Inspection on 06/04/04 for Humphry Repton House

Care Home For Older PeopleHumphrey Repton HouseBrentry Lane Bristol BS10 6NAUnannounced Inspection6th & 27th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Humphrey Repton House Address Brentry Lane, Bristol, BS10 6NA Email address admin@aspectsandmilestones.org.uk Name of registered provider(s)/company (if applicable) Aspects and Milestones Trust Name of registered manager (if applicable) Ms Lynn Williams Type of registration Care Home No. of places registered (if applicable) 30 Tel No: 0117 9592255 Fax No: 0117 9709301Category(ies) of registration, with (number of places) Dementia (30), Dementia - over 65 years of age (30), Mental disorder, excluding learning disability or dementia (30), Mental Disorder, excluding learning disability or dementia - over 65 years of age (30) Registration number D050000329 Date first registered Date of latest registration certificate 1st August 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 17th February 2004 YES YES 24\10\02 If Yes refer to Part CHumphrey Repton HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 36th April 2004 09:30 am Sam FoxID Code072854Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMary Webb ­ Team co-ordinatorHumphrey Repton HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementHumphrey Repton HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Humphrey Repton House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Humphrey Repton HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Humphrey Repton House is operated by Aspects and Milestones which is a non-profit making charity. It is registered to accept people who are over the age of fifty who have dementia and who require nursing care. In addition to this they can accommodate up to five people for day care in the same category. The home is set on large grounds and is purpose built, as such it is fully accessible and has a number of aids and adaptations. There are three wings which are joined together in a cruciform style on the ground floor. Each have their own separate lounge and dining area as well as bathing facilities.Humphrey Repton HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The findings at this inspection indicated that Humphrey Repton continues to provide a good standard of care with a warm and friendly environment. Members of staff have the training and expertise to deliver a specialised service tailored to meet with the needs of people who have dementia. This inspection was conducted over two visits, the second of which was to meet with the manager. Findings from both these will be included within this report. All the standards were not assessed, however, and this report should be read in conjunction with others so that a fuller picture can be gained of the home. Humphrey Repton has employed a new manager who submitted an application in January. She is currently undergoing the fit persons process to become registered. During the course of the inspection it became apparent that the certificate of registration did not accurately reflect the service provided at Humphrey Repton House. At present this states that the home can provide support and accommodation for people who have both dementia other forms of mental health needs. The latter would not be appropriate for the service provided at home, which is tailored towards older people with specific forms of dementia, primarily associated with the ageing process. An agreement was made with the manager to change the certificate of registration so that it more accurately reflects this. Within this there will be a provision that, whilst the majority of residents should be 65 years or over, five of them can be 50 years or over. This will allow for the home to support people who develop dementia at a younger age. In addition to the above the home has requested to increase its day care provision to 6 due to the high demand for this service ­ the manager has been requested to put this proposal in writing to the Commission for Social Care Inspection (CSCI). Choice of Home (Standards 1-6) 4 of 4 standards assessed were met Humphrey Repton has a detailed Statement of Purpose which describes the facilities and services available in the home. They also have a brochure and a number of information leaflets, which enable residents and their relatives to make more informed choices about the future. Aspects and Milestones have an established admissions procedures and it was apparent that the home takes a careful and considered approach to this process so that they can be Humphrey Repton House Page 6 sure they will be able to meet needs. In addition to this they actively seek the support and advice of specialists who often supply assessments prior to admission. Health and Personal Care (Standards 7-11) 4 of 5 standards assessed were met Care plans are maintained to a good standard and provide a detailed picture of individual needs and the support required by each resident to lead a fulfilled lifestyle. They also evidence that the home takes a holistic approach to the provision of care which includes emotional, social and personal needs. Residents are fully supported to access the relevant health care professionals and the home seeks the advice of specialists when they need further guidance. Records held in relation to medication were generally found to be maintained to a good standard. The home must, however, carry out regular stock checks of medication given on an as and when basis. A requirement is also made that they develop guidelines in relation to tablets given on an as and when basis. Issues in relation to death and dying are dealt with in a sensitive and appropriate manner. It was apparent that there is an emphasis on maintaining the privacy and dignity of residents during this time. Daily life and Social Activities (Standards 12-15) 2 of 3 standards assessed were met One of the main philosophies of Humphrey Repton is to enable residents to determine their own routines and observation at the time of the inspection indicated that there is much freedom in the home. This is particularly important for a number of residents who are unable to directly verbally communicate their wishes and preferences. The home has a planned programme of activities throughout the week which are designed both to