Inspection on 18/06/08 for Lady Spencer House

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Poor service.

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

Lady Spencer House 20/10/08

Lady Spencer House 06/02/08

Lady Spencer House 05/06/07

Lady Spencer House 22/11/06

Lady Spencer House 13/10/05

Lady Spencer House 26/04/05

Lady Spencer House 15/11/04

Lady Spencer House 29/09/04

Lady Spencer House 30/03/04

Lady Spencer House 23/10/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Lady Spencer House 52 High Street Houghton Regis Bedfordshire LU5 5BJ Lead Inspector Sally Snelson Unannounced Inspection 18th June 2008 10:10 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 Lady Spencer House DS0000014923.V364862.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. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lady Spencer House Address 52 High Street Houghton Regis Bedfordshire LU5 5BJ 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) 01582 868516 01582 868516 Resicare Homes Limited Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2008 Brief Description of the Service: Lady Spencer House is a residential home for older people. The home is situated within walking distance of the centre of Houghton Regis, and also provided easy access to the town’s amenities and to Dunstable. It is a modern, purpose built house over three floors, it offers accommodation in 24 single rooms. The communal space includes two lounges, one on the ground and one on the first floor. The ground floor lounge has a small conservatory added. A lift is used for access to the first and second floor. A number of toilets and washing facilities are located throughout the building. There are parking spaces behind the building that provide limited spaces for staff and visitors. The home also has a small back garden. Fees for this service range from £495.00 - £550.00 per week depending on room. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection of Lady Spencer House was a key inspection, was unannounced and took place over parts of two days. The first part involved the pharmacist inspector, Derek Brown carrying out an inspection of medication procedures on 18th June 2008. The second part, on the 20th June 2008, involved an inspection of other areas by Sally Snelson lead inspector and Angela Dalton Inspector. The manager Rehana Ali was present for the pharmacist inspection and from midday for the main inspection. At the time of the inspection she had been in post for less than a month. Feedback was given to her throughout the inspection and at the end. During the inspection it was planned to track the care of three people who used the service (residents). This involved reading their records and comparing what was documented to what was provided. However when it became apparent that the new manager, had not been able to alter and prepare all the necessary new documentation in the short time she had been in post, it was decided to track only one person in detail and sample other files, as we were aware that care records would not have changed significantly. However we did observe that many of the outcomes for people living at Lady Spencer House had improved. In addition to sampling files, people who lived at the home, visitors and staff were spoken to and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. We received one completed questionnaire from a service user and two from family members. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 6 At the time of the inspection there were 20 people living at Lady Spencer House and 19 staff employed to care for them. There were a number of requirements made at the end of this inspection and a timescale was given in which the provider should do them. An improvement plan will be requested to detail how the manager and provider intend to do this. Where requirements were repeated from previous inspection reports the date of the inspection was given as the date for compliance, as a new date cannot be given to an exsisting requirement. When it was not possible to assess a requirement the date of the inspection was also given to this repeated requirement. However, given the improvements so far, and that the new manager has only been in post a few weeks, we are taking a proportionate view and extending the timescale of requirements and not moving to enforcement. However, any further failure to comply will result in enforcement action following the next inspection. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: What has improved since the last inspection? The manager demonstrated a commitment to leading the team forward and staff, service users, and visitors were aware of the improvements she has made in the short time she has been managing the home. The accuracy of records made when medication is given to residents has improved but further improvements are needed. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 7 What they could do better: There are a number of requirements and recommendations made as a result of this inspection. It is also apparent from the completed AQAA that the manager also knows of improvements she needs to, and would like to, make. Some of the areas that need improving are:The home must ensure that the statement of purpose and service user guide contains all the relevant information as per the regulation. The home must evidence that each person using the service is provided with a statement of terms and conditions as per the regulation. The home must evidence that each person using service has a care plan which sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs are met. The home must evidence that each service user plan is reviewed and updated to reflect changing needs and current objectives for health and personal care. Including assessing service users for the risk of developing pressure areas, poor nutrition etc. Complete and accurate records must be kept of all medication received, administered, or not, together with a reason why the medicine was not given, in order to demonstrate that residents receive the medicines prescribed for them. Medicines including controlled drugs must be stored properly, securely, and in appropriate environmental conditions. All staff must be aware of how to safeguard vulnerable adults, including how to report incidents of suspected abuse. The home must evidence that appropriate actions have been taken to prevent risks from Legionella and from scalding. The home must evidence effective quality assurance and quality monitoring systems and must have an annual development plan for the home, based on a systematic cycle of planning - action - review - reflecting aims and outcomes for service users. The manager must ensure that all staff are offered meaningful supervision at least six times a year. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 8 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. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 9 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 Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 10 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): 1,3,6. People who use this service experience adequate quality outcomes in this area. The Statement of Purpose and the Service User Guide needed some changes to ensure they provided enough information for the people wishing to live at Lady Spencer House to make an informed choice and decision about the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In the short time the manager had been in post she had updated the Statement of Purpose and produced a Service Users Guide, which was enhanced by coloured photographs. Both documents could be provided in large print if needed and were displayed in the entrance hall of the home, along with the last inspection report. The manager now needed to check that Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 11 the documents contained all the information required by standard 4 and 5 and schedule 1 of the National Minimum Standards, and that the information was written in sufficient detail to describe the service. For example the Statement of Purpose stated that Lady Spencer House could accommodate people with a mental disorder, when in fact none of the staff had had specialist training, other than in the care of people with dementia. Some necessary changes and suggestions were discussed with the manager following the inspection. Because of concerns raised at previous inspections the commissioners had imposed an embargo on admissions to the home until improvements were seen. Therefore it was not possible to assess the quality of the pre-admission assessments or the admission processes under the new manager. However the written process for admissions was correct and offered potential residents the chance to visit the home in advance. The home did not offer intermediate care. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 People who use this service experience poor quality outcomes in this area. Medication practices and procedures have improved slightly but are still not robust enough to ensure that people receive their medication correctly at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The care plans were stored in the office on the second floor, and staff kept the daily notes on the ground floor and wrote in these. The manager had plans to change the care plan system, and she had someone coming to meet with her and discuss this imminently. She was also aware of the need to have the care plans with, or close to, the person they related to, so that staff would use them as working documents. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 13 The care plan looked at had not been reviewed monthly, had not been written or agreed with the service user, and did not cover all aspects of the persons care needs. For example, this person had a history of seizures, but there was no information about the type of seizure, or how a seizure should be managed. There was also a diagnosis of arthritis, and again nothing about the management or pain control. Risk assessments had been started, but had not been written in sufficient detail to describe how the risk was to be managed. For example, a person who was confined to bed did not have sufficient detail about the care needed to ensure the risk of pressure sores was reduced, such as nutritional screening and turning plans. Turning charts, fluid charts and continence chart were being used, but again they were not being completed in an accurate and meaningful way. For example, the 24-hour clock was not used, and statements such as ½ cup, did not indicate how much had been taken, as cups could be of all different sizes. It did however show that people were offered regular drinks and snacks. It was apparent from the number of different GP’s listed that the people living at Lady Spencer House were encouraged and supported to keep their family GP, if at all possible. Community nurse visited the home daily to administer a person’s insulin and to take blood sugar readings. Staff could therefore ask them for advise about any health matters when they were visiting. The nurses were also dressing a healing sore on alternate days. The home was very hot, it was a warm day and the heating was on and as a consequence a number of people were dozing. Staff were aware of the need to encourage extra fluids and all residents were offered a drink following an exercise session they had with the activity co-ordinator. We noted that a number of people had swollen ankles and legs and that there was little evidence of furniture that could be used to elevate their legs, such as footstools. A Pharmacist Inspector inspected practices and procedures for the safe use of medicines on 18 June 2008. He reported, ‘ The main storage area for medicines on the ground floor is secure but the temperature at the time of inspection was 25C. It is of some concern that the daily temperature records show it has been above this range every day (up to 28C) since 29/05/08. The storage of medication above the manufacturer’s recommended range could put residents at risk of receiving medication that is ineffective. The cupboard used for District Nursing supplies, which houses the medication fridge, is secure. The key is now kept with a staff member and not on a chain at the side of the door, as noted on the previous inspection. The temperature of the medication fridge is recorded daily and is satisfactory. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 14 There is now a second trolley on the first floor containing medication for those residents, which is stored in the first floor dining room. It is secured to the wall and locked when not in use. The manager plans to use one trolley for all medications and keep the medications waiting to be used or returned to the pharmacy in the second. The cupboard used to store controlled drugs still does not comply with the Misuse of Drugs (Safe Custody) Regulations. This has been recognised by the new manager and evidence that a proper cupboard has been ordered was seen There is no register in use for controlled drugs only bound exercise books, as before. The entry for one resident prescribed fentanyl patches states “transdermal patch”, i.e not the name of the medication and although the balance is recorded as 9, the actual stock is 19 since the new supply of 10 patches has not been recorded. Similarly for another resident’s temazepam, which is recorded as 7, the actual is 