Inspection on 24/07/07 for La Luz

This inspection was carried out on 24th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 17/01/08

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 Joseph Croft Unannounced Inspection 24th July 2007 11:00 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.V338756.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.V338756.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 Angelo 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.V338756.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 26th February 2007 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 is set over two floors with access to the first floor by stairs. The home has fourteen single rooms and one shared bedroom over the two floors. Three bedrooms offer en-suite facilities. The communal area is ‘U’ shaped with two dining areas and a sitting area. A conservatory leads from the sitting area to the large garden at the rear of the home. The manager informed the Inspector that the weekly fees range from £450 to £575. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 24th July 2007 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspectors Mr Joe Croft and Mrs Sandra Holland undertook this visit. The registered manager Mr Angel Soto, who is also one of the owners of the home, assisted throughout. This site visit took place over a period of seven hours, commencing at 10:50 and concluding at 18:20. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspectors had discussions with members of staff on duty and several residents who were present during the site visit. Residents informed the inspectors that they were happy living at the home, that the staff help them and the food is good. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. An Annual Quality Assurance Assessment (AQAA) was provided to the home and this was completed and returned. Information supplied in the AQAA will be referred to in this report. A number of CSCI feedback forms were supplied to the home for distribution to residents, relatives and visitors and healthcare professionals. Only one survey was received from a resident who informed that the only weakness of the home is the lack of activities. Five surveys were received from relatives/friends, some of who had been sent the wrong forms to complete, however, there were no negative comments in regard to the home. Comments included ‘more day trips would be nice’ ‘People are from different ethnicity and religions, and church services visit the home,’ ‘excellent food, staff, clean, attention and care.’ ‘Nice garden.’ ‘The staff are kind and do their best.’ A random focussed inspection was undertaken at the home on the 11th June 2007 to examine staffing levels and recruitment procedures. Requirements made during the random inspection have been included in this report, as the timescales have not expired. Feedback was provided to the manager at the end of this site visit. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection La Luz DS0000013695.V338756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Contracts have been supplied to residents, but these need to be signed by both parties. Assessments of the needs of prospective residents must be carried out before they are admitted to the home. EVIDENCE: The files of a number of residents were seen, including the file of a recently admitted resident. From the residents’ files, it was noted that a contract had been drawn up stating the terms and conditions under which residents’ live at the home. It was noted that the contracts did not record the number of the room to be occupied, and all of the contracts seen had only been signed by either the resident or the providers, but not by both. It is necessary for both parties entering into a contract, to sign and date the contract to indicate their understanding of, and agreement to, the contract. Some of the contracts had not been dated. The manager stated that assessments of the needs of prospective residents are carried out before they are admitted to the home, and are carried out wherever the resident is living at the time, whether that is at their own home, La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 9 in hospital or another care home. The manager also stated that an amended form was being used to record the assessment of residents’ needs. It was observed however, that the assessment of the needs of the recently admitted resident had been carried out on the day the resident was actually admitted to the home. The assessment of the resident’s needs was recorded on the new style of assessment form, but it was noted that this did not record all the information required, as recommended by the National Minimum Standards for Older People. It was also observed that the assessments carried out on the older style form had not been signed or dated and had areas that had not been completed. It was not possible to know when these assessments had been carried out or who had carried them out. A requirement was made following the inspection carried out on 26th February 2007, that assessments must be carried out before residents are admitted to the home, by someone trained to do so. They must contain all the details required to meet the needs of the resident, and be signed by the resident where possible and be dated. This requirement was given a timescale for compliance of 22nd June 2007, but this has not been met. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 10 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): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual plans of care have been drawn up, but further improvement to these is required. Risks to the health and safety of residents must be fully assessed. The standard of medication administration must be improved to safeguard residents. EVIDENCE: The manager stated that a new style of individual care plan is being developed and he is in the process of changing residents’ individual plans over to this, as he considers the new style to be more straightforward to use. From the individual plans seen, it was evident that the plans had been reviewed on a monthly basis, as was required following the inspection carried out on 26th February 2007. It was noted however, that not all information in the plans had been fully reviewed. For one resident the care plan recorded that the resident was unable to assist with housework, but the resident was seen carrying out a number of household tasks. It was also required following that inspection, that residents or their representative must sign the care plan if possible. A timescale for compliance of 25th May 2007 was given, but this has not been fully met. The manager La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 11 stated that the new style of care plan incorporates spaces for residents, their representatives and staff to sign, and this will be carried out as each resident’s care plan is changed over to the new style. A requirement was made following the inspection on 26th February, that risk assessments must be carried out on all daily activities carried out by residents. The assessments must detail the concern, action taken and be dated, signed and reviewed when necessary. A timescale for compliance of 25th May 2007 was given, but this has not been fully met. The manager stated that any risks involved in the residents’ daily activities have been incorporated into their care plan, including any actions to be taken. The care plans did record the residents’ daily activities, but did not fully assess any risks involved and gave only minimal information regarding control measures. For one resident who has a sensory impairment, no specific assessment had been carried out of the increased risks this resident may face with mobility for example. From the records and documents seen, it was clear that a number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), optician, chiropodist, dietician, speech and language therapist and hospital specialists. The providers stated that medication is supplied to the home by a local pharmacy and is supplied in original packaging. As the pharmacy does not provide printed medication administration record (MAR) sheets, the home prints a MAR sheet that they have developed. The MAR sheet has spaces to record the receipt of medication received into the home and these were seen to be used for that purpose. On checking the amounts of medication held against the records held, it was noted that no record is maintained of when new supplies of medication are started. As a result, it is not possible to calculate how much medication should be present or to follow an audit trail. It was also noted that the amount of one medication received had been inaccurately recorded, and the amount of medication actually present was double the amount recorded. The home’s medication policy and procedure has been reviewed and updated, but it was clear that this is not being followed in the home. During discussions with the providers, it became clear that the supplies of medication belonging to a resident who had died very recently, had been returned to pharmacy two days after their death. It is recommended by the NMS for Older People, that these are retained for seven days in case any enquiries arise and this is stipulated in the home’s medication policy and procedure. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 12 The provider stated that no stock was held of one medication that was listed on a resident’s MAR sheet, which was to be administered “when required”. When asked how this resident would be able to receive this medication if required, the provider stated that another resident’s supply of the same medication would be used. This must not be permitted, as medication is the property of the person for whom it is prescribed. Administering one resident’s medication to another places residents at risk of receiving incorrect medication and may lead to a resident not receiving their medication as prescribed. The home’s medication policy and procedure stipulates that medication that is supplied to residents is for their sole use. The home’s medication policy and procedure also stipulates that only staff qualified or trained to administer medication will be required to do so, but the providers stated that untrained staff are required to check medication with a member of staff who has received medication training. At present only one of the providers has a certificate to confirm that they have undertaken medication training, although it was stated that another member of staff has also completed this. An immediate requirement was made following the inspection carried out on 26th February 2007, that a review of the policy, procedure and practices for the administration of medication must take place to ensure that they are up to date and accurate, and staff know what to do when administering medication. As this was an immediate requirement, action was to be taken immediately to safeguard residents, but this has not been carried out and the requirement has not been met. A requirement was made at the inspection carried out on the 26th February 2007, that the daily notes kept by the home as part of the residents’ care plan, must be detailed, dated and signed, must respect the privacy and dignity of residents and must meet the requirements of data protection. A timescale of 24th April 2007 was given and this has been partially met. The daily notes are now more detailed, have been dated and signed, but do not fully safeguard residents’ privacy or fully meet the requirements of data protection. Each resident’s individual sheet of daily notes are still stored in a communal file and have not been incorporated into their care plans. An immediate requirement has been made regarding Standard 9. La Luz DS0000013695.V338756.