stimulate and for residents enjoyment. The input of friends and family is valued and encouraged. Complaints and Protection (Standards 16 ­18) 1 standard assessed was nearly met Aspects and Milestones have an established complaints procedure which meets with the requirements of the legislation. This is clearly displayed in the home. One complaint has been received this year and the manager was advised to log actions she has taken in relation to this. One relative said he would feel confident to speak with staff at any time if he had concerns. Environment (Standards 19-26) 6 of 8 standard assessed were met Humphrey Repton is purpose built and well designed for its purpose. There are a number of aids and adaptations throughout the home to assist people with impairments. Humphrey Repton House Page 7 All areas of the house were found to be well maintained, comfortably furnished and homely in appearance. Bedrooms are personalised and reflect individual tastes ­ indicating that choice and independence are promoted in this respect. There are a number of guidelines in place for the control of infection and the standard of cleanliness was good. One area of the home has an unpleasant odour and a requirement is made for the home to continue to explore ways to reduce this. Humphrey Repton has a distinct lack of storage space which has led to the bathrooms being used to house wheelchairs and lifting equipment. This has reduced the homely feel in these rooms. A requirement is made for the home to take action to create more storage space. Staffing (Standards 27-30) 3 of 4 standards assessed were met Staffing rotas provided evidence that Humphrey Repton meets with, and often exceeds, levels required by their staffing notice. Residents benefit from the support of a well trained and enthusiastic staff team. Clinically trained staff are encouraged to update their knowledge and all members of staff have received specialist training in relation to dementia care. Aspects and Milestones have an established recruitment procedure, which is designed to protect vulnerable adults. A requirement is made, however, that personnel information is retained on the premises. Management and Administration (Standards 31-38) 4 of 5 standards assessed were met The manager has a number of years senior management experience and is currently undergoing the fit persons process to become registered. It was apparent that she is well respected and has an open and transparent style. Members of staff take on delegated responsibilities and are aware of their roles within the home. They benefit from an established formal supervision system, which enables them to discuss concerns and develop work practice. There are established systems in pace for health and safety. Records in this respect are well maintained.Humphrey Repton HousePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Humphrey Repton HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 2 3 4 13(2) 13(2) 4(a) 22 OP9 OP9 OP10 OP16 Regular stock checks to be carried out of medication given on an as and when basis Guidelines to be written for the administration of medication given on an as and when basis All personal information to be discreetly stored Log all actions taken in respect of complaints made to the home Explore ways of creating additional storage space Further action to be taken to reduce unpleasant odour Personnel information to be retained on the premises 30\5\04 30\5\04 30\5\04 30\5\04 Action Plan: 30 June 2004 30\5\04 30\6\04523(2)(a)OP216 716(2)(k) Schedule 4(6)OP26 OP29RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. Humphrey Repton House Page 10 No.Refer to Standard * OP26Good Practice Recommendations1Further training to be sought for the housekeeper* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Humphrey Repton HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NA NO YES YES YES NO NO YES NO YES NO YES YES NO NO NO YES NO YES 9 1 X YES YES YES NO X X 6/4/04 8.30 13Humphrey Repton HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Humphrey Repton HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 680 To (£) XAny charges for extrasYESIf yes, please state what the extras are: toiletries, hairdressing 3 Key findings/Evidence Standard met? Humphrey Repton has a detailed Statement of Purpose which highlights the aims and objectives of the home and a number of the services to be provided. This is a detailed document which meets with all requirements of the legislation. There were dementia care guidelines displayed in the entrance to the hall. These were developed by specialists and members of staff team. They detail some of the aims of the home and describe good practice in relation to working with, and communicating with, people who have dementia. This gives visitors to the home some useful basic information. The home has a brochure and a service user guide. These were not looked at in detail during the time of this visit.Humphrey Repton HousePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not fully assessed during the visit and will be a focus of the next inspection.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Aspects and Milestones have an established admissions procedure which includes the need to have a full assessment prior to admission. This is included in the homes Statement of Purpose. There were initial assessments in personal files written by social workers and other professionals. In addition to this the home have developed their own assessment tool which focuses on cognitive need. The inspector noted that all staff are given a brief personal profile of new residents which detail their history and interests before they move in. This is good practice particularly because of the nature of the service provided in the home. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Humphrey Repton provides a service for people who have dementia. They also specialise in supporting people who display complex behaviours as a result of this. Records provided evidence that specialist support and guidelines are sought prior to admission. This enables the home to ensure that they can meet individual need and that they have the right support systems in place. The manager displayed an awareness of issues that needed to be discussed and analysed prior to admission. It was apparent that the home takes a careful and considered approach to this process.Humphrey Repton HousePage 15 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Members of staff confirmed that trial visits are encouraged and that relatives are also invited to look around the home.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard is not applicable.Humphrey Repton HousePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Opportunity was taken to look at three personal files. All of these were found to contain the following information: · · · · · · Personal details and profiles Daily input sheets Formal assessments and six monthly reviews Care plans Risk assessments and personal handling policy Activity profilesEach wing has a clinically trained member of staff who takes responsibility for co-ordinating care plans, reviewing information and updating risk assessments. The information seen in the files were found to be well maintained and written from a person centred perspective. They provided evidence that the home takes a holistic approach to the provision of care which takes in to account emotional, social and physical needs. Records provided evidence that family members and significant people are invited to care plan reviews and this was confirmed by one relative who showed the inspector a copy of the care plan they had received. Care plans also included identified risks and actions to be taken to reduce these, for example, in relation to the use of bed rails. Humphrey Repton operates a keyworking system through which each resident has a named member of staff who plays more of a central role in co-ordinating the services that they receive. Discussion with staff indicated that they had a good understanding of their roles in this respect and that it is used to achieve greater consistency.Humphrey Repton HousePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 1 13 Key findings/Evidence Standard met? Records seen at the time of this visit provided evidence that residents are supported to see the relevant health care professionals and associated specialists. Members of staff said that they benefit from having a supportive GP who is knowledgeable about dementia and keeps up to date on current medical developments. Staff explained that one resident has a pressure sore that they developed whilst in hospital. The inspector noted that there were guidelines in relation to this and that pressure relieving equipment was available. Personal files seen also contained an up to date Waterlow Risk assessments. There were records to evidence that residents are supported to see dentists and opticians.Humphrey Repton HousePage 18 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The home operates a monitored dosage system for the administration of medication that is delivered at regular intervals by the local pharmacist. Records held on relation to the handling, administration and disposal of these were found to be maintained to a good standard and met with the requirements of the legislation. The home holds some controlled rugs ­ the inspector noted that these are stored appropriately and that a register is maintained. The home was advised that they need to carry out regular stock checks on medication that is given on an as and when basis. Discussion took place about ways in which this could be achieved. In addition to this guidelines need to be written for those residents who have prn medication designed to alter their moods ­ these should include trigger points and methods which staff may wish to use before using tablets. There was an in- house medication policy available and a needle stick contamination procedure. Currently Humphrey Repton does not accommodate anyone who requires oxygen. The team co-ordinator explained that they have developed a medication profile for each resident. This describes the tablets they take, the reasons for this and, crucially, how they like to take it. Some residents have lost the ability to swallow tablets whole and may need their tablets crushed for them. The home have devised a form through which they will seek both the GPs and advocates consent for this. This is a positive development and indicates that the home endeavours to promote and protect human rights.Humphrey Repton HousePage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Care plans included good detail in relation to personal care needs and individual preferences. They would enable new members of staff to support residents in a way that is tailored to suit them. The home is currently experiencing difficulties with one resident with their personal care needs. It was apparent, through discussion with the manager and staff, that the home has sought creative responses to this and that they are reflective about working practice. This is good practice. The inspector was impressed by the way that members of staff spoke with residents. They were respectful and communicated in a calm and sensitive manner which was tailored to individual need. The inspector noted that there was some information about a resident relating to their personal care openly displayed. In order to protect the dignity and privacy of individuals, such information should be more discreetly displayed. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 4 Key findings/Evidence Standard met? Aspects and Milestones have a number of formal policies in relation to death and dying, including guidelines of action to be taken in the event of sudden death. Members of staff explained that the majority of residents are supported within the home if they have a terminal illness and if it is apparent that they are dying. There are clinically trained nurses on the premises who are able to deliver the appropriate nursing care with advice from the GP. It was apparent that there is an emphasis on maintaining the privacy and dignity of residents during this time. Care plans included arrangements to be made in the event of death and of spiritual needs that have to be taken into account, for example, due to religious persuasion. It is important that staff obtain this knowledge from family and friends, as residents may not be able to remember this. One relative showed the inspector a pamphlet developed by the home which discussed issues in relation to death and dying. He said that, whilst this is sensitive