. It also says that confidentiality will be maintained in dealing with their personal information. Where this needs to be shared their permissions will be asked and they will be treated with dignity in the way in Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 16 which the staff deals with dressings, bathing, feeding, incontinence and all other needs. There are broad statements that are in keeping with the aims and objectives of the service, but these do not state factually how these objectives would be fulfilled. There is no evidence in the form of clear guidance documents and training plans to identify how these statements would be acted upon by staff, to ensure the outcomes stated in the service’s Statement of Purpose would be delivered. The service does not currently hold any medication, and there were no specific storage arrangements for medication in place. The manager reported that filing cabinets in the office would be used, when people moving into the home required medication. The Royal Pharmaceutical Society of Great Britain’s guidance ‘Handling medicines in social care’ states that “…the storage of medicines needs to be in the right place. Filing cabinets are not suitable for storing medicines. “ There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Insufficient evidence was made available to enable us to make a judgement in this outcome area. . EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as adequate, and judged that “People considering living at the service can be assured that staff will have some understanding of how to listen to their concerns and act upon them.” The evidence considered for this was; “The service has a complaints policy in place and this contains the elements of the National Minimum Standard. There was only one written version available and other formats should be developed to ensure prospective residents with a range of communication abilities are able to access this. The safeguarding procedures for the home set out a series of instructions to staff in responding and reporting allegations of abuse. There is also an explanation of the Department of Health’s Protection of Vulnerable Adults (POVA) list and the company’s responsibilities in this respect when carrying out recruitment. There is a separate whistle blowing policy that clearly sets out what is expected of staff if they witness alleged abuse and how the service will respond to their reporting of their concerns. There is not additional information to staff on the areas that constitute abuse. The policies do not give information about what other agencies are involved in responding to an allegation of abuse and the process that is followed when a report is made. It is important in supporting staff to deal with allegations of Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 18 abuse that they are aware of the weight of importance given to the matter and are given a full understanding of the way in which abuse is dealt with outside of the home.” There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as good, and judged that, “People considering living at the service can expect to be supported in an environment that is clean, comfortable, and domesticated.” The evidence considered for this was; “A tour of the premises was undertaken in the company of the home’s registered manager on this visit and the premises and furnishings were unchanged from the last inspection visit on 2nd November 2007. The home was clean and tidy and presented to a good standard. Furniture and fixtures were domestic in nature and were of a good quality, and the home had been re-carpeted throughout. All of the radiators had been covered with radiator guards. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 20 All the bedrooms were equipped with a bed, a wardrobe, a bedside cabinet with a lockable drawer, and a chest of drawers. Rooms were equipped with a sufficient number of power points, and each had a television point. There were hand basins in each room, all of which were fitted with hot water temperature restrictors, to minimise the risk of scalding. The home’s laundry facility was equipped with domestic style washing machines and dryers, and hand-washing facilities were available. The laundry had a locked cupboard for the storage of cleaning products.” There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as adequate, and judged that, “People entering the home could be confident that they would be safeguarded by the home’s recruitment practice. They could not however, be confident that the staff skills would support their needs. “ The evidence considered for this was;” The service has not appointed any new staff since the last inspection. As stated at the last inspection the documentation held on the Registered Managers file contains documents required by the Care Homes Regulations 2001. These include an application form, two written references, Criminal Records Bureau Check (CRB), and evidence of qualifications. The discussions with the manager indicated that whilst they understood a need for a robust system of recruitment, they had already identified people who previously worked at the home and lived locally as returning to the service employment when required. It is not possible to further test the statements made in the service’s recruitment policy. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 22 As stated there were no staff appointed at the time of the inspection, apart from the registered manager. The Statement of Purpose states “dependent on the needs of the individual residents there will be a minimum of 2 staff on duty each day shift. At night there is one sleeping support worker unless additional waking support workers are commissioned for a particular resident.” In relation to the skills required by the staff group, the Statement of Purpose says, “ the appointed person will be supported by a team of support workers, full and part time, some with several years care experience in this field. These support workers will be trained to NVQ level 2/3 or equivalent in care or currently working towards it. All new staff members will be required to register for NVQ training in accordance with the CSCI recommendations. All care and ancillary staff receive our own induction training, in accordance with Skills for Care guidelines, as well as additional training particular to our field of care in learning disabilities problems, where we specialise in helping adults who present with challenging behaviour needs.” There are basic training requirements for staff working in the residential care sector. These include induction training programmes, subjects relating to health and safety legislation and items directly linked to the services statement of purpose. It would be expected that these subjects were included in an annual training programme with identified providers and an agreed budget allowance. Specifically the services statement in respect of their specialism in supporting challenging behaviour needs would require staff to undertake significant levels of training in this area. Although the service does not currently employ staff there was no evidence of a proactive approach to the basic requirements of a new staff teams development or that the manager has developed a model training programme with agreed budget implications and source providers as part of the evidence of the service’s levels of competency checks. “ There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 23 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 Insufficient evidence was made available to enable us to make a judgement in this outcome area. EVIDENCE: At the inspection on 2nd May 2008 the Commission judged the quality of this outcome group as poor, and judged that, “People considering living at the home could not be confident that the management would consult with them and improve the quality of the service delivered. The evidence considered for this was; “The Registered Manager has 46 years experience on working with people with learning disabilities in a number of settings. He holds qualifications as a nurse. He is currently contracted to work at the home for two days a week and develop the service to improve the outcome of inspection quality ratings in order to enable the service to Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 24 successfully admit residents. He informed the Commission that he has agreed with the providers to remain at the home, for sufficient time to train a new manager from the staff team to take over the post, once the service is fully operational. The Annual Quality Assurance Assessment (AQAA) submitted by the manager was incomplete and did not provide the information required. The manager stated that he had not done so as he had not wanted to misinform the Commission about what was happening in the service, given that the service was empty and unable to demonstrate the statements. The primary purpose of the AQAA is to inform the Commission about how the Registered Persons understood the strengths and weaknesses of the service in meeting its regulatory obligations and how they were seeking to address these. Whilst there are limitations to the way in which a service that is not operational can demonstrate this, it is possible to provide factually based statements of the services present circumstances and their intentions in meeting the regulatory requirements made of them. In not completing the AQAA fully the manager had not only missed an opportunity to tell us how the service was improving from a poor service, but also acted in breach of Regulation 24 of the Care Homes Regulations 2001. The service’s statements in regard to the quality assurance systems were not in place at the time of the inspection. Throughout the inspection it was noted that many documents including policies and procedures refer to the services previous name of Sandford House. This gives confusing information to the reader and does not provide a sense of consistency and confidence to the service’s statements. There was evidence that fire safety checks are carried out regularly, and insurance certificates were on display for the current year. “ There was no evidence available at this inspection visit to determine whether this position had changed. Hope House DS0000017926.V371189.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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. Standard Regulation 1. 2. YA1 YA43 4, Schedule 1 38, 43 Requirement The registered persons must provide their address details in the statement of purpose. Where the registered manager is absent from the service for a period of 28 days or longer the providers must inform the Commission in writing of the reason for the absence, the expected length of the absence, the arrangements for running the care home in the managers absence and the details of the person who will be responsible in that absence within one week of the absence. Timescale for action 15/09/08 15/09/08 3. YA23 13(6) Training related to safeguarding must 04/10/08 be provided to ensure service users are not placed at risk of abuse and are kept safe This is a repeat requirement not met within set timescale. 4. YA43 17(2) Schedule 4 (3) The registered person shall maintain and keep a record of all accounts in the care home. This is a repeat requirement not met within set timescales. 30/10/08 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 27 5. YA3 12 The home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home must be demonstrated to ensure residents’ needs are met. This is a repeat requirement not met within given timescales. 31/10/08 6. YA5 5 (c) The contract agreed between the service user and the home must specify all arrangements as detailed in NMS 5.2 and the individual is provided with a copy to ensure they are aware of their rights. This is a repeat requirement not met within given timescales. 