Inspection on 06/02/08 for Lady Spencer House

This inspection was carried out on 6th February 2008.

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

Lady Spencer House 20/10/08

Lady Spencer House 18/06/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lady Spencer House 52 High Street Houghton Regis Bedfordshire LU5 5BJ Lead Inspector Pursotamraj Hirekar Unannounced Inspection 06th February 2008 12:00 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 Lady Spencer House DS0000014923.V358650.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.V358650.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 no email as at 4.7.7 Resicare Homes Limited Vacant post 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.V358650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th September 2007 Brief Description of the Service: Lady Spencer House is a residential home for older people, specialising in the care of people with mental and physical disabilities. The home was situated within walking distance of the centre of Houghton Regis, and also provided easy access to the town’s amenities. It is a modern, purpose built house and with three floors, it offered accommodation of 24 single rooms. The communal space included 2 comfortable lounges, one with a small conservatory attached, for service users to sit together, and the staff are able to spend time with them, paying attention to all individuals. A lift was used for access to the first and the second floor. A number of toilets and washing facilities were located throughout the building, allowing easy access. The parking space behind the building and a small garden was sufficient for staff and visitor’s cars. Fees for this service range from £445.00 - £485.00 per week. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 06/02/08 by Pursotamraj Hirekar over 7 hours 50 minutes. A specialist pharmacist inspector Derek Brown looked at medication handling procedures, medication storage, medication records, and associated care records; and watching some medicines being given to residents. The trainee manager coordinated the inspection and the responsible individual was available for part of the inspection and a feedback. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, relevant care delivery documents, and discussions with staff, conversation with service users’, relatives of people using service and partial tour of the building. A random inspection was carried out on the 24/09/07 to check the compliance of out standing requirements from the previous key inspection and the findings are also considered in this report. What the service does well: What has improved since the last inspection? What they could do better: Practices and procedures for the safe handling and administration of medicines must be improved to make sure residents receive the medicines as prescribed for them by their GP and that they are given safely. The home must evidence that so far as is reasonable practicable the health, safety and welfare of service users is met. The home must evidence all care staff receive formal supervision at least 6 times a year. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 6 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 home must have a registered manager to run the home and meet its stated purpose and objective. The home must ensure that the statement of purpose and service user guide contains all the relevant information as per the regulation, is reviewed, and updated to reflect the current changes. 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 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 person’s care plan meets relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, with particular attention to prevention of falls. 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 and actioned. The home must evidence that each person’s care plan is drawn up with the involvement of the service user; agreed and signed by the service user whenever capable and/or representative if any. The home must evidence that each person using the service had the opportunity to exercise their choice in relation to leisure and social activities. The home must evidence that each person’s care plan must identify diet required, health care professionals advice received where necessary and details of any plan relating to the service user in respect of nutrition is provided. The home must evidence that each person using service and their family members are enabled to easy access of current complaints policy and procedure. The home must evidence that all allegations and incidents of abuse are followed up promptly and action taken is recorded. The home must evidence that appropriate actions have been taken to prevent risks from Legionella and to prevent from scalding. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 7 The home must evidence all staff have two written references are obtained before appointing and any gaps in employment are explored. The home must evidence all staff are confirmed in post only following completion of a satisfactory police check. The home must evidence that all staff have received all the mandatory training for the job roles they perform. 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.V358650.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made arrangements for pre-admission assessment of the potential people wanting to use the service. The home was not able evidence that the potential service user or their representatives were engaged in the needs assessment and agreed with the outcome. Also, the statement of purpose and the service user guide did not provide enough information for the people to make informed choice and decision. EVIDENCE: On this inspection a sample of 5 service users needs assessments were seen, the preadmission assessments carried out were detailed which covered information about personal care and physical well being, diet and weight, dietary preferences, sight, hearing and communication, foot care, mobility and dexterity, history of falls, continence, mental state and cognition, religious and cultural needs, personal safety and risk, carer and family involvement. However, none of these care plans had evidence that service user’s or their representatives have participated and agreed. Some of these