35. Records were made of when medicines were received into the home and the current stock left over was carried forward on the form. Records were made of when medicines were given to residents and these had improved over previous inspections, but there still were a few problems with these records. For three residents medicines had been omitted since they were out of stock, one for a period of 5 days. This means residents are not always receiving continued treatment and could be at risk. When medicines prescribed on a “when required” basis are not required there is a practice of recording a code “C” on the form which refers to a note made on the back of the form. This note reports what the medication is required for but does not clearly indicate if the medication has been given or not. There were number of stock discrepancies found where either there was more medication left over than there should have been if the records were accurate, and also in some cases less medication left over than there should have been. In the medication trolley there was an envelope containing medication but with the written instruction “[resident name] lunchtime medication (12pm)”. There was no indication of what this medication was. It was reported that this had been prepared for the resident to take out with them the previous day at lunchtime but they had not done so. However the record showed that the medication had been taken. A senior carer was observed giving medicines to residents at lunchtime and she did so hygienically and with regard to the person’s privacy and personal choice. For medicines prescribed a “when required” and variable dose (e.g. one or two tablets) basis there is a note on the back of the medication form of what the medication is required for but this cold be expanded and should form part of the care plan to give guidance as to what dose to give in what circumstances. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 15 Three of the five requirements made for medication (standard 9) on the last key inspection have been met (including the immediate requirements). The requirement for accurate and complete medication records has not been met fully. The timescale for this to be completed has been rolled forward 3 times and would now normally result in enforcement action. However, given the improvements so far and that the new manager has only been in post a few weeks, we are taking a proportionate view to extend the timescale of this requirement. However, any further failure to comply may result in enforcement action.’ We witnessed some very good interaction between staff and people living at Lady Spence House but we were concerned that two members of staff who had very little English could not make herself understood to us very well, so would have difficultly conversing with residents. However they were trying and were not conversing amongst themselves. We also saw staff walking into people’s room without first knocking and being given permission to do so. A visitor commented that there was nowhere in the home were they could meet with their relative in private, and told us that they had witnessed personal care being delivered in communal areas. They went on to say that over the last few weeks things had improved, but they were concerned that the communal space would be affected by the proposal to build additional bedrooms onto the home. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 16 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): People who use this service experience adequate quality outcomes in this area. The recent recruitment of a dedicated activity co-ordinator should mean that staff would be able to provide a range of stimulating activities that will meet the needs of the people living at Lady Spencer House. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: An activity co-ordinator had recently been employed to work part of three days every week. She had already set up an activity plan and had a number of ideas for the future. During the inspection we witnessed an exercise session and one resident was taken out for a walk. He told us, “I hadn’t been round the village for years and years, I went round today and it had changed”. The activity co-ordinator had arranged for an entertainer to come into the home the next week and was planning to invite friends and family to join the residents for a buffet. It is hoped that in the future the activity co-ordinator will be able to show, through documentation, that she had spoken with the people using the service about their past interests and hobbies and that she Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 17 had prepared an activity timetable that linked to their individual and collective needs. This timetable should be for all staff to work with so that people are offered stimulation all the time, not only when the activity co-ordinator is on duty. A record should also be kept of the people that participate in an activity and the outcome for them (care plan). A number of the people living at the home were availing themselves of the visiting hairdresser who comes in once a week to offer a service. Visitors confirmed that they could visit as and when they wished and that since the arrival of the new manager they are felt more welcomed. Staff did not open service users mail, but we were concerned that there was an unopened letter in a persons care file that could have been there for sometime and although staff were aware that the family dealt with correspondence there was nothing in the file to suggest this. People living at the home had the opportunity to chose and wear their own clothes. However some of the clothes were in need of repair and we were not sure that this was the person’s choice. For example some ladies were wearing cardigans with missing buttons and others were wearing socks with skirts. One gentleman had cut the sleeves off his jumper to make himself a short-sleeved jumper, but this looked very ‘tatty’. One person told us that due to her failing eyesight she preferred to stay in her room, as she felt more confident. This means that her choices were restricted and we did not see anything to suggest that the home was trying to offer her independence, such as a rail from her room to the communal areas, or that her choice to stay in her room and been explored and discussed with her. We also learnt that a persons who behaviour challenged was encouraged to spend time away from those who found the behaviours difficult. This also needs to be explored further to ensure everyone wishes and choices are met equally. We spoke to the cook who works 9am-3pm six days a week. She told us that she was looking forward to doing her own menu planning and shopping under the new manager. Currently the staff at another home in the group did it. The cook prepares and serves lunch, prepares tea, which includes a cooked option and makes a cooked breakfast on a Saturday. Care staff served the breakfast and tea. At lunchtime people had the choice of breaded fish or soft fish with parsley sauce and chips or creamed potatoes, or ham or egg salad, followed by lemon crunch, yoghurt or fresh fruit. Because everyone was using the ground floor communal areas (because the first floor lounge was being decorated) the area was cramped and staff were standing over, or perched on the arms of the chair, of people they were supporting at lunchtime. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 18 People living at the home were offered a choice of meals in the morning for that day. The cook was aware of the need to look into photo menus to help those with dementia and poor communication skills. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 19 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): People who use this service experience adequate quality outcomes in this area. The manager indicated that she had a clear understanding of the procedure for processing complaints. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager told us that there had not been any complaints made to, or about, the home since her appointment. She had written a complaints policy as part of the Service Users Guide and was clear that she needed to document any complaints made and how they had been investigated, and include the outcome. We were therefore confident that in the future complaints would be dealt with appropriately. The introduction of a key-working system would also make it easier for people living at the home to relate to a member of staff and share concerns. Some staff had completed safeguarding training and while we were at the home the manager secured places for five staff on training run by the Local Authority. The manager had secured a copy of the local safeguarding policy, and was aware of her responsibility to refer any suspected abuse, or injuries that could not be accounted for. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 20 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): 19,26 People who use this service experience adequate quality outcomes in this area. The home was clean and tidy and the manager was making every effort to make it more homely for the people who lived there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There had been no major changes to the environment since the last inspection. However since being employed the manager had thrown away much of the furniture from the first floor lounge, which she considered unsuitable for the needs of the residents, and had requested the handyman to redecorate the lounge. The redecoration of the lounge meant that other communal areas Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 21 appeared cramped as the entire home were sitting in the ground floor lounge or the conservatory. The entrance to the home was dim and having a light on made it feel hot. It was also the only area of the home that had an odour, but it was the area that everyone went through, and gave some people their first impressions of the home. The smell was from the carpet in one bedroom, which was regularly washed, but this was not solving the problem. We discussed the different options available as floor coverings and possible ideas of addressing the problem with the manager. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 People who use this service experience adequate quality outcomes in this area. If the manager continues to show a commitment to staff training, there will be evidence that the staff team have the skills, training and experience to care for the people living at Lady Spencer House. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager reported that some staff had resigned when she had first started, but she had successfully advertised and recruited to these posts and was ready to start replacements when their checks were completed. She had a permanent staff group of 19 staff and on duty on the morning of the inspection there was four care staff, a cook, two domestics and an activity co-ordinator. There would be four staff on in the evening and two overnight. There was nothing to suggest that this ratio of staff to service users, at the time of the inspection, did not meet the needs of the people living at the home. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 23 Staff reported that they were working extra shifts. Some were doing 14-hour days, but the manager told us that she insisted that had regular days off, and no one complained about the extra duties when it was necessary. Staff that worked long days were offered a meal at the home. The duty rota did not indicate who was the shift leader and a swap that had been made for that day was not documented. Staff rotas are one of the documents that have to be kept by the home for at least three years. The manager had tidied all the staff files and had divided them, making a second file up as a training file. The information from the training file had been used to start a training matrix, so that she was aware of what training staff had had, needed and needed refreshing. The training matrix needed to include induction training and some specialist training to provide the evidence that the staff team was able to meet the needs of the people living at lady Spencer House. The manager had already secured places for five staff to do an NVQ level 2 qualification, which would ensure that the home had in excess of 50 of the staff trained to this level or above. During the process of tidying the staff files the manager had identified documents that were missing or needed explaining in staff files. For example, job descriptions had not been updated as roles had altered. We looked at a file the manager had made for a person she had recently interviewed and was waiting to start. It had all the necessary documentation and clearance checks to ensure that the staff were suitable to work with vulnerable people. Staff files also included copies of the equal opportunities policy, health and safety policy and the medication and fire procedures. Staff were asked to sign these to confirm that they had read them. Staff also signed to agree that if they left within a year of completing a training course £25.00 would be taken from their final salary. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 24 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): 31,33,36,37,38 People who use this service experience adequate quality outcomes in this area. The manager demonstrated a commitment to leading the team forward and staff, service users, and visitors were aware of the improvements she has made in the short time she has been managing the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager had NVQ level4 and the Registered Manager Award (RMA) and was currently studying to become an assessor. She was hoping to complete our registration process as soon as possible to become the registered Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 25 manager. The staff team would benefit from knowing that they are being lead by a manager who is experienced and committed to them and the people living at Lady Spencer House. A quality audit had been sent to family and friends of the people living in the home on 11th April 2008. This questionnaire was not a true questionnaire as it had asked for information that needed a reply and so could not be anonymous. However it was apparent that changes had occurred as a result of the audit. For example there had been improvements in the type and amount of activities provided, and the cook now offered the option of a cooked breakfast on a Saturday morning. We were not aware of the proprietor completing a monthly report, which would also assist the manager in planning services, and was a requirement under Regulation 26. We also did not see an annual development plan but the manager told us that there were plans for the home to change Responsible Individual (RI) as part of the de-merger of Resicare Homes Ltd. According to the manager, the current RI, Mr Thandi, was not active in the home. Following the inspection we received an AQAA from the manager and this also showed us her plans for improving the home. The home only held monies on behalf of two service users and it was reported that these were rarely used; they were not looked at during this inspection. Staff supervision over the past two years had been extremely ad-hoc For example, one file showed that a member of the care staff had been supervised in January and March of this year but before that in 2006. The manager had made a plan, that if kept to, would ensure that staff were supervised the required six times a year. She also planned to change the documentation so that staff had the opportunity to discuss a number of issues during supervision and make this a meaningful time. As referred to in this report staff must ensure that documentation is completed accurately and all the records detailed in schedule 4 of the national Minimum standards are in place The manager had made arrangements for the handyman to do all the regular safety checks in the home and had made herself aware of the fire systems. The cook was completing fridge and freezer temperatures daily. Lady Spencer House DS0000014923.V364862.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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 X X 1 2 2 Lady Spencer House DS0000014923.V364862.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 OP1 Regulation 4, 5, and Schedule 1 Requirement The home must ensure that the statement of purpose and service user guide contains all the relevant information as per the regulation. The home must evidence that each person using the service is provided with a statement of terms and conditions as per the regulation. This requirement could not be assessed at this inspection. 3. OP7 15 schedule 3 (1) (b) The home must evidence that each person using service has a care plan which sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs are met. 18/06/08 Timescale for action 01/09/08 2. OP2 5 (b) (c) schedule 4 (8) 18/06/08 4. OP7 15 (2) This requirement is re-stated, previous timescale 15/03/08 The home must evidence that 18/06/08 each service user plan is DS0000014923.V364862.R01.S.doc Version 5.2 Page 28 Lady Spencer House reviewed and updated to reflect changing needs and current objectives for health and personal care and actioned. This requirement is re-stated, previous timescale 15/03/08 5 OP8 13(4) Staff must assess service users for the risk of developing pressure areas, poor nutrition etc. Complete and accurate records must be kept of all medication received, administered, or not, together with a reason why the medicine was not given, in order to demonstrate that residents receive the medicines prescribed for them. This is a repeated requirement. Previous timescales of 31/12/06, 30/06/08 & 29/02/08 not fully met. 7. OP9 13(2) Medicines including controlled drugs must be stored properly, securely, and in appropriate environmental conditions. This will protects residents from harm and their medication from diversion. This is a repeated requirement. Previous timescales of 29/02/08 not met. 8 OP18 18 All staff must be aware of how to safeguard vulnerable adults, including how to report incidents of suspected abuse. The home must evidence that appropriate actions have been taken to prevent risks from Legionella and from scalding. DS0000014923.V364862.R01.S.doc 01/09/08 6. OP9 13(2)17(1 )(a) 18/06/08 18/06/08 01/09/08 9. OP25 13 (4) (a) (c) 18/06/08 Lady Spencer House Version 5.2 Page 29 This requirement was not assessed at this inspection. 10. OP33 24 (1) (2) (3) The home must evidence effective quality assurance and quality monitoring systems and must have an annual development plan for the home, based on a systematic cycle of planning - action - review reflecting aims and outcomes for service users. This requirement was partly met but is re-stated, previous timescale 15/03/08 11 OP36 18(2) The manager must ensure that all staff are offered meaningful supervision at least six times a year. 01/09/08 18/06/08 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 3 4 5 6 7 Refer to Standard OP7 OP10 OP12 OP14 OP15 OP28 OP30 Good Practice Recommendations Wherever possible a care plan should be drawn up with the involvement of the person it relates to. Consideration should be given to providing a private area for visitors to meet with residents. There should be evidence that the activities provided meet the needs of the service users. There should be documentation to support a service users decision to wear inappropriate or ‘scruffy’ clothes. Staff should sit at the same level as people they are supporting at mealtimes. The manager should continue to encourage and support staff to complete NVQ training. The manager should continue to ensure that the staff team have the necessary skills and qualifications to care for the DS0000014923.V364862.R01.S.doc Version 5.2 Page 30 Lady Spencer House 8 OP31 people living at Lady Spencer House. The provider should support the manager so that she stays in post and goes on to become the registered manager. Lady Spencer House DS0000014923.V364862.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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