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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A very limited range of activities and meals are offered to residents. EVIDENCE: A requirement was made following the inspection carried out on 26th February 2007, that the home must provide a range of suitable recreational and social activities for residents and ensure adequate records are kept. A timescale of 27th April 2007 was given and this has been partially met. The providers stated that the home does not have an activities programme, so residents are not made aware of any activities that are available. A member of the care staff is allocated to carry out activities with residents, usually each afternoon. On the day of inspection, the member of staff was organising games of dominoes and hoop-la and had supplied residents with a number of jigsaw puzzles. Two residents were enjoying the sunshine on the patio in the garden and another resident had been out for a walk and is able to do this independently. It was noted from the recent daily records, that residents had taken part in similar indoor activities. The only community activity recorded was residents going for walks, either on their own if they are able, or with their visitors. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 14 Information provided in the AQAA informs that there are 13 residents who are White British and two other residents from other White backgrounds. One of these was from Portugal. The manager informed the Inspectors that this resident was specifically placed at the home, as the owners are able to meet their communication needs. The other resident is from Spain and was able to converse with the Inspectors in English. It was observed that a number of more dependent residents were not engaged in any meaningful activity during the day, some of who were sleeping in their armchairs and others who were wandering around the ground floor of the house. Residents are supported to maintain contact with their families and friends. From the records seen and from speaking to residents, it was clear that a number of visitors come to the home, some on a regular basis. A small number of residents go out with their families or friends when they visit, either for a walk or for meals out. Some residents have telephones in their rooms to enable them to keep in touch with their families and friends. Others can receive telephone calls, using the home’s cordless phone and one resident receives regular calls from a relative who lives abroad. Residents were spoken to whilst they were enjoying their lunchtime meal and those residents who were able said that the food was good. A choice of two main courses was available. One of the main courses matched the menu that was displayed on the dining room wall, and staff advised that the second option was being offered, as not all residents liked the first option. A requirement was made following the inspection carried out on 26th February 2007, that the menu must be updated to ensure that it is an accurate record of the food provided to residents, and where food supplements are in use, provision of these must be clearly recorded, including the reason why these were necessary. A timescale of 27th April 2007 was given, but this has not been met. The providers stated that the menu had been reviewed and a daily menu was now being displayed instead of the weekly one that was previously displayed. Each of the ten, individual daily menus that were available was seen. The provider stated that these are offered in rotation, but no record is maintained of which meal has been served on which day, so it would not be possible to know what has been served or what should be served next. The ten main meal options included three varieties of roast meat. A record has been maintained of the temperature of the hot food served at the main meal, but this does not record what food was served, but simply records the date and the temperature reading. In the event of an outbreak of any La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 15 illness or stomach upsets for example, it would not be possible to know what food had been served. The care plan of a resident who occasionally requires prescribed food supplements, records that these may be required if the resident declines to eat, to ensure they receive a healthy diet. The care plan also records that staff need to encourage the resident to eat and may need to assist, if the resident requires it. It was observed that the lunchtime meal was served in an alternative form to suit the needs of a resident and aids, including plates with rims and alternative cutlery, were provided for those residents requiring them. During discussions, residents stated they food was good, and they are provided with a choice. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Staff require training in Safeguarding Vulnerable Adults, and Policies and Procedures must be produced to ensure residents are fully protected from abuse. EVIDENCE: The Commission For Social Care Inspection has not received any complaints in regard to the home. The home has produced a Complaints Policy and Procedure that was dated 14th May 2007. This included the timescale for responding to complainants and the Commission For Social Care Inspection local office contact details. Copies of this document were observed in the bedrooms that were visited by the Inspectors. This was a requirement made during the previous key inspection, and has now been complied with. During discussions, some residents stated they would talk to the manager if they had any concerns or complaints. The Complaints records were viewed during the site visit, and evidenced that the home has received one complaint since the previous inspection that was resolved by