Inspection on 17/01/08 for La Luz

This inspection was carried out on 17th January 2008.

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 but made no statutory requirements on the home.

Other inspections for this house

La Luz 24/07/07

La Luz 15/09/05

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 Jane Jewell and Denise Debieux Unannounced Inspection 10:30 17 January 2008 th X10015.doc Version 1.40 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 La Luz DS0000013695.V355526.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 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 DS0000013695.V355526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service La Luz Address 4 High Street Tadworth Surrey KT20 5SD 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) 01737 813781 asoto195@msn.com Mr Angel Soto Mrs Maria Del Carmen Soto-Regueira Mr Angel Soto Care Home 16 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 16. Date of last inspection 24th July 2007 Brief Description of the Service: La Luz is a large converted domestic detached house in a quiet residential area in the village of Tadworth. The home is registered to provide residential care for up to sixteen older people including people who have dementia. The home is presented over two floors with access to the first floor via stairs or a chair lift. Resident’s accommodation consists of fourteen single rooms and one shared bedroom, with three bedrooms providing en-suite facilities. Communal areas consist of large combined lounge and dining area and a conservatory. The conservatory overlooks a large rear garden. The front is paved to provided off road parking. The fees for residential care are currently £460 to £575 per week, depending on the services and facilities provided. Extra such as: newspapers, hairdressing, chiropody, transport , toiletries are additional costs. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced inspection undertaken by two inspectors over seven and half hours and information gathered about the home prior to the inspection. This includes discussions with relatives and stakeholders involved in resident’s care and information obtained during an unannounced random inspection of the home on the 6th November 2007. The purpose of the random inspection was to assess the progress made towards meeting a number of areas of shortfall noted at an earlier inspection. The inspection was facilitated in the main by Mr Soto (Registered Provider /Manager). There were thirteen residents living at the home at the home at the time of the inspection. The focus of this inspection was to identify whether all the areas of previous shortfall have now been addressed as well by looking at experiences of life at the home for people living there. This involved observing residents and their interactions with staff and examination of the homes facilities and documentation. Signs of residents well-being/ill-being (terminology used for observing behaviour for people with dementia) were observed and are also included in this report. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspectors would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: Residents live in a clean and homely environment, which is decorated and maintained to a good standard. Resident’s private accommodation is personalised, safe and comfortable. Comments received about environment included; “it’s small and homely and that is why I chose it”; “always nice and clean” and “everything is so clean its sparkly”. Resident’s are supported to maintain relationships with their families and friends. Residents receive input from health care professionals to help meet their health care needs. Residents are helped to exercise choice and control over their lives with flexible routines being an integral part of daily practice at the home. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 6 Meal arrangements are good ensuring a variety of well-presented meals eaten in a relaxed and informal atmosphere. Residents spoke positively about the food, a sample of their comments include: “first class home cooking”; “if you don’t like something I dare say they would give you something else”; “very nice” and “Carman is a very good cook everything is fresh”. The home is able to meet most needs of residents who spoke positively about their experiences at the home and a sample of their comments include: “ The home does most things well”; “Very nice relaxed I feel quite at home”; “very comfortable place to live”; “Its like your own home it’s the best place to stay”; and “quite nice”. Relatives commented: “On the whole it’s a good home and they are kind” and “I don’t think I could find a much better place to be honest” Residents’ benefit from a stable, and enthusiastic staff team that know them. What has improved since the last inspection? All of the previous shortfalls in practices were assessed as met or evidence seen to indicate that sufficient steps are in place to ensure that they will be fully met in the near future. This has improved resident’s safety through more robust medication and recruitment practices and additional staffing levels enable more time to be spent with residents. Much work has been undertaken to the care planning process to provide staff with guidance to be able to support residents. Staff competencies opportunities. continue to improve through increased training Standards of administration continue to improve, which has ensured practices at the home are underpinned by clearer protocols to promote consistency and good practices. The home is gradually undergoing a refurbishment programme this has seen the redecoration of several bedrooms creating a pleasant environment for the people living there. Staff now have the appropriate guidance and training to ensure that they know what to do if abuse is suspected. What they could do better: The home has implementing many new practices and procedures in response to shortfalls in practices noted at the previous inspection. There now needs to be a period of sustained good practices in order for the home to be able to evidence an overall rating of good under the Commissions Key lines of Regulatory Assessment (KLORA). The manager demonstrated much commitment to ensuring that improved standards at the home could be maintained. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 7 Once implemented the homes assessment documentation should ensure that prospective residents are fully assessed prior to an admission being agreed. Good practice recommendation is that resident’s needs be re-assessed following hospital admissions prior to discharge back to the home. This is in order to identify any changes in needs and to determine whether their needs can continue to be met by the home. Staff need to have clear guidance on the specialist needs of residents in order to ensure that their needs are being met in a consistent manner in accordance with their preferences and wishes. In order to enrich residents lives further it has been required that residents social interests are identified and recorded so that suitable opportunities for occupation and recreation can be provided. The home is developing its system of self-review to ensure that residents, relatives and other stake holder’s can feedback on the quality of the services and facilities in order to help effect future service developments. Staff need to undergone specialist training in visual impairment and mental health to ensure that the staff have the knowledge to meet the range of residents needs the home accommodates. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 3 and 4 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have a written contract stating their terms and condition with the home this helps to ensure that they are aware of their rights and responsibilities. Once implemented the homes assessment documentation should ensure that prospective residents are fully assessed prior to an admission being agreed. Although most needs of resident are being met, further minor work is needed to the care planning and staff training to ensure that specialists needs can be fully met. EVIDENCE: La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 10 The manager stated that there has not been any new residents admitted or assessed by the home since the last inspection, it was not therefore possible to fully assess this standard and the previous shortfalls in practices. However, the manager was aware of the admission criteria for the home and knowledgeable about admissions practices that would ensure a range of information is gathered about prospective residents. This would then inform their decision whether prospective residents’ needs could be safely met at the home. It was therefore agreed that the previously made requirement would be removed and the new admission documentation would be inspected on future visits to the home. A good practice recommendation was discussed with the manager that resident’s needs should be re-assessed following a hospital admissions prior to their discharge back to the home. This is to identify any changes in needs and to determine whether their needs can continue to be met at the home. The manager said that residents are provided with a written contract of terms and conditions of residency with the home, which they or their representatives have signed. This helps to ensure residents and their representatives are aware of the placement arrangements and to clarify mutual expectations around rights and responsibilities. There is a wide range of residents needs being accommodated, which includes residents who live independent lives and residents who have dementia, physical needs, visual impairments and mental health needs. The evidence seen indicates that although most needs of residents are being met, further work is needed to the care planning process and staff training to ensure that the full range of residents needs can be identified and met. This is discussed further on in this report. It was discussed with the manager the point at which residents needs go beyond which the home could continue to safely meet. The manager showed an understanding of the review process that should now be initiated for two residents to ensure that their needs can continue to be safely met by the home. Residents spoke positively about their experiences at the home and a sample of their comments include: “ The home does most things well”; “Very nice relaxed I feel quite at home”; “very comfortable place to live”; “Its like your own home it’s the best place to stay”; and “quite nice”. Relatives commented: “On the whole it’s a good home and they are kind”; “I don’t think I could find a much better place to be honest” and “do the best they can”. The manager reported that as part of a social services review of the home all residents’ underwent a review of their placement in October 2007. The outcome of which was that resident’s needs could continue to be met at the home. Intermediate care is not offered at the home therefore this standard is not assessed. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a care planning process, which provides staff with guidance on how to support them, further work is however needed to them to ensure any specialist needs are identified so that staff know how to meet them. Residents receive input form health care professionals to help meet their health care needs. The system for the administration of medications are good with clear and comprehensive arrangement in place to ensure residents safety. EVIDENCE: The manager has been introducing a new care planning process and documentation. Eight individual plans of care were inspected and were found to contain guidance for staff to follow on the individual needs and preferred routines of each resident. Good examples were noted whereby resident’s plans contained clear instructions on how to support the continence of individual La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 12 residents. However, additional work has been required to the care planning process in order to ensure that specialist needs such as: visual impairment, dementia and mental heath needs are fully identified and the appropriate guidance provided for staff on how to meet them. Staff demonstrated an understanding of each resident’s needs and preferences but were not always clear on the agreed actions on how to meet them. This is with particular reference to the needs of residents who had dementia. A record of daily events and occurrences is maintained. The tone of some of the language used did not always promote residents dignity or a person centred approach to care planning. Following discussing with the manager they agreed that this was not appropriate and would address this immediately. The manager stated staff would now be trained in care planning. Risk