and difficult subject, it has helped him to ensure that the appropriate arrangements are in place. Members of staff said that they talk about issues in relation to death and dying and that they are supportive of each other during this time. The manager said that she provides time for staff to talk about these issues and gave examples where this has been used to good effect.Humphrey Repton HousePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? One of the main philosophies of the home is to allow residents to have the freedom to dictate their own routines and to develop their own means of communication. This was apparent during the inspection. The inspector observed that residents are able to get up when they choose and have meals when and where they choose. They also had unlimited access to all areas of the home. The manager explained how important it was to promote choice and freedom for residents, many of whom are unable to directly verbally communicate their wishes. She said that, whilst there are some boundaries in place for the protection of residents, the home endeavours not to impose rules and that if they were to do so then this would have a detrimental effect on residents welfare. There were details of activities displayed throughout the home and it was clear that staff encourage visitors and family to become involved in these. Events organised included singa- longs and exercise groups. In addition to this the home employs activity co-coordinators who have planned programme of activities throughout the week. There were tea and coffee facilities available for family and friends. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The inspector observed a number of family and friends visiting during the inspection and it was apparent that there were no restrictions on this. One relative said that he visits the home every day for a number of hours and that he was pleased and felt valued by members of staff. This is good practice.Humphrey Repton HousePage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed during the visit.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? Opportunity was taken to observe the serving of breakfast and to join residents with their main meal which was fish and chips. Generally residents were served in a calm and sensitive manner. The inspector observed, however, one member of staff assisting a resident to eat whilst standing up. This would not be considered acceptable practice. The housekeeper explained that there were always two main choices available and she displayed an awareness of different dietary requirement related to medical need. For example some residents are on low fat diets and one resident is allergic to fish.Humphrey Repton HousePage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 1 X X X 1 X 100 2Key findings/Evidence Standard met? Aspects and Milestones have an established complaints procedure which includes timescales for action to be taken. This meets with requirements of the legislation.The complaints procedure was displayed in the entrance to the home. This was written in plain English and provides the contact number of the CSCI to which concerns can also be made. There has been one complaint made this year and a senior manager within Aspects and Milestones has responded to this. The manager was advised that she needs to log actions taken as a result of this. One relative said that he found staff approachable and that he would feel confident to speak with them or the manager if he had any concerns.Humphrey Repton HousePage 23 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not fully assessed during the visit and will be a focus of the next inspection.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists X X0 Key findings/Evidence Standard met? Although discussed, this standard was not fully assessed during the visit and will be a focus of the next inspection.Humphrey Repton HousePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Humphrey Repton House is situated in large grounds and is purpose built. It has an enclosed courtyard and the garden provides a secure area to which residents can have unlimited access. These areas were found to be well maintained. In addition to this the home has established a sensory garden which provides further stimulation for residents. The living area of the home is situated on the ground floor ­ there is a second story, which is used by staff and administrators. It has three wings which are distinct and identified by colour. Each are accessible and follow in a circle around a courtyard. The inspector observed that residents have unlimited access to all communal areas of the home. There is a staff room and training area as well as a main office which are all located on the first floor. Members of staff said that they were pleased to have this additional space away from the main building in which to relax. The inspector found the home to be cleaned to a good standard, well maintained and homely in appearance.Humphrey Repton HousePage 25 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? Each wing has its own communal area which consists of both a dining facility and lounge area with a television. These areas have recently undergone redecoration, with the addition of new fireplaces and carpets. They were found to be homely in appearance and comfortably furnished. There is a separate activity room which was being redecorated at the time of the inspection. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? Humphrey Repton has sufficient bathing and toilet facilities to meet with the needs of those residents currently accommodated. They also have specialised bathing facilities including a high\low bath. During this visit the inspector noted that the bathrooms were being used as storage spaces and as a consequence housed wheelchairs and lifting equipment. This significantly reduced the homely feel of the bathrooms and created an institutionalised feel to these areas. Discussion with the manager indicated that this equipment is moved when residents have a bath but that the lack of storage space has been a source of frustration for staff. Discussion took place about ways in which these difficulties can be resolved and the inspector noted that the home is situated on large grounds, part of which could be used for additional storage space. A requirement is made that the home explores ways in which they can provide additional storage. In addition to this the inspector noted that some toiletries were left in bathrooms. This could represent a health and safety risk in terms of residents ingesting dangerous chemicals. Members of staff said that this would not be normal practice and undertook to remove these.Humphrey Repton HousePage 26 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? As noted earlier in this report Humphrey Repton is purpose built and as such has a number of aids and adaptations. All areas of the home are fully accessible, including the garden, and have wide corridors. All residents areas have low ­ level sills enabling them to look out at the garden. The home has electrical hoists, electric beds and various manual handling equipment. In addition to this there are specialised bathing and toilet facilities. The home has an emergency call bell system.Humphrey Repton HousePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 30 X X X 30 XX X X X3 Key findings/Evidence Standard met? Humphrey Repton meets with this standard although no rooms have ensuite facilities.Humphrey Repton HousePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Opportunity was taken to view a number of bedrooms. These were found to be personalised and to reflect individual tastes. It was apparent that residents are encouraged to bring in small items of furniture and to make their rooms homely. Some residents chose to have their rooms locked throughout the day and there were instructions for staff about personal preferences in this respect. Discussion took place with the manager about the dilemmas of maintaining peoples privacy whilst also enabling residents to have unlimited access to were they want to go throughout the home. This can cause some difficulties. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? All areas of the home were found to be bright with both natural light and domestic style lighting. It was well ventilated and heated to a suitable temperature. There is emergency lighting throughout the home. There was a certificate to confirm that the water systems had been cleaned in September 2003and a hand test of hot water indicated that temperatures are being kept to within safe levels.Humphrey Repton HousePage 29 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? Generally all areas of the home were found to be cleaned to a good standard. Opportunity was taken to talk with the housekeeper who co-ordinates the cleaning of the premises. She displayed a commitment to providing high standards and is responsible for the supervsion of other housekeepers and of ordering cleaning materials. She displayed a good awareness of health and safety issues and of the homes responsibilities under the Control of Substances Hazardous to Health (COSHH). Cleary the housekeeper has a wide range of responsibilities and is enthusiastic about her role. A recommendation was made that the home seeks more formal training for her in relation to COSHH and health and safety issues ­ this would enable her to develop in her role. The inspector noted that the home had polices in relation to infection control, these were, however, not looked at in detail at the time of this visit. The home also has a policy in relation to the disposal of clinical waste and there were specialist storage facilities available to enable them to achieve this safely. There is a sluice disinfector in the home and adequate laundering facilities which are equipped with industrial dryers and separate hand washing facilities. One wing was identified as having an unpleasant odour and discussions took place with the housekeeper about ways in which staff have tried to reduce this. It was apparent that they have made strenuous efforts to resolve this difficulty. Further action, however, needs to be taken to reduce this odour and this may necessitate the replacement of furniture or flooring.Humphrey Repton HousePage 30 Humphrey Repton HousePage 31 StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 3Humphrey Repton HousePage 32 Staffing rotas provided evidence that, as a minimum, there are seven staff on duty throughout the waking day. Two support workers are based on each wing and a qualified member of staff oversees the shift. In addition to this there are ancillary staff including housekeepers, administrators and activity co-ordinators. These staffing levels meet with, and often exceed, the homes staffing notice. Throughout the night there is a support worker allocated to each wing and one clinically trained member of staff. There are particular staff allocated to each wing. The manager said, however, that all are expected to know the needs of every resident so that they can work effectively as a team. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 X X 0 Key findings/Evidence Standard met? This standard was not fully assessed during the visit and will be a focus of the next inspection.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Aspects and Milestones have an established recruitment procedure which is based on the use of completed application forms, the obtaining of references and police checks. This culminates in a formal scored interview. There was no staffing information available. This continues to be the subject of discussion with the CSCI and will remain a requirement until the issue is resolved. Records provided evidence that all existing staff have had criminal checks.Humphrey Repton HousePage 33 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Members of staff consulted with said that there were lots of opportunities to train and they were pleased with the support they receive from Aspects and Milestones in this respect. The clinically trained staff are also encouraged to keep up to date with current good practice which enables them to update their portfolios and retain their Pin numbers. The manager said that she has identified areas that need updating, including pressure care. One member of staff confirmed that a number of staff have recently benefited from a four day training course relating to dementia care which included assessment, evaluation and treatment approaches. She said that the home has benefited from this specialised training and used information