assessments Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 10 were signed by care staff, not dated, and have used assessment format of Ashton Lodge, another home, instead of Lady Spencer House. The home was unable to provide service user contracts that detail terms and conditions within the home. The statement of purpose and service user guide had not been updated to include information about the new manager and the commission’s new address as well. Also, the service user guide presented on this inspection was different to the one that was presented on the random inspection dated 24/09/07, which covered details (1). Full board and accommodation costs, including all lighting and heating (2). Full 24-hour personal care (3). Full catering including provision for special diets (4). Personal laundry (but not delicate or dry cleaning items) (5). All communal facilities. However, section 1.2 of the guide stated the charge is £ (blank) per week, reviewed six to eight weeks after admission. Nevertheless, under fees and room reservations section, the guide mentioned, the fees in this home range from £425/- to £495/-. This home was not presently providing any intermediate care. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual care plans are incomplete and do not reflect changing needs to provide appropriate information for the staff to refer before providing care. The systems and practices for the administration of medication are failing which may compromise the safety and well being of service users. EVIDENCE: A random inspection was carried out on the 24/09/07 to check with compliance of out standing requirements from the previous key inspection and the findings are as follows: The home in their improvement plan dated 30/08/07, which the commission received on 03/09/07, stated that MAR sheet provided by the chemist have now reverted back to the original code system. One system is now in place and all staff has been retrained and have an understanding of the present code system. Management with regard to coding and signatures makes regular checks of the MAR sheets. With regards to reconciliation the stocks remaining, again management are checking on a regular basis. Training has also been given regularly to ensure all staff dispensing medication shows a good knowledge and understanding. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 12 On this inspection it was found that the home has been using a MAR sheet with codes provided at the foot by the chemist. The codes are A=absent, N=nausea or vomiting, H=hospitalised, D=destroyed, R=refused, C=carer’s notes, O=other (define). During the random inspection of 24/09/07, 5 service users’ MAR sheet and the stocks remaining were seen with regards to their reconciliation. When medication was administered to people who use this service it was not clearly recorded to ensure that people have received the correct levels of medication. The summary findings of 5 service users’ are as follows: Service user – 1-Diazepam 2mg tablets recorded on MAR sheet, as O. There was no other information recorded anywhere else, to know the meaning of O, as mentioned at the foot of the MAR sheet. Temazepam – 10mg tablets of control drug was recorded as given in the control drug register, but the MAR sheet was blank for this medication. However, the available stock of medicine and the control drug register matched. Service user – 2 Fybogel total stock 87, administered as per the MAR sheet on 2 days, the stock available on the day of this inspection was 84, and there was no information provided with regard to the 1 medicine missing. Meloxicam – 7.5mg tablets total tablets 48, administered as per the MAR sheet for 11 days, the stock available on the day of this inspection 41 tablets, this means the stock had 4 tablets in excess. Service user – 3 Zopiclone – 3.75mg take one at night; the total quantity received was not recorded on the MAR sheet. The stock had 47 tablets and it was difficult to reconcile with the MAR sheet. Further, the home had used two different chemists MAR sheet that had two different sets of codes at the foot, for the same duration of medication. The home should endeavour to correct and maintain one single coding system for clarity of purpose. Service user – 4 reconciliation of MAR sheet with medicine in stock had no issues. Service user – 5 furosemide 40mg tablets, total 31 tablets, administered 11 as per the MAR sheet, as on 23/09/07. The stock available in the home was 18, which means there was no information with regard to 2 missing tablets. On this Key Inspection of 06/02/08, a specialist pharmacist inspector looked at medication handling procedures, medication storage, medication records, and associated care records; and watched some medicines being given to residents. Written medicine handling procedures were available to the care staff but these are not always followed. Clear records were kept of all medicines Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 13 coming into and leaving the home. Records were kept when medication was given to residents. However, there were some problems with these records. It was not always possible to account for all the medications in use, as the date on which the container was started was not recorded. Some medication was recorded as given to a resident but the corresponding dose remained in the blister pack of medicines. If medicines were not given to residents the reason why was not being clearly recorded. One resident was prescribed a painkiller in the form a skin patch to be applied every three days and the records showed that it was used every four days. This resident was also not given the dose of paracetamol prescribed by their GP. An immediate requirement notice was served to investigate why this resident did not receive their medication as prescribed. Another resident’s medication form stated that a cream should be used for “one week only” but it had been recorded as being used continuously for the previous 15 days. When medication is prescribed on a “when required” basis, there are no guidelines in care plans for their use. This is important to ensure there is a consistent approach by staff and residents do receive treatment inappropriately. Some of the hand-written medication record forms did not clearly indicate the date on which medication is given. When handwritