Inspection on 05/06/06 for Inglemere

This inspection was carried out on 5th June 2006.

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

The inspector found 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Inglemere 21/09/07

Inglemere 19/12/05

Inglemere 31/05/05

Inglemere 29/10/04

Inglemere 21/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Inglemere 2 Pollards Hill East Norbury London SW16 4UT Lead Inspector Barry Khabbazi Key Unannounced Inspection 5th, 13th and 15th June 2006 9:00am Inglemere DS0000025798.V297863.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 Inglemere DS0000025798.V297863.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. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglemere Address 2 Pollards Hill East Norbury London SW16 4UT 020 8679 6726 020 8679 6726 NO EMAIL 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) Surrey Oaklands NHS Trust Mrs Melanie Davies Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Inglemere provides residential care for up to nine adults with moderate to severe learning disabilities. Some service users are also visually impaired. Each service user has their own bedroom, which is decorated to suit their individual tastes. The home is situated on a corner plot surrounded by gardens and a patio area. The home has a communal lounge area as well as a dining room. It is within walking distance of Norbury high street and transport links. The home is close to the Croydon /Merton boundary. . Fees for this home are from £1194.00 per week. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key un-announced key inspection focused on all the key standards, following up on previous requirements, and new issues identified during the inspection. The current manager was on leave at the time of this inspection and was anticipated to be going directly from this leave on to Maternity leave. This meant that the deputy manager was the officer responsible for the home during this inspection period. This inspection was slightly longer than the normal duration, as it had to be split over separate days. On the first morning there was no member of management present to provide documentation relating to all the key Standards {e.g. staff files etc.} so this part of the inspection was mainly used to talk to service users and observe the morning care. A second visit was then arranged to meet the deputy manager and gain access to staff files etc. The deputy manager was not able to provide a time where she would have time for the inspection process until 8 days after the first visit, and then only could offer about an hour. This raised concerns about the availability of management to participate in management tasks, which has been addressed in this report. At this second visit it was also discovered that the deputy did not have access to staff files. Due to the limited time made available to the inspector, and the need to examine staff files a third visit was then arranged to meet a service manager. This inspection report therefore refers to all the visits required to complete this inspection. During this inspection period, the service users were met, a staff member and the deputy were interviewed and two service managers were met. Records, staff files, policies, care plans, and the building were examined. What the service does well: The service manager has plans in place to temporarily transfer another manager from the organisation to this home, while a temporary manager’s post is being recruited to. This should address the drift in standards identified in this report. All the residents now have a ‘person centred’ plan of care. This is seen as good practice as service users are involved in producing these which therefore records care needs from a service user’s perspective. It was seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in Rectal Diazepam usage. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the Statement Of Purpose contains most of the information required it is not yet complete, completing this will help relatives and placing social workers to have a good picture of what the home provides and help them choose between different homes. {Time was not made available to assess implementation of this requirement.} The service users guide is still not satisfactory as it does not contain the views of the residents. This is important so that new residents can be clear about how other residents feel about living in this home. The care plans still do not reflect all of a resident’s needs. This could affect the staffs’ knowledge of the needs of the residents and therefore their ability to meet them. To ensure that all of a service user’s needs and changing needs are known, plans of care must be reviewed by the home on a 6 monthly basis. Risk assessment guidelines are not always be followed, and specifically in this instance, where directions to promote dignity and privacy were recorded but not followed. Staff must use their separate facilities to store their belongings, and should not leave their bags and coats in the service users’ communal or individual space as this practice does not promote dignity and respect for the service users, or their space. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 7 Residents do not always receive support in the way they require. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty {for example the kitchen gate is locked denying access to all service users}, and in addition risk assessments do not contain all the information required, in particular, details of how training and other options have been explored to avoid the limitations of liberty. Including this information could reduce unnecessary restrictions of liberty for the residents. Restraints Policies and guidance are not known to all staff. Residents do not have sufficient opportunities to be part of the local community and to take part in appropriate activities. Although holidays are available, residents do not receive the placing authority funded holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for residents that they do not have to contribute towards. Although the food provided is sufficient in quantity and is now more nutritious, there was no evidence that the dietician’s strategies for improving the nutritional quality of the food that the residents actually eat were being implemented. This is important to ensure good health. Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this the involvement of the residents and relatives could be limited. The home must ensure that at least 50 of staff have an appropriate care qualification, i.e. a NVQ 2 in care. To ensure staff are appropriately supervised, staff must receive a minimum of six regular supervision sessions per year. To facilitate completion of management tasks {which includes providing information to inspectors} the provider must ensure that sufficient and suitable management staff are employed. The requirements of the recent 5 year wiring test must be implemented to promote safety at the home 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. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Although the home provides most of the information needed for potential residents to make an informed decision about moving in to the home, the residents do not have all the information they need. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard has been previously met. EVIDENCE: The last report contained the following requirement under Standard 1: The service user guide should be in a format suitable for the service users. Since that time the service user guide has been produced in a symbol format and a taped version. This requirement is now thefore met. The last report also contained the following requirement under Standard 1: The service users guide must contain the views of the service users. The deputy manager said she did not know if this had happened and the residents ‘service users guides’ sampled did not contain this information. This requirement therefore remains in force. The last report also contained the following requirement under Standard 1: Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 10 The Statement Of Purpose must specify room sizes and both the Statement and the service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. Due to the limited time made available to the inspector, the inspector decided to focus on key Standards and service users. This particular requirement was therefore assessed as not directly affecting care and will therefore be assessed for compliance at the next inspection. This requirement will therefore remain in force until it can be fully assessed. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard has been previously met. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and, 9. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ assessed needs, and how the home meets these needs, are not fully recorded. In addition reviews of the plans of care are not happening regularly. This could affect the home’s ability to meet all a resident’s needs. Service users are supported to make decisions about their lives. Service users are not appropriately supported to take risks as part of their independent lifestyle, as risk assessments do not contain all the information required to facilitate minimising restrictions of liberty for the residents, and risk assessment guidelines are not always followed. EVIDENCE: The last inspection report contained a requirement for a record of all of a service user’s needs and how they are to be met and by whom, to be recorded in their plans of care. The care plans have been re-written and are much improved and more holistic. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 12 However, the care plans still do not reflect all of a resident’s needs. For example, support at mealtimes and educational and spiritual needs. This could affect the staffs’ knowledge of the needs of the residents and therefore their ability to meet them. This requirement remains in force. The last inspection report contained the following recommendation: Daily notes should be recorded daily and reflect how the care plan was implemented on that day. There had been a marked improvement in daily notes, those sampled are now recorded on a daily basis. This recommendation is met. Care plans examined had not been reviewed by the home on the six monthly basis required as a minimum under Standard 6. The following requirement is now set to address this: Plans of care must be reviewed by the home on a 6 monthly basis. Standard 7 requires that staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. Requirements to facilitate and evidence this process have been made under Standard 9 below. There, risk assessments are required to be amended to refer to the above parameters and therefore evidence the above process fully. Although a minor shortfall in meeting this Standard therefore exists, a requirement has already been made and will not be duplicated here. The last inspection report contained the following requirement under Standard 9: The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty are assessed as necessary for the protection of service users. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty, for example the locked kitchen gate denies access to the kitchen for all service users. The existing requirement regarding this will remain in force until fully met. The last inspection report contained the following requirement: Risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. This has not occurred. The existing requirement regarding this will also remain in force until fully met. Risk assessment guidelines are not always followed. A baby monitor is used to monitor a service user at night until he goes to sleep. The monitor receiver was on, in the residents’ lounge on the first and second mornings of the inspection, despite guidelines stating that it should be turned off at night once the service user goes to sleep. Although this creates a further shortfall under Standard 9, a requirement will be set under Standard 18 which refers to Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 13 dignity and respect as a number of other dignity and respect issues were uncovered and addressed there. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users do not have sufficient opportunities to be part of the local community and to take part in appropriate activities. Service users do engage in appropriate leisure activities and holidays, although the residents do not receive all the placing authority funded holidays they are entitled to. Service users rights are not always respected. The food provided is sufficient in quantity, and it is sufficiently nutritious, but evidence of staff encouraging residents to follow dietary plans was not available. EVIDENCE: Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 15 The last inspection report contained the following requirement: The home manager must develop the range of fulfilling activities available to service users in and out of the home. This affects both the activities and community interaction Standards. These are still limited with infrequent weekend outings. The expectation would be evening outings during the week and additional outings at weekends. The deputy told the inspector that more outings were occurring but had not been recorded. The requirement remains in force untill fully met. Residents are offered a holiday with £150 of extra staffing hours. The residents are currently required to pay for the cost of the holiday themselves. The last inspection report contained a recommendation for each service user to be offered a seven day holiday. Holidays are still funded by the service users and not the organisation. The existing recommendation remains in force. The staff team at Inglemere encourage service users to remain in contact with their family members. There is an open visitors policy. The home has regular social events, such as a Christmas party. Family and friends are invited to any social events held at the home as well as reviews. The home has a key worker system and it is part of their role to keep parents and carers informed of their progress. Visitors can be seen in any of the home’s communal areas as well as the service users’ bedrooms. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. At the weekends there is more flexibility with breakfast and bedtimes. Staff do not always respect residents rights, see Standard 9 and 18 for details where requirements have already been set regarding this. The menu at Inglemere is based on a four-week rota, which reflects the likes and dislikes of the residents. The dietician employed by the Trust then checks the menus. Referrals to the dietician are made where required. Alternative meals are provided if the service users do not like the main option. The last report recorded that ‘a number of residents are of low weight and records showed that they are continuing to lose weight. For instance, in one case a drop from a low 43 kg to 40 kg was recorded. Communications with the dietician identified that this was due to the staff not encouraging residents sufficiently to follow dietary plans.’ The following recommendation was set at that time. The home should devise a coherent strategy for balancing a resident’s food choices with appropriate encouragement for nutritional requirements. This strategy should be recorded and its outcome included in daily notes. Daily notes sampled at this visit did not evidence implementing the dietician’s dietary plans. However the menu had improved in nutritional content. The recommendation remains in force. This area should be examined in detail at the next inspection where a requirement will be set if necessary. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents do not always receive personal support in the way they require. Residents’ physical and emotional health needs are generally met. Residents’ medication is well managed to ensure maximised good health. EVIDENCE: The last report recorded the following: Three staff bags, two coats and a jumper were observed on furniture and the floor in the service users’ lounge. Staff do have separate facilities to store their belongings and should not infringe on the service users’ space. On the first day of this inspection, three staff bags and one coat were again stored in the residents’ lounge. As this poor practice has continued after being pointed out in the last report, it now represents a clear lack of respect for the residents, their space and their rights. As this practice has continued the previous recommendation now needs to be replaced with the following requirement: Staff must use their separate facilities to store their belongings, and should not leave their bags and coats in the service users’ communal or individual space Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 17 Care plans did not contain all the information required and had not been reviewed with the required frequency. This affects the staffs’ ability to know all a service user’s care needs, their changing needs, and how to meet them. Although this creates a shortfall under Standard 18 {personal care}, a requirement has already been set under Standard 6 and does not need to be repeated here. Risk assessment guidelines are not always followed. A baby monitor is used to monitor a service user at night until he goes to sleep. The monitor receiver was on, in the residents’ lounge on the first and second mornings of the inspection, despite guidelines to minimise loss of dignity stating that it should be turned off at night once the service user goes to sleep. This meant that anyone in the lounge on those days could have overheard any noises in the service user bedroom removing any privacy on these days. Although this creates a further shortfall under Standard 9, a requirement will be set here under Standard 18 which refers specifically to dignity and respect. The following new requirement is now set: Risk assessment guidelines must always be followed, and specifically in this instance, where directions to promote dignity and privacy are recorded. On the 26 of April 2005, an early morning additional inspection occurred. The residents were observed to come down into the lounge without any staff supervision or support. A blind resident was seen to be confused and could not find a chair. This resident eventually sat down on a chair that another resident was sitting in. The resident already in the chair became very distressed and attempted to hit the blind resident. The inspector guided the blind resident into a vacant chair before an incident occurred. The following requirement was then set to address this lack of staff personal support and guidance observed: Staff must always provide adequate supervision, support and guidance for the residents. At the time of the following inspection, it was again noticed that residents were left to go from breakfast to the lounge unsupervised. It was however noted that the period left alone was shorter than last time. This requirement remained in force at that time. On the first day of this inspection it was again noticed that for a period of an hour no staff were present or observing the lounge and dining room. There were service users in both areas, some waiting for support with breakfast and some in the lounge. None were observed to receive any support at this time. The requirement therefore remains in force. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 18 Healthcare needs are recorded in the service users’ files. Service users are supported to attend outpatient appointments and other medical appointments as required. The service users at the home are registered with a local G.P. They are able to access community health facilities such as opticians and district nurses as required. The service users also have access to dentists and chiropodists. District Nurses and other healthcare professionals attend when required and meet service users in private. It was seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in rectal diazepam usage. The home has a copy of the British Medical Association guide to medication and a copy of the British National Formulary in place. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept securely in a locked metal cabinet fixed to the wall. This home uses a controlled register when controlled drugs are used. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s policies and procedures relevant to protection are not all known to staff and therefore do not fully facilitate protecting residents from abuse. Complaints are generally managed well and there were no complaints since the last inspection. EVIDENCE: The last annual inspection report recorded the following: ‘The organisation has its restraints policy and guidance spread over 3 separate documents. The home was only able to produce one document containing limited restraints guidance called “Responding to Aggression and Violence” policy and procedure. This states that physical restraint should only be used as a last resort and should be recorded to justify the action taken. This did not contain any guidance about what forms of restraint were acceptable and which forms were not acceptable, for example holding clothing instead of flesh to avoid damage to service users. A brief minor unplanned restraint was observed during breakfast, where a member of staff pulled a service user by the arm to the dining table. The following requirement is therefore set: Guidance regarding the use of unplanned restraint and guidance regarding acceptable forms of restraint, and the use of other techniques to avoid restraint must be made available to staff and these procedures must be known by them. Although this guidance has now been produced, only the deputy manager had signed to confirm they had read and Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 20 understood it. The requirement will therefore remain in force until these procedures are known by staff.’ At the following inspection the shift leader could also not find the required policies or the sheet signed to confirm staff had read and understood this. Although the manager may have been able to find these, all staff needed to be aware and understand these procedures fully. The requirement therefore remained in force. At this inspection, the senior staff member interviewed was not able to describe this policy and guidance and told the inspector that although she was not familiar with them she would soon be going on training regarding this. This now represents three inspection years where staff interviewed have not been aware of restraint guidance and now therefore represents a major shortfall. This requirement therefore still remains in force. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and, 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The environment and furniture generally meet the residents’ needs, although the environment does not always promote the residents well being. Service users’ bedrooms generally promote independence and contain all the furniture required. The home is not particularly hygienic and clean. This environment therefore does not fully facilitate the residents’ health and emotional well-being. EVIDENCE: Requirements under Standard 18 regarding the residents’ environment not being respected by staff also affect Standard 24 and does not promote the residents’ well being. However, a requirement will not be repeated here. See Standard 18 for details. The building is generally well maintained with regular maintenance provided by the Trust’s works department. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 22 The last few inspection reports have highlighted concerns about the level of service user supervision provided at the home. See Standard 18 for details. The positioning of the dining room and lounge are at opposite ends of the building, with no direct line of sight from one room to another on the ground floor. This makes indirect observation difficult, for example, staff in the dining room have to walk around a corner and down a corridor to see into the lounge. The inspector also found it impossible to observe both these areas at once or even within a short period of time. The following recommendation is set to explore this: The provider should examine the suitability of the current layout of the building and explore whether it is conducive to safely meeting the care needs of the service users, based on current staffing levels. The last inspection report contained the following requirement: Service users’ rooms must contain all of the items listed in Standard 26.2, unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. This has now occurred and this requirement is met. The last annual inspection report recorded that there were no general or individual occupational therapist assessments for aids and adaptations available for inspection. In addition there were no specialist assessments or equipment for the service user with a sensory impairment or the service user that uses a wheelchair. The following requirement was then set to address this shortfall: The home must acquire an occupational therapist’s assessment for aids and adaptations for the general environment and individual service users. This has now occurred and this requirement is met. The home has specific policies on the disposal of clinical waste, infection control and Control of Substances Hazardous to Health. There are laundry facilities with a sluice and an industrial type machine, which is capable of washing at high temperatures. The laundry is separate from the kitchen and has floors and walls that are easy to clean. The cleanliness of the home was borderline at best, but definitely not tidy at the time of the unannounced inspection. As a cleaner is about to be recruited this area will be monitored and requirements only made if the service manager’s strategy for improvement in this area does not bring the improvements needed. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, and 36. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are not appropriately qualified to meet the residents’ needs. The home’s recruitment procedures protect the residents through vigorous staff vetting. Staff are not satisfactorily supervised at this time. This therefore does not ensure good practice and a continual improvement of practice. EVIDENCE: An initial ‘in house’ induction is provided for all staff from their starting date. There have been no new staff since 2000. This Standard will therefore be examined in more detail once a new staff member starts. At that time the required 6 weeks induction and six month foundation training to Sector Skills Council workforce training targets will be inspected. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 24 Staff recruitment files were examined and found to be in order. There are now 4 /12 fte staff with a NVQ 2 qualification. This falls short of the 50 ratio required under Standard 32. The following requirement is therefore set under Standard 35: The home must ensure that at least 50 of it’s staff have a NVQ 2 in care. Supervision records were sampled. These did not meet the six regular sessions per year required under the Minimum Standards. For example, one record examined showed only one supervision session for the first 6 months in 2006. At least 3 should have occurred. The following requirement is set to address this: The provider must ensure that staff receive a minimum of six regular supervision sessions per year. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visits to this service. The home does not currently have a manager working at the home {see summary}, and has also had previous gaps in management. The home is therefore not currently well managed. Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this, the involvement of the residents and relatives could be limited. The environment is generally safe although the recent wiring test did raise concerns that need to be addressed. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home’s previous manager left in 2005 leaving the deputy to cover until a manager was recruited. The deputy’s post was not covered at that time and a requirement was set for sufficient management cover. This was then met by the employment of a new manager in October 2005. This manager has been on leave since the 9th of May and was expected by the deputy to then go on to maternity leave. This only allowed the current manager a period of just over 6 months to engage in the management of the home. As of now the home is in the same position as when the previous manager left, i.e. the deputy covering her own post and the manager’s post. The providers intend to recruit a temporary manager until the current manager returns and have one of their own managers cover until recruitment is successful. There has been a significant drop in quality under the management Standard due to the above periods of inconsistency and one member of the management team covering both posts. This is reflected in the number of requirements unmet since 2004, and the number of new management requirements in this report. This is also reflected by the deputy stating that she did not have the time to meet the inspector {see also Summary where only one hour was offered over an 8 day period}. In addition the staff supervision is not occurring with the minimum frequency {see Standard 36 where a requirement has been made.