the manager. Requirements made at the previous key inspection in regard to training and production of a policy and procedure for safeguarding adults has not been fully complied with. Only two members of the staff team had received training in regard to Safeguarding Adults in May 2007. The home has a copy of the Surrey Multi-Agency Procedures in regard to the Protection of Vulnerable Adults, but La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 17 has failed to develop their own policy and procedure to work alongside this. These requirements are therefore carried over and must be complied with. During discussions, one member of staff informed the Inspector they would report all allegations to the manager, however, they were not aware that the Surrey Multi-Agency Procedures must be followed by the management once they have received an allegation of abuse. Other staff were aware of the types of abuse that may occur and stated that they would report any concerns to the providers, who are in day-to-day control of the home. One member of staff advised that they had recently received abuse training. The home is currently subject to a Protection of Vulnerable Adults investigation that is being undertaken by the Surrey Multi-Agency Procedures. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 18 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): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are provided with communal and individual living space. Improvement to identified areas is needed to ensure residents live in a homely comfortable and safe environment. EVIDENCE: A tour of the premises was undertaken. Accommodation is situated on two floors, and consists of one double bedroom, 14 single bedrooms, three of which have en-suite facilities. There is a dining room and lounge, conservatory, kitchen and a garden to the rear of the property. The requirement made at the previous inspection in regard to the garden fence has been met. Bedrooms were appropriately decorated with residents’ personal possessions around them. However, one bedroom had a vanity unit that had suffered damaged to the edge. The manager informed the Inspectors that there are plans to redecorate all bedrooms as and when they become vacant, and to replace all vanity units. However, these plans were not in a written format. The requirement made at the previous inspection in regard to the environment La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 19 had only partially been met. The dining room door did not close properly, and had been kept open by the use of a chair. An immediate requirement in regard to this has been under the management and Administration section of this report. The home has a Parker bath. The manager informed the Inspector that this had not been serviced by an external professional, as the past joint owner of the home used to undertake the maintenance. Requirements in regard to this have been made under the management and Administration section of this report. Headboards on the beds were observed to be clean, and each bedroom visited had call alarms that were within reach of residents’ beds. One communal toilet had a broken seat that must be repaired, and the manager informed the Inspectors this had only recently happened and would be repaired. It was noted that a bedside light in bedroom D had been broken and was in need of immediate repair. An immediate requirement in regard to this was made. Two other immediate requirements were made in regard to Health and Safety that have been addressed under the Management and Administration section of this report. The manager informed the Inspectors that new carpets for the hall and dining area of the home have been ordered, and are waiting from the date the carpet fitter to lay the new carpets. Residents had unrestricted access to communal parts of the home. It was noted that paper towels and liquid soap were available in most appropriate places to maintain hygiene and prevent infection. However, no liquid soap was provided in the toilet designated for staff use. A small bar of soap was present, but the use of this is not a good hygiene practice. On the day of the site visit the home was clean, tidy and free from offensive odours. A requirement has been that the identified areas in regard to the environment must be attended to. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff are not provided in sufficient numbers to meet the needs of residents. Robust recruitment procedures are not always been followed when recruiting staff, therefore not fully protecting the residents. Attention is required in regard to training for all staff. EVIDENCE: On the day of the site visit the home employed seven members of staff that included the manager/owner and his wife. The duty rotas for the three weeks preceding this site visit, and for the week of the site visit were provided to the inspectors. Two weeks of the duty rota had not been fully completed for two members of staff, so it was not possible to know if they were on annual leave, sick leave or training. The duty rota for the week of the site visit included seven members of staff, and provided evidence that there were three members of staff on duty for the early shift, and two members of staff for the late shift, with the exception of Saturday. It was noted that there were times when the manager had been working 66 hours in two separate weeks, and had worked 48 hours that included waking night duties without any sleep. Discussions took place with the manager in regard to this, and the effect this could have on the health, safety and welfare of himself and the residents if he is not getting the appropriate rest in-between shifts. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 21 The inspection of the 26th February 2007, the random focussed inspection of the11th June 2007 and the inspection of 24th July 2007 all raised concerns regarding the levels of staffing and the roles and responsibilities held by those members of staff. A requirement was made in February 2007 that a review of the staffing levels take place and that two waking night staff be provided. The provider wrote the commission on the 10th May 2007 to sated that he considered one waking and one sleep-in staff as adequate. On the 11th June the requirement was made again – the provider again confirmed to the commission that night staffing levels being provide were in his opinion sufficient. On the 24th July 2007 the following was confirmed that the home does not employ a cook and care staff are responsible for carrying out the cooking, domestic and laundry duties. These hours were not clearly identified on the duty rotas. The care duty rota must specify the care hours and separately identify the hours and times for domestic duties, this will ensure the home provides adequate staffing to carry out personal care tasks and make sure residents needs are met. A requirement has been made that a review of the staffing levels of the home must be undertaken, and take into account the care hours required to meet the needs of residents. The manager informed the inspectors that he is currently trying to recruit a further two members of staff. Three staff recruitment files were sampled, one of which belonged to member of staff who had recently commenced employment at the home. Each file contained an application form and two written references, Criminal Record Bureau clearances and POVA checks. One application form did not include the names of two referees, however, two references were evidenced in the file. The full employment history for this person was on a separate form written in Portuguese. A good practice recommendation has been made that all documentation in regard to recruitment should be translated into English. A requirement was made at the random focus inspection of the 11th June 2007 that application forms must be updated to ensure they include a full employment history and a reason for gaps in employment. It was noted that the application form for the most recent member of staff met with this requirement, however, there was no proof of identity or a recent photograph on their file. The manager continues not to comply with The Care Home La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 22 Regulations Schedule 2 in regard to the recruitment of staff working at the home. Requirements were made in regard this at the random inspection of 11th June 2007, which is still within the time scale to be complied with. For the most recently recruited member of staff, their induction record had not been completed. As a result, it is not clear if this person has received any induction or what that induction may have covered. A requirement was made in regard to this at the random inspection of 24th February 2007 and 11th June 2007. These have now been amalgamated into one requirement and brought forward from both inspections. Staff training continues to be lacking at the care home. Evidence was seen that only one member of staff had undertaken training in regard to food handling and hygiene, one had completed their training in safe administration of medicines. The manager informed the inspectors that one other staff member was due to complete the medication training. There was no evidence that staff had attended current training in regard to first aid, manual handling, fire, infection control or health and safety. No staff had undertaken specialist training in regard to dementia. One member of staff holds the National Vocational Qualification (NVQ) level 3, one is currently undertaking the NVQ level 2. A requirement was made following the inspection carried out on 26th February 2007, and this has not been met. The manager informed the inspector that another member of staff would commence duties once their Criminal Record Bureau (CRB) disclosure and references have been received. The manager informed the inspector that one member of staff is currently having English lessons, and when competent, will attend the training as required. During discussions, residents informed the Inspectors that the staff help them a lot, and there is always some one at the home if you need them. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not run in the best interests of the residents and further improvement is necessary to ensure the health, safety and well being of service users is promoted and protected. EVIDENCE: The manager informed the Inspector that he commenced working at La Luz in 1995, had undertaken the City and Guilds ‘Management in Care’ training that was completed in 1997, but has not undertaken any training in regard to managing a care home since then. A requirement in regard to this has been made. A number of weaknesses in the management of the home have been identified, both at this and previous inspections, which indicate that the home is not being effectively managed, is not being run in the best interests of the residents and La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 24 is not protecting or promoting the health and safety of all those who live and work at the home. All of the outcomes for residents assessed in this report have been assessed as poor, apart from the environment outcome group, which was assessed as adequate. This indicates that the home is not meeting the National Minimum Standards for Older People. The Commission will determine what action will be taken to ensure standards are improved, requirements are complied with and residents are fully safeguarded. During discussions the manager informed the inspector that quality assurance had not taken place. The manager stated that he was of the understanding this was what the service user surveys sent by the Commission For Social Care Inspection were for. The home does not seek the views of residents, their families or other associated professionals in regard to the care the home provides to residents. Meetings with residents do not take place. A requirement was made at the inspection of the 26th February 2007 in regard to ensuring quality assurance systems are established and undertaken, but the management have failed to comply with this. The manager informed the inspector that the home only holds small amounts of money for one resident. The records for this resident were viewed. The home maintains receipts, and records matched the balance of money held. During the sampling of staff files, evidence was seen that one member of staff had received two recorded formal one to one supervision sessions. There was no evidence in the other two files sampled, to inform that these members of staff were receiving regular formal supervision. The manager stated he talks to staff every day, but the manager was advised this was not the same as formal, one to one recorded supervision. A requirement in regard to this has been made. The accident book was viewed, and there were two recorded accidents since January 2007. The manager informed the inspector that the accident of 28/01/07 was notified to the Commission For Social Care Inspection through the Regulation 37 notification. The other accident concerned one resident who had a fall in the garden and sustained laceration to their right arm. This had not been notified through the Regulation 37, and the manager has been advised that any event in the care home which adversely affects the well-being or safety of any resident must be notified to the CSCI. The Saturday before this site visit one resident passed away and the manager had sent a Regulation 37 notification to the CSCI. Regulation 37 requires the care home to notify CSCI of significant events that affect residents, such as serious accidents, serious illness, infectious diseases or deaths. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 25 A requirement was made at the inspection of the 26th February 2007 that all Policies and Procedures must be reviewed and updated to include any legislative changes including the health and safety policy. This will ensure that the health, safety and welfare of service users and staff are promoted and protected. The manager proceeded to add the date of this site visit to one policy, and stated ‘there, that has been reviewed’. The manager was advised that this is not good practice. This requirement had not been complied with from the inspection of 26th February 2007, and will be repeated in this report. As stated under the staffing section of this report, staff are not receiving mandatory training required by law. The management of the home has not fully complied with this requirement, which has been made continuously since 15th September 2005. The Annual Quality Assurance Assessment (AQAA) completed by the manager informed that annual servicing of equipment had been undertaken within the appropriate timescales. However, viewing these records during the site visit evidenced that in two cases the information was incorrect. The AQAA informed that the premises electrical circuits had been tested in June 2003. On viewing the last test certificate held at the home, this was dated as 4th February 1999. The Portable Appliance Test (PAT) according to the AQAA had been undertaken in May 2007, however, the certificate viewed stated the last test was undertaken in June 2006. The gas testing according to the AQAA was undertaken in May 2007, the certificate evidenced was dated 25/04/06. The manager informed the inspector this had been undertaken in May and would forward a copy of the certificate to the Commission For Social Care Inspection. Discussions took place with the manager in regard to providing false information in the AQAA. Evidence of annual testing on the stair lift, fire alarms, emergency call alarms and weekly fire alarm testing were viewed. The home had fire risk assessments in place. It was noted that the specialist, easy access bath had not been serviced by an external professional since it was purchased. Two other issues in regard to health and safety were identified during the site visit. Fire doors were being kept open through the use of wedges and other objects, and one smoke detector had the cover missing. Immediate requirements were made in regard to these. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 26 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 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 1 X 1 La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14 Requirement a) Pre – admission assessments must be conducted by a person who is suitably trained. Timescale from the inspection of the 26th February 2007 had not been met. b) Assessments must be completed prior to the admission of any new resident. Care plans must contain all the information required to meet the needs of the service user and where possible be signed by them or their representative. This will ensure that the health, personal and social care needs are set out in an individual plan and can be met. Timescale from the inspection of the 26th February 2007 had not been met. Risk assessments must be carried out on all daily activities carried out by the service users, DS0000013695.V338756.R01.S.doc Timescale for action 24/08/07 2. OP7 15 24/08/07 3. OP7 13(4) 24/08/07 La Luz Version 5.2 Page 28 the assessment must detail the concern, action taken and be dated, signed and reviewed regularly and when necessary. This will ensure that service users safety and well being is promoted and protected. Timescale from the inspection of the 26th February 2007 had not been met. 4. OP9 13 (2) Medication records must be held 24/07/07 to enable an audit trail to be followed and staff at the home must administer medication in accordance with the home’s stated policies and procedures. A review of the policy, procedure 24/08/07 and practices for the administration of medication must take place to ensure that they are up to date and accurate and that members of staff know what to do when administering medication. This will ensure that service users are protected by the home’s policy, procedure and practices. Timescale from the inspection of the 26th February 2007 had not been met. The home must provide a range of suitable recreational and social activities to all residents and ensure adequate records are kept. Timescale from the inspection of the 26th February 2007 had not been met. The menu must be updated to ensure that it is an accurate record of the food provided to service users. Where food DS0000013695.V338756.R01.S.doc 5. OP9 13(2) 6. OP12 16(m) 24/08/07 7. OP15 16(i) 24/08/07 La Luz Version 5.2 Page 29 supplements are in use provision must be recorded clearly including the reason why. This will ensure that service users receive a wholesome, appealing and balanced diet. Timescale from the inspection of the 26th February 2007 had not been met. 8. OP18 13 (6) A policy and procedure for safeguarding adults must be completed and implemented by the home. This will ensure that service users are protected from abuse. Timescale from the inspection of the 26th February 2007 had not been met. The broken bedside light in bedroom D must be repaired or replaced as this is a hazard to the health, safety and welfare of the identified service user. 24/08/07 9. OP19 23 (2) (c) 24/07/07 10. OP19 23(2)(b) The areas identified as in need of 24/08/07 repair or replacement must be undertaken to ensure residents live in a homely comfortable and safe environment. An accurate copy of the duty rota must be maintained and the rota must specify the care hours and separately identify the hours and times for domestic duties, including cooking, cleaning and laundry. This will ensure the home provides adequate staffing to carry out personal care tasks and make sure residents needs are met. A review of the staffing levels within the home must take place DS0000013695.V338756.R01.S.doc 11. OP27 18 (1) (a) 24/08/07 12. La Luz OP27 18(1)(a) 24/08/07 Page 30 Version 5.2 and ensure there are enough care staff on duty, taking into account the needs of the residents. This will ensure that sufficient staff are on duty at all times to meet the needs of the residents including care and domestic tasks. Timescale from the inspection of the 26th February 2007 had not been met. 13. OP29 19(1) (b) 19 (5) (c) Schedule 2 Ensure that persons employed to 11/09/07 work in the home are fit to work at the care home and the information and documents specified in paragraphs 1 to 9 of the Care Homes Regulation 2001 (amended) Schedule 2 have been obtained in respect of those persons. This requirement was made at the random inspection of the 11th June 2007 and is still within the time scale. A review of training provision must take place to identify training needs, plan dates and provide the training. Training must be provided to all members of staff including the registered persons. For example a formal induction programme for new staff, manual handling, first aid, risk assessment, administration of medication, Safeguarding Adults, and specialist training such as dementia and access to National Vocational Qualifications. This will ensure staff are appropriately trained including carrying out assessments. Timescale from the inspection of the 26th February 2007 had not been DS0000013695.V338756.R01.S.doc 14. OP30 18(c)(i) 26/09/07 La Luz Version 5.2 Page 31 met. Timescale from 11th June random focussed inspection re formal induction not met. 15. OP31 12 (1) (a) & 9 (2) The manager must attend up to date training to ensure that he has the qualifications and skills for managing the care home. He must ensure the care home is conducted so as to promote and make proper provision for the health and welfare. A system for carrying out a quality assurance audit must be put into place, implemented and the outcomes made known to service users and their relatives. This will ensure that the home is run in the best interests of the service users. Timescale from the inspection of the 26th February 2007 have not been met. The home’s policies and procedures must be reviewed and updated to include any legislative changes including the health and safety policy. This will ensure that the health, safety and welfare of service users and staff are promoted and protected. Timescale from the inspection of the 26th February 2007 had not been met. The equipment provided at the care home for use by residents and staff must be maintained in good working order. 24/09/07 16. OP33 24 24/08/07 17. OP38 13 (4) (c) 24/09/07 18. OP38 23 (2) (b) (c) 24/09/07 La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 32 19. OP38 23 (4) (c) (i) Fire doors must not be kept open 24/07/07 through the use of wedges or other objects, this is to ensure that the health, safety and welfare of service users is maintained at all times. The smoke detector outside 24/07/07 bedroom number 6 has the cover missing and must be replaced or repaired to ensure the health, safety and welfare of service users is maintained at all times. 20. OP38 23 (4) (c) (i) 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 OP29 OP10 Good Practice Recommendations All documentation in regard to recruitment should be translated into English. Daily records kept by the home should respect the privacy and dignity of residents and meet the requirements of data protection. This will ensure that service users are treated with respect and their right to privacy is upheld. La Luz DS0000013695.V338756.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI La Luz DS0000013695.V338756.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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