31/10/08 7. YA6 14(2)(a,b) 17(1)(a) Schedule 3 (1)(a) The assessment of service users’ needs must be kept under review and revised at any time when it is necessary to ensure their needs are met. This is a repeat requirement not met within set timescale. 31/10/08 8. YA9 14(2)(a,b) 17(1)(a) Schedule 3 (1)(a) The registered person shall ensure that the assessment of service users’ needs is kept under review and revised at any time when it is necessary to do so having regard to any change of circumstances. This is a repeat requirement not met within set timescale. 31/10/08 9. YA7 12 The registered person must ensure rights are only limited through an assessment process, recorded in the care plan and regularly reviewed. This is a repeat requirement not met within given timescales. 31/10/08 81 YA17 17 (2) A record of the food provided for DS0000017926.V371189.R01.S.doc Version 5.2 31/10/08 Page 28 Hope House 20. Schedule 4(13) service users must be kept in sufficient detail to enable the person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for the individual. This is a repeat requirement not met within given timescales. 91 1. YA19 17(1)(a) Schedule 3 (3) (m) A record of any plan relating to the service user in respect of medication, nursing, specialist health care or nutrition must be kept to ensure their health care needs are met. This is a repeat requirement not met within agreed timescales. 31/10/08 12. YA20 13 Staff must receive appropriate medication training and formal assessment of their competence to ensure they do safely administer medicines. This is a repeat requirement not met within given timescale. 04/10/08 13. YA32 18(1)(a) The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This is a repeat requirement not met within given timescales. 31/10/08 14. YA37 Care Standards Act Section 22 The Registered Person must ensure that the home complies with the Care Standards Act and Regulations. The Responsible Persons must ensure that action is progressed within agreed timescales to implement requirements identified in CSCI inspection reports. 30/09/08 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 29 This is a repeat requirement not met within agreed timescales. 15. YA38 12 The Registered Person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users and; to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. This is a repeat requirement not met within given timescales. 16. YA39 24 The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. This is a repeat requirement not met within set timescales. The requirements set out below are repeated from previous inspection visits on 20th September 2006, 4th May 2007, 2nd November 2007 and 2nd May 2008. They are repeated here, as there was insufficient evidence of the service’s compliance at this inspection. 17. YA41 17(1) The registered person shall maintain in respect of each service user a record that includes the information, documentation and other records specified in Schedule 3 relating to the service user. This is a repeat requirement not met within given timescales. 18. YA41 17(2) Schedule 4 (8) The registered person shall keep a record of the care home’s charges to service users, including any extra DS0000017926.V371189.R01.S.doc Version 5.2 30/09/08 31/10/08 31/10/08 30/09/08 Hope House Page 30 amounts payable for additional services not covered by those charges, and the amounts paid by or in respect each service user. This is a repeat requirement not met within set timescales. 19. YA41 17 (3) The registered person shall ensure 04/10/08 that the records referred to in Schedule 3 and Schedule 4 are kept up to date; and are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the home. This is a repeat requirement not met within given timescales. 20. YA41 19(1)(b) The registered person shall not employ a person to work at the care home unless they have obtained in respect of that person all the information and documents specified in paragraphs 1-7 of Schedule 2. This is a repeat requirement not met within given timescales. 21. YA39 24(2)(3)(4 ) The service must review and develop the service to improve the outcomes for people living there. Specifically the registered person must provide the Commission with an Annual Quality Assurance Assessment when requested to do so. Failure to comply with this request is an offence. This is a repeat requirement not met within given timescales. 22. YA43 25 People living at the home must be able to feel secure and confident about the viability of the service. Specifically the registered person must supply to the Commission the annual accounts of the care home DS0000017926.V371189.R01.S.doc Version 5.2 04/10/08 02/10/09 30/10/08 Hope House Page 31 certified by an accountant. This is a repeat requirement not met within given timescales. 23. YA2 14 (1) (a,b,c,d) Sch3 (1a) People admitted to the home must be able to be confident that their needs are understood and will be met by the service. This must be demonstrated by a full assessment of their needs. This is a repeat requirement not met within given timescales. 24. YA6 15(1)(2)(a ,b,c,d) 17(1)(a) Schedule (1) (b) People living at the home must be assured that the way in which the staff support them is determined after consultation, is recorded in care plans and understood by staff to ensure they receive support that consistently meets their assessed needs. This is a repeat requirement not met within given timescales. 25. YA7 12(2)(3) People living at the home must be supported to participate in consultations about how staff can best meet their needs and the way in which the home operates. Specifically the service must have knowledge of advocacy services available in the locality. This is a repeat requirement not met within given timescales. 26. YA9 13(4)(b) People living at the home must be able to take risks as part of their daily lives, with the support and guidance of staff. Specifically the outcomes of risk assessments must be included in the persons care plan. This is a repeat requirement not met within given timescales. 27. YA12 16(2)(m)( People living at the home must be DS0000017926.V371189.R01.S.doc Version 5.2 30/10/08 31/10/08 04/10/08 31/10/08 31/10/08 Page 32 Hope House n)(3) able to expect to access appropriate choices in fulfilling their lifestyles outside the home. Specifically the staff must have knowledge of what education and occupational facilities are available in the local community and how to promote the individuals access to these, and that this is recorded as part of their care plan. People living at the home must be able to expect to access appropriate choices in fulfilling their lifestyles outside the home. Specifically the staff must have knowledge of what recreational services are available in the local community and how to promote the individuals access to these, and that this is recorded as part of their care plan. This is a repeat requirement not met within given timescales. 31/10/08 28. YA13 16(2)(m)( n)(3) 29. YA14 16(2)(m)( n)(3) People living at the home must be able to expect to access appropriate choices in fulfilling their lifestyles outside the home. Specifically the staff must have knowledge of what recreational services are available in the local community and how to promote the individuals access to these, and that this is recorded as part of their care plan. This is a repeat requirement not met within given timescales. 31/10/08 30. YA15 16(2)(m)( n)(3) People living at the home must be supported to develop and maintain relationships outside of the home, and this must be documented in their plan of care and include how staff will support this. This is a repeat requirement not met within given timescales. 31/10/08 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 33 31. YA16 12(4) People living at the home must be confident that the service will operate in a way that respects their choices and independence and that this is recorded in care plans. Specifically this relates to the provision of clear guidance to staff in supporting the services aims and objectives statements. This is a repeat requirement not met within given timescales. 04/10/08 32. YA18 12(4) People living at the home must be supported by staff that understands how to respect their choices, whilst protecting and maintaining their dignity. Specifically these choices must be documented in care plans. This is a repeat requirement not met within given timescales. 31/10/08 33. YA19 17(1)(a) Schedule 3 (3) (m) 31/10/08 People living at the home must be supported in maintaining their health and wellbeing. Specifically this relates to the way health needs are supported by care planning and the monitoring tools used to identify health issues as they arise. This is a repeat requirement not met within given timescales. 34. YA32 18(1)(a) People living at the home must be assured that the staff group will have sufficient skills to meet their assessed needs. Specifically this refers to the development of a training programme with associated budgeting to meet the aims and objectives of the services Statement of Purpose. This is a repeat requirement not met within given timescales. 04/10/08 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 34 35. YA35 18(1)(a) People living at the home must be assured that the staff group will have sufficient skills to meet their assessed needs. Specifically this refers to the development of a training programme with associated budgeting to meet the aims and objectives of the services Statement of Purpose. This is a repeat requirement not met within given timescales. 04/10/08 36. YA43 12(1) People living at the service must be 30/09/08 confident that there is effective management that understands how to improve the services compliance with the Care Homes Regulations 2001 and in providing good outcomes for them. Specifically the manager must ensure they are aware of the responsibilities and expectations placed upon them by the Care Homes Regulations 2001. This is a repeat requirement not met 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. Refer to Standard YA20 Good Practice Recommendations The Registered Person should ensure service users are encouraged and supported to retain and administer their own medication where able, within a risk management framework. The Registered Person should ensure policies and procedures are service specific and staff are aware of and understand the contents and apply these in practice. 2. YA23 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 35 3. YA40 The Registered Person should ensure policies and procedures are service specific and staff are aware of and understand the contents and apply these in practice. The Registered Person should ensure that service users responsibilities for housekeeping tasks (e.g. cooking, cleaning etc is agreed; according to and specified in individual support plans. The Registered Person should ensure that staff have clearly defined job descriptions linked to achieving service users individual goals as set out in the service user plan. The Registered Person should ensure that the contribution of volunteer workers does not replace paid staff roles and that volunteers do not undertake tasks, which are the responsibility of paid staff. The Registered Person should ensure that staffing levels day or night, are regularly reviewed to reflect service users changing needs, and maintain their health, safety and welfare. People should be able to understand clearly from policies, procedures and other records that they relate to the service and its ethos. Specifically this refers to the inconsistencies in the title the home is given in documents. 4. YA16 5. YA31 6. YA31 7. YA33 8. YA41 Hope House DS0000017926.V371189.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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