CARE HOMES FOR OLDER PEOPLE
La Luz 4 High Street Tadworth Surrey KT20 5SD Lead Inspector
Lesley Garrett Unannounced 03 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service La Luz Address 4 High Street, Tadworth, Surrey, KT20 5SD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01737 813781 Mr Angel Soto, Mrs Maria Del Carment Soto, Mr Jose Manuel Castro, Mrs Aurea Castro Mr Angel Soto Mrs Aurea Castro Care home only (PC) 16 Category(ies) of Old age, not falling within any other category registration, with number (OP), 16 of places Dementia - over 65 years of age (DE(E)), 5 La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Date of last inspection 09 Novemeber 2005 Brief Description of the Service: La Luz is a large detached house in a residential road in Tadworth. The home is registered for 16 older people over the age of 65 years. The home has fourteen single bedrooms and one shared bedroom. Three bedrooms offer ensuite facilities. The home provides car parking to the front of the house and has a large rear garden. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection by the Commission for Social Care Inspection for 2005/06 and two inspectors were in attendance. Service users were sitting in the lounge or conservatory and were willing to speak to us. The lunch was being prepared with pleasant aromas coming from the kitchen. The Manager was helpful and we would like to thank him for his assistance during this inspection. The requirements from the last inspection had now been met but business and financial plan had not been sent to CSCI as recommended as the owners are in the process of selling the business. What the service does well: What has improved since the last inspection?
The home is about to be sold by the present owners. The requirements from last inspection had been met. The bedroom that had suffered damp has now been dealt with it required an extractor fan to be installed and this has now been completed. The manager still finds it difficult to approach service users or their representatives about issues surrounding death but he has now started to document these issues in care plans. No service user has requested a lock on their door.
La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 & 5 Prospective service users and representatives are able to make an informed choice prior to admission and information is available to them. EVIDENCE: Service users needs are assessed prior to admission. The files that were seen, during this inspection, all contained pre-admission assessments. There is a service user guide available to all new service users containing all the relevant information. The staff welcomes visits to the home prior to admission and this allows all new service users and representatives the opportunity to see the home and assess the quality for themselves La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 & 10 Service users have individualised care plans and have support from their local G.P, CPN and district nurse. EVIDENCE: Care plans were seen and those sampled showed individual care plans, which were reviewed on a monthly basis. There was a range of documentation and the daily notes were hand written twice a day and then produced on the computer. The G.P and district nurse are a good support to the home both based nearby. On the day of inspection the district nurse also called to see one service user. The CPN can be contacted if needed. Community Eye Care visits twice a year for regular NHS eye tests. The dentist visits every six months and the chiropodist visits as necessary. No service user is self-medicating. There is no medicine trolley and all medication is in a locked cupboard in the office. Service users have their own named tablets. The home uses bottles not blister packs. The tablets are put into pots one service user at a time then taken to them from the cupboard. Only one service user was on a controlled medication, which was Temazepam. The controlled drug book was checked and the total was accurate.
La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 10 Privacy and dignity policy was seen and when speaking to a member of staff she had a good knowledge of this. All rooms are single with one double room, which has only one service user at the moment. A curtain divides the room for double occupancy to ensure privacy. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 There is no formal activity provision in the home but service users maintain contact with family and friends. Meals are cooked on the premises. EVIDENCE: There was no evidence of formal activity arrangements. Any organised activity will take place in the afternoon and is usually a board game or cards. The service users are asked if they wish to participate but generally they enjoy a rest in their chair. Religious services are held every other week but one service user maintains links to the local church and was attending a meeting the afternoon of inspection. She also attends Sunday services and her friend collects her on these occasions. Outings have been arranged in the past and visits to the local shops are taken and staff will accompany them. Birthday parties are also organised. All meals are prepared and cooked on the premises using fresh ingredients. On the day of inspection the service users were enjoying mixed grill. There is a four-week menu plan. Special diets are also catered for. There are two diabetics and food can be pureed if necessary. The dietician can be contacted for advice with any special diet. Reference to eating and diets were seen in the care plans sampled. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 There is a complaints procedure and staff are aware of the abuse policy. EVIDENCE: There is a complaints policy, which is displayed in the reception and is also in the service user guide. This is made available to all new service users and their representatives and contains the address of CSCI. This was not discussed in detail with the service users. The last complaint received was in 1997 and the Manager resolved this. The home has an abuse policy and also a copy of the Surrey Multi Agency procedures. The member of staff spoken to by the inspector showed a good knowledge of the abuse policy. Service users are responsible for their own money, which is given to them by their families or representatives. The home does not hold any of their money. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,24,25&26 Service users live in a pleasant environment with access to the garden. Their rooms have been personalised and the home was clean and tidy. EVIDENCE: The home was clean and tidy and free from offensive odours. Service users were sitting in the lounge or conservatory and were able to walk freely to their rooms or bathroom. There is a well-maintained garden with a purpose built ramp for easy access. On the day of inspection it was raining but in good weather the manager stated that a gazebo is erected to give shade if they wish to sit outside. The bedrooms had been personalised with pictures on the wall and their own ornaments and possessions. Please see standard 38 (health & safety) The home was clean and all communal areas and bedrooms smelt pleasant. There was no offensive smells. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 & 30 There was a mix of staff on duty on the day of inspection. The recruitment policy was seen and staff files seen. EVIDENCE: The registered manager, his wife and one carer were on duty on the day of inspection. The carer stated this was sufficient to meet the needs of service users as some liked to be up early and providing they did not require a bath the night staff helped to get them washed. The recruitment files were seen and all had application forms, two references and all but one had CRB checks. Only one file had a photograph in place. Two carers had completed NVQ level 2 and were awaiting their certificates. The domestic had completed her NVQ level 1 in housekeeping. The registered manager had City & Guilds in advanced management, which is equivalent to NVQ level 4. Mrs Soto, who does most of the cooking, has basic food hygiene certificate. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Only 38 was looked at on this occasion as there were some health and safety issues to address by the owners. EVIDENCE: There is a split in the carpet in the main dining area of the lounge, which could be a trip hazard. There are no covers on the radiators or pipes in communal areas or bedrooms. Chemicals were found in easily accessible cupboards e.g. Hydrogen peroxide, air freshener and harpic toilet cleaner in communal bathrooms. Also in bathroom cupboards were talcum powder, diprobase cream for named service user and shampoo. There were no hand towels available in bathrooms or soap dispenser but there were communal soap bars which is not in line with infection control. No taps had thermostatic control valves except for the baths. Window restrictors were in place and working.
La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 1 2 x x x 1 1 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 1 La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 17 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19.1&2 Regulation 13(4) (c) Requirement Carpet is split in the dining area of the lounge.This is a trip hazard Manager to ensure repair or replacement There are no covers on the radiators or pipes arrangements must be made to cover these Toxic chemicals should be in a locked cupboard and all toilettries should be kept in each service users bedroom and not in communal bedroom. There was soap and towels in communal bathrooms and no soap dispensers or paper towels to comply with infection control procedures. Valves to be fitted to the taps that service users have access to. One staff member had a police check a CRB check must now be completed Fire alarms to be tested and recorded at least weekly and drils and evacuations to be practised twice yearly. Timescale for action 2 weeks 2. 3. 25.5 38.4 13(4) (a) (c) 13(4)(a) one month Immediate 4. 26.3&5 13(3) Two weeks 5. 6. 7. 25.8 29.3 38.2 13(4)(c) 7 19 & schedule 2 23(4)(v)( d)(e) One month Immediate Immediate 8. La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations La Luz H58 S13695 La Luz V223791 030505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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