} The following requirement is set to address these concerns: The provider must ensure that sufficient and suitable management staff are employed to facilitate completion of management tasks{which includes providing information to inspectors}. The last annual inspection report contained the following requirement under Standard 39: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home should also ensure that an annual development plan is produced and is open to the service users, to allow measurement of achievement in improving quality. An annual development plan is still needed and this should reflect recent user satisfaction surveys where appropriate. In addition this information needs to be feed back to the service users to make them central to the process. This requirement remains in force until fully met. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 27 At the last inspection, the front gate was dragging on the floor whilst the inspector was trying to open it making it difficult to open. The following requirement was set to address this: The front gate should be repaired to improve ease of use and access for the service users. This has now occurred and this requirement is now met. At the last inspection, an up to date 5 year wiring certificate was not available. The following new requirement was then set to address this: An up to date 5 year wiring certificate must be sent into the Commission. This has now been received and this requirement is therefore met. However, concerns were raised about the safety of the wiring so the following new requirement is now set: The requirements of the recent 5 year wiring test must be implemented. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 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 3 23 1 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 3 x 1 x 2 x x 2 x Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 29 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 123 Requirement Timescale for action 01/08/06 2. YA1 3. YA6 4. 5. YA6 YA9 The Service Users Guide must contain the views of the service users. {Timescale of the 1/12/2004 not met}. 41C The Statement Of Purpose must specify room sizes and the S.O.P. and service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. {Timescale of the 1/12/2004 not met}. 15 A record of all of a service users needs and how they are to be met and by whom must be recorded in their plans of care. {Timescale of the 1/12/2004 not met}. 15 Plans of care must be reviewed by the home on a 6 monthly basis. 171a 137 The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty or preplanned restraints are assessed as necessary for the protection of service users. {Timescale of the 1/9/2004 not met}. DS0000025798.V297863.R01.S.doc 01/08/06 01/08/06 01/09/06 01/08/06 Inglemere Version 5.2 Page 30 6. YA9 137 Risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. {Timescale of the 1/9/2004 not met}. The home manager must develop the range of fulfilling activities available to service users in and out of the home. {Timescale of the 30/4/2004 not met}. 01/08/06 7. YA12 16. (2)(m)(n) 01/08/06 8. YA18 9. YA18 10. YA18 11. YA23 Staff must use their separate facilities to store their belongings, and should not leave their bags and coats in the service users communal or individual space. {From the last inspection} 12[4]a Risk assessment guidelines must always be followed, and specifically in this instance, where directions to promote dignity and privacy are recorded. 12[4]a b Staff must always provide adequate supervision, support and guidance for the residents. {Timescale of the 01/07/05 not met}. 17 1214b Guidance regarding the use of unplanned restraint and guidance regarding acceptable forms of restraint, and the use of other techniques to avoid restraint must be made available to staff and these procedures must be known by them. {Timescale of the 1/9/2004 not met}. The home must ensure that at least 50 of it’s staff have a NVQ 2 in care. DS0000025798.V297863.R01.S.doc 12[4]a 01/08/06 01/08/06 01/08/06 01/08/06 12. YA32 18[1]a 01/12/06 Inglemere Version 5.2 Page 31 13. YA36 18[2] 14 YA37 18[1]a 17[3]b The provider must ensure that staff receive a minimum of six regular supervision sessions per year. The provider must ensure that sufficient and suitable management staff are employed to facilitate completion of management tasks {which includes providing information to inspectors} The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home must also introduce user/relatives satisfaction surveys and an annual development plan that is open to the service users, to allow measurement of achievement in improving quality. {Timescale of the 1/12/2004 not met}. The requirements of the recent 5 year wiring test must be implemented. 01/09/06 01/08/06 15 YA39 24,1,2,3 01/08/06 16 YA42 12 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA14 YA17 Good Practice Recommendations Each service user should be offered a seven-day holiday paid for by the home. The home should devise a coherent strategy for balancing a resident’s food choices with appropriate encouragement for nutritional requirements. This strategy should be recorded and its outcome included in daily notes. DS0000025798.V297863.R01.S.doc Version 5.2 Page 32 Inglemere 3 YA24 The provider should examine the suitability of the current layout of the building, and explore whether it is conducive to safely meeting the care needs of the service users, based on their individual needs and current staffing levels. Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Inglemere DS0000025798.V297863.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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