assessments had been completed on most risks residents faced and posed, this included such risks associated with: leaving the building unescorted and manual handling. However examples were noted whereby not all risks that had been identified included the actions to manager or reduce the risk. The manager agreed to rectify this to ensure that staff had the necessary guidance to promote residents safety. Care plans evidenced that they were being reviewed regularly to ensure that any changes in needs could be identified. Residents consulted with expressed little or no interest in the development and review of their care plans, but felt that they could ask to see what is recorded about them at any time. Records of medical intervention showed that residents receive input from a range of health care professionals including GP’s, chiropodist, district and specialist nurses. All residents consulted with felt that when they have requested medical intervention this has been sought promptly. A relative spoke of the intervention of a health care professional and how much this has improved the quality of life of their relative. During the inspection staff were seen to be respectful and considerate to residents and visitors. A resident said: “Staff always knock on the door before they come in”. Staff were observed using residents preferred forms of address. Staff consulted with showed an understanding of good practices in preserving resident’s rights to privacy and dignity and were able to give examples of how they promote these rights in their every day care practices. The manager reported that a new system for the administration of medication has been introduced and that staff have undergone medication training. The medicine administration practices observed were seen to be safe and the records demonstrated that systems have been established to ensure staff are appropriately trained and records are accurate and provide a history of what was given by who and when. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are helped to exercise choice and control over their lives with flexible routines being an integral part of daily practice at the home. Meal arrangements are good ensuring a variety of well-presented meals eaten in a relaxed and informal atmosphere. Links with families are valued and supported by the home. Residents lives would be further enhanced thought increased opportunities for suitable occupation and stimulation. EVIDENCE: Observation of the daily routines and discussion with residents confirm that staff accommodate resident’s personal wishes with regard to meal times, going to bed, rising and bathing. During the inspection residents were observed to move around the home choosing which room to be in and what level of company they wanted to enjoy. For a few people living at the home, being able to exercising their choice was difficult due to their level of dementia. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 14 However staff were seen to use their acquired knowledge of a person to help them make choices. Several residents spoke of going out independently to local shops and social clubs. The manager spoke of a karaoke machine having been purchased, which they said residents enjoyed. Variable feedback was received on the opportunities provided for occupation and stimulation for residents. The main activity that resident’s, staff and visitor all said is primarily offered is jigsaws. A visitors commented: “sometimes I see them doing jigsaws but other than that not much going on” and “don’t seem to do very much just sit in the arm chairs”. A sample of residents comments included: “don’t seem to do anything here just sit around” and “they play cards, jigsaws but I like to occupy myself and I am always kept busy”. Staff did not always demonstrate an understanding of appropriate occupations for people who have dementia. Consistent feedback was received from residents and visitors about limited opportunities for residents to go out, however it was acknowledge that during the winter months this is not an issue. Residents and visitors did comment on how nice it is to sit in the garden in the warmer weather. In order to enrich residents lives further it has been required that residents social interests are identified and recorded so that suitable opportunities for occupation and recreation be provided. Further more additional training in dementia has been recommended in order to increase staff awareness of dementia. Visitors commented upon being made to feel welcomed during their stay, this included being offered beverages or meals and staff being friendly and approachable. A resident spoke of the importance of having their own telephone so they could keep in contact with their relatives. Maintaining a high level of personal appearance was very important to some residents in order to help maintain their individuality. This was respected by staff who were knowledgeable and sensitive on this matter Residents spoke positively about the food, a sample of their comments include: “first class home cooking”; “if you don’t like something I dare say they would give you something else”; “very nice”; “Carman is a very good cook everything is fresh” and “nice range of food”. The mealtime at inspection was relaxed and staff were observed providing discrete attentiveness to those residents who needed assistance. Resident’s individual preferences were respected. Staff said that a record of resident’s weights is maintained and that this would help to identify any significant changes in eating patterns. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A complaints procedure and appropriate adult protection policies and staff training helps to protects the rights and interests of residents. EVIDENCE: There is a written accessible complaints procedure in place for residents, their representative and staff to follow should they be unhappy with any aspects of the service. All residents and relatives consulted with said that they were aware of how to raise any concerns and felt comfortable to do so and that where they have had to raise minor concerns in the past this has usually been dealt with satisfactorily. The manager reported that there have no formal complaints made since the previous inspection. In line with the previously made requirement the homes safeguarding adults procedure has been reviewed in accordance with Surrey Multi-agency Procedure for the Protection of Vulnerable Adults (2005). The manager said that staff have now all undergone safeguarding adults training. Staff consulted with knew where to refer to if they suspected abuse. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 16 There have been three adult protection referrals made to social services in the last twelve’s months made by outside agencies. These have been investigated by social services and recommendations made by them have now been addressed by the home. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 24 25 and 26 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment, which is decorated and maintained to a good standard. Resident’s private accommodation is personalised, safe and comfortable. The manager had developed a proactive programme of redecoration and repair. EVIDENCE: The home comprises of a converted domestic dwelling in a residential area on the outskirts of the village. One resident described, “local shops are a good walk away”. Standards of maintenance were good with the manager having developed a programme of decoration and refurbishment. This included any areas in which it was noted at inspection to be in need of improvement. This included the exterior paint work of the home. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 18 Since the previous inspection some bedrooms have been decorated which have been completed to a good standard. Much effort is made throughout the home to promote a domestic and homely feel. A resident said: “it’s small and homely and that is why I chose it”. Communal space consists of a large combined lounge dining room and conservatory, which overlooks a large well-maintained rear garden. A resident said: “In the summer we all sit outside”. All residents consulted said that they liked their bedroom and that they provided everything they needed. Bedrooms were observed to have been individualised with resident’s personal effects and residents spoke of being able to bring to the home small items of furniture. There are sufficient number of toilets and bathrooms located around the building this includes assisted baths. In line with the previous requirement a crack in an assisted bath had now been repaired. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, chair lift and grab rails. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. A resident said that “staff are normally pretty quick” when she have used the call bell system. Many positive comments were received regarding a good standard of cleanliness and hygiene. Comments included: : “Clean every morning the place is always kept clean”; “always nice and clean” and “everything is so clean its sparkly”. All parts of the home visited were observed to be clean with any melodious odours confined to a bedroom which the manager was in the process of dealing with. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 19 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a stable, and enthusiastic staff team that know them. However further training is needed to ensure that the staff have the knowledge to meet the range of residents needs the home accommodates. Not all of the training that staff have received is translated into good care practices. Although recruitment practices have improved further work is still needed to ensure that they are robust in order to safeguard residents. EVIDENCE: The manager spoke of additional staff that have now been employed which has increased the daily staffing levels. Staff visitors and residents felt that there were sufficient numbers of staff on duty for staff to undertake their roles in a timely manner. A staff member said that they provide “good quality professional care” at the home. As part of their duties care staff are also responsible for some cooking and cleaning duties. A sample of comments made about staff included: “very good with the residents who have disabilities and seem to have a lot of patience for them”; “Ok don’t have any difficulties with any of them”; “quite caring”; “lovely girls”; La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 20 “very helpful if you need anything”. Feedback was received from residents and relatives regarding difficulties in being understood by some staff who’s first language is not English. The manager had previously identified this and some staff members were attending English lessons. A staff member who’s commend of English was described as “poor” by the manager said that they do not work alone and other staff help them with written English. The staff on duty had a good rapport with residents, which promoted a relaxed atmosphere in the home. Residents were observed showing signs of recognition towards staff and being relaxed and comforted by their presence. However not all staff showed an understanding of the needs of people who have dementia. This is with particular reference to staff’s understanding of the ill-being and well-being signs of people who are not able to verbally communicate. Although staff have recently undergone training in dementia it is recommended that further training is sought in order to increase staffs understanding and awareness of good practices in the care of people who have dementia. The personal files of newly appointed staff were inspected and these showed that a recruitment process is followed which includes the use of an application form, interviews, Criminal Records Bureau (CRB) checks and written references prior to employment commencing. However due to an error on a CRB form one staff member had not had an accurate up to date police check. The manager took immediate steps to ensure that the staff member did not work until a new application could be made and agreed to be more vigilant in checking the accuracy of all CRB forms. The manager said that they would also be undertaking further checks on the eligibility to work in the Uk of a member of staff who’s documentation was unclear. Subsequent to the inspection the manager reported that they received notification from CRB that the error had first occurred within their process. The manager reported that they have been working with a training organisation since Nov 07 in creating and delivering a training and development plan for the home. Evidence was seen that staff have undergone or about to undergo mandatory training such as manual handling, first aid, medication, safeguarding adults in order for them to work safely with residents. Although some areas of specialised training have been undertaken, including dementia and equal opportunities, there is a need for staff to also undergo training in visual impairment and mental health. This is to ensure that staff have an understanding of the range of residents needs accommodates. An example of poor manual handling was observed, despite staff having received manual handling training. This was rectified immediately by the manager once they had been informed of this. The manager agreed to review the situation to establish whether the training they received was appropriate or whether staff have not understood fully the training. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 21 The manager reported that currently the majority of staff are working towards obtaining a National Vocational Qualification (NVQ). A new member of staff spoke of the induction they undertook which included an introduction to residents, staff and completion of an induction check list that specified the areas of training to be covered in the initial stages of employment. Although staff now received a structured induction, in line with previous requirement, the manager had not accessed the Common Induction Standards published by the Skills for Care Organisation. This is designed to help ensure that all new staff entering into the care industry has a minimum level of initial training. The manager agreed to obtain copies of this as a matter of priority. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 22 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 and 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefited from a manager who is motivated to continue to improve standards at the home. The home is developing its system of self-review to ensure that residents, relatives and other stakeholder’s feedback on the quality of the services and facilities are sought and acted upon. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 23 The Provider/Manger reported that they have started the recommended management qualification of an NVQ 4 (management) in October 2007 and anticipates that this will be completed by May 2008. Both providers work in the home daily and they spoke of the immanent appointment of a deputy manager in order to provide additional management support and to enable them to take regular breaks from the home. The manager demonstrate a commitment, and once identified, showed an understanding of the areas for further improvement and had undertaken much work in order to meet the number of outstanding areas of concern from the previous inspection. A sample of comments regarding the manager included: “up front”; “good manager”; “very concerned about the residents and staff” “can speak very loudly” and “very nice really”. In line with previous requirements the manager stated that they are currently in the process of collating information received from residents regarding the quality of the services and facilities. As positive steps were evidenced that the previously made requirements relating to the need to develop a system for the self assessment of the home were in the process of being addressed it was agreed that this requirement would not be carried forward but assessed in full at the next inspection. The manager stated that they are involved in holding the personal monies for one resident and that social services monitor the records for this particular resident. Staff are in the main supervised by the provider/manager working along side them each shift and all staff consulted with felt supported by them to undertake their roles. Care staff spoke of receiving formal supervision on a regular basis. In line with previous requirement key policies and procedure have been localised and updated in line with changes in legislation. This helps to underpin the homes practices and further support the induction of new staff. Written guidance is available for staff on issues related to health and safety. As previously noted an example was observed of poor manual handling techniques which did not promote residents safety. The manager immediately rectified this. Systems are in place to support fire safety, which include: regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills were reported to have been undertaken or due to be serviced. The manager reported that they had undertaken a recent fire risk assessment, which records significant findings and the actions taken to ensure adequate fire safety precautions in the home. La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 x 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 x 2 La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Timescale for action 30/04/08 2 OP12 16(2)(n) 3 OP30 18(1)(c) 4 OP30 18(1)(c) (i) That care plans detail the actions needed to ensure that all aspects of the health and social care needs of the service users are identified and which make explicit the actions needed to meet these needs, this is with particular reference to the specialist needs of visual impairment, dementia and mental health needs. That service users hobbies and 30/04/08 social interests are identified and recorded on individuals care plans and suitable opportunities for occupation and recreation be developed accordingly. 30/04/08 That staff receive specialist training in accordance with the needs of the service users accommodated, in order that they can provide the appropriate support to people with a visual impairment and mental health needs. The manager must ensure that 30/04/08 structured staff induction training is supplied to all staff employed after October 2006. DS0000013695.V355526.R01.S.doc Version 5.2 La Luz Page 26 The training must comply with the mandatory Common Induction Standards published by the Skills for Care Organisation. Timescale of 26/09/07 and 14/01/08 not met. 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 OP3 Good Practice Recommendations That resident’s needs are be re-assessed following hospital admissions prior to discharge back to the home in order to identify any changes in needs and to determine whether their needs can continue to be met by the home. That staff undergo additional training in dementia care to increase staffs understanding and awareness of good practices in the care of people who have dementia. 2 OP30 La Luz DS0000013695.V355526.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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