gained to reflect on work practice and improve upon the standards of care. The inspector was of the opinion that the home values training and this is used to improve services within the home and the quality of lives for residents. There was evidence to confirm that staff have received statutory training including manual handling, first aid and health and safety.Humphrey Repton HousePage 34 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The new manager has been in post for a number of months and is currently going through the fit persons process to become registered under the Care Standards Act. Prior to this she was deputy at the home and is familiar with the surrounds and has a number of years senior management experience. The manager is a registered nurse and discussions with her indicated that she has undertaken a number of courses to update her knowledge and improve her managerial expertise. The inspector noted that she displayed a clear awareness of her responsibilities within the home and of the legal responsibilities. It was also apparent from discussions with her that she had an in-depth knowledge of the needs of people with dementia and a creative and reflective approach to service provision.Humphrey Repton HousePage 35 Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? All members of staff consulted with spoke positively about the management structure within the home and of the manager, who they said was open and approachable. Staff have delegated tasks and specific areas of responsibility and it was apparent from discussion with them that they valued this and were clear about their roles within the home. There were minutes of staff meetings available that take place at frequent intervals. Members of staff said that they find these useful in terms of ensuring consistency and that it provides them with a means to influence work practice. This is good practice. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not fully assessed during the visit and will be a focus of the next inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not fully assessed during the visit and will be a focus of the next inspection.Humphrey Repton HousePage 36 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 Key findings/Evidence Standard met? This standard was not fully assessed during the visit and will be a focus of the next inspection. X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Humphrey Repton has an established system for the formal supervsion of staff and this was confirmed through records and discussion with staff. It was apparent that this is effective and that the team valued time to talk about their work and have an opportunity to discuss ways in which they could develop their work practice.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All those records seen at the time of this visit were well maintained and written in a sensitive and respectful manner so as to protect the dignity of residents. All personal information is kept in locked cabinets in the office upstairs.Humphrey Repton HousePage 37 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The fire logbook provided evidence that tests and checks of the alarm system take place at the appropriate intervals. It was noted that in previous months there was some inconsistency with the weekly testing of the fire alarm systems. This was because it was the responsibility of one member of staff and when she was not there it was not always carried out. The manager explained that they have now changed this system and a certain day of the week has been identified for this test to be carried out. This should improve consistency. There was a workplace fire risk assessment available. Lengthy discussion took place with the team co-coordinator about the fire procedure within the home. There are a number of fire exits and areas to which residents could be evacuated to ­ for example in the secure garden area. The fire logbook indicated that staff have refresher training at regular intervals and that drills take place throughout the year. Electrical portable appliance testing was taking place at the time of the inspection. There were up to date records in relation to fridge and freezer temperatures and information available in relation food hazard analysis. There was a certificate relating to a gas safety check carried out on 29\3\04 There was evidence to confirm that the pin numbers of clinically trained staff are checked annually to ensure that they are still in date.Humphrey Repton HousePage 38 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSam Fox Not Applicable Lyn Davis 16th June 2004Signature Signature SignatureHumphrey Repton HousePage 39 Public reports It should be noted that all CSCI inspection reports are public documents.Humphrey Repton HousePage 40 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.Please limit your comments to one side of A4 if possible We are now undertaking a regular stock take of medications used on an as and when basis, and this will be carried out monthly. All of our residents who have as and when medication will have care plans around the need for this medication and why this medication needs to be used. Any personal information about a resident is now stored in a care file which is in a lockable filing cabinet or kept in their bedrooms if it is needed for direct nursing care. Complaints and any action taken regarding the complaint is logged in our complaints book. Storage has always been a problem at Humphry Repton House but I have some ideas which I am discussing with our facilities manager next week. (28th May 2004) The odour was in one particular part of the house and even after various cleaning fluids were used the odour would not go, now the old flooring has been removed and new flooring put down which appears to have rectified the problem. I will discuss with personnel the possibility of holding personnel information here at Hunphry Repton House.Humphrey Repton HousePage 41 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 3rd June 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOHumphrey Repton HousePage 42 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation DateHumphrey Repton HousePage 43 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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