Inspection on 15/09/05 for La Luz

This inspection was carried out on 15th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

La Luz 17/01/08

La Luz 24/07/07

La Luz 03/05/05

La Luz 09/11/04

La Luz 06/04/04

La Luz 23/10/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE La Luz 4 High Street Tadworth Surrey KT20 5SD Lead Inspector Lesley Garrett Announced 15 September 2005 10:00 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 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 Older People. 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. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service La Luz Address La Luz 4 High Street Tadworth Surrey KT20 5SD 01737 813781 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Angel Soto, Mrs Maria Del Carmen Soto, Mr Jose Manuel Castro, Mrs Aurea Castro Mr Angel Soto Mrs Aurea Castro Care Home (CRH) 16 Category(ies) of Old age, not falling within any other category registration, with number (OP), 16 of places Dementia - over 65 years of age (DE(E)), 5 La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Date of last inspection 03 May 2005 Brief Description of the Service: La Luz is a large detached house in a residential road in Tadworth. The home is registered for sixteen older people over the age of sixty-five years. The home has fourteen single rooms and one shared bedroom. Three bedrooms offer ensuite facilities. The home provides car parking to the front of the house and has a large rear garden. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over three hours and was the second inspection to be undertaken in the Commission for Social care Inspection year April 2005 to March 2006. Lesley Garrett lead inspector for the service, carried out this inspection and Mr Angel Soto Registered Manager was present as representatives for the establishment. A full tour of the premises took place and documents inspected included some policies and procedures, medication records and some service user administration files. The inspector saw all of the residents and spoke with four in more depth. A number of returned comment cards were used to write the report. Unfortunately the pre-inspection questionnaire sent to The Commission by Mr Soto had still not been received by the inspector on the day of inspection. This was a positive inspection and the inspector would like to thank the service users, staff and manager at La Luz for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? All the requirements from the inspection on the 3rd May 2005 have now been met. In June 2005 the inspector visited twice with the pharmacist, as there was concerns around the medication procedures. The system has now La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 6 improved and the inspector saw less medication in the cupboard as they are now having deliveries every month. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. 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. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Each administration file sampled had a contract and terms and conditions. EVIDENCE: All service users have a signed contract from either social services or from the home and a signed copy of the terms and conditions. These are all kept in the locked office downstairs. The administration files are kept together with the individual plans of care and although these are neat and tidy and information can be easily obtained it would be a appropriate to separate the two files for housekeeping purposes. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s 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. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 & 11 The systems for the administration of medicines have improved. The issues surrounding death and dying needs to be addressed by the home. EVIDENCE: During the pharmacy visits in June the registered persons had stated that they intended to change the system for administering of medicines to blister packs. This has proved to be too difficult for the home to do however, the system has improved as the MAR sheet labelling now corresponds with the medicine labels. There were no gaps on the MAR sheet and the controlled drugs were checked and correct. The home also operates a returns book for unused or wasted medicines and they are returned to pharmacy. In the inspection report of May 2005 the inspector noted that the issues surrounding death and dying had not been addressed. The wishes of the service users at the time of their death had not been sought. It was not made a requirement but the inspector asked that the subject be discussed. The registered manager stated that he found this a difficult subject for him to tackle but he would now make this part of the admission process and he would start to speak to the service users and their families about their wishes. It was suggested by the inspector that care plans should then be started and this will be a requirement at the end of the report. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 10 Service users are able to be cared for at the home, in most cases, up until death as the home has good support from the G.P. and district nurse. It would of course, be dependent on the need for specialist equipment or nursing as to whether they could stay at LA Luz. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 There is no formal activity programme at the home. EVIDENCE: The registered manager told the inspector that there is no activity programme at the home as the service users had never requested it and when offered are reluctant to join in. The staff has tried to organise board games or cards on a Thursday afternoon but only a few join in. The service users spend most of their day sitting in the lounge or conservatory. One service user attends a social club at the church and is collected every Sunday for the service. The home is able to take service users out in the car on a one to one basis for shopping. The Christmas party is a highlight and family and friends are invited. The inspector has asked the home to look at some activity on a regular basis and a questionnaire for all service users would help to see what they would enjoy. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. 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. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The registered persons have knowledge of adult protection but their knowledge needs updating. EVIDENCE: The registered manager has a good understanding of adult protection but he attended the Surrey Multi Agency course some while ago. The inspector suggested that he attend the next available course and then to cascade the information to the rest of the staff. The manager told the inspector that the subject is covered in the NVQ course and by the manager himself in induction. The manager needs to obtain the February 2005 Surrey Multi Agency procedures, as the homes copy is out of date. The manager also needs to bring the homes policy on adult protection in line with Surrey. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. 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. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 21 & 24 There are an adequate number of toilets and washing facilities to meet the service users needs. There are no locks on the bedroom doors. EVIDENCE: The home has two bathrooms one assisted bathroom downstairs and a parker bath upstairs. These bathrooms were clean and tidy. There are five assisted toilets and the home has three en-suite bathrooms. All bathrooms and toilets now have soap and paper towel dispensers. During the tour of the home the inspector noticed that there were no locks on the bedroom doors. The manager stated that the service users had never asked for them but there has been no service user consultation and this question is not asked on admission therefore this will be a requirement. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. 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 home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 The service users have an adequate number of staff that has the appropriate training required to meet their needs. EVIDENCE: All four owners of the home are hands on caring and take an active role in the running of the home. The manager stated that all of them could do any job that is required within the home. The home also employs four carers and a cleaner. The manager has NVQ level four and two members of staff have NVQ level three and a further two have NVQ level two. The manager does an induction with all new members of staff, which covers all aspects of the home, an introduction to the service users, COSHH and health and safety. The induction lasts for one day but the inspector suggested that the induction is in line with a more formal induction programme that links in with the NVQ programme. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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 home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The home has no quality monitoring system to seek the views of the service users, families or visiting professionals. Service users financial interests are protected by the managers system of pocket money accounts. EVIDENCE: The home has no quality assurance and quality monitoring system. There has never been a survey conducted in the home to seek the views of the service users or their families. These surveys could include the type of activity programme the service users may like to do. The inspector told the manager these surveys need to be made available to current and prospective service users. The registered manager told the inspector that there are only two residents who have a pocket money account. The rest of the service users are looked after by their family. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 16 The manager has set up a logbook for the two service users with money in and out of the account clearly marked. The service users have access to their money when they need it and both the manager and service user sign it for. The entry sheets for the transactions are continuous and the inspector suggested that maybe a monthly system might be easier to follow. La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x 3 x x 1 x x STAFFING Standard No Score 27 x 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 1 x 3 x x x La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 18 No 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 11.3 Regulation 12(3) Requirement The registered persons to ensure that the wishes of the service users about death and dying are documented. The registered persons to arrange suitable activities for service users following consultation. The registered manager to attend vulneraqble adult training to update knowledge and cascade information to other members of staff. The registered persons to obtain the February 2005 copy of Surrey Multi Agency procedures and to bring in line the homes own policy on adult protection. The registered persons to remove towel covering the window in upstairs toilet and replace with a suitable blind or curtain. The registered persons to ensure that all service users dors are fitted with locks. The registered persons to ensure that all inductions are now linked with TOPPS and last longer than one day. The registered persons shall Timescale for action 15/10/05 2. 12 16(2)(m) 15/11/05 3. 18.2 13(6) 15/11/05 4. 18.5 13(6) 15/10/05 5. 20.7 16(2)(c) 15/10/05 6. 7. 24.5 30.2 & 30.3 33.1 12(4)(a) 18(1)(i) 15/12/05 15/11/05 8. La Luz 24 H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 19 ensure a quality assurance and monitoring system is in place to seek the views of the service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 La Luz H09 H58 S13695 La Luz V238042 150905 Stage 4.doc Version 1.40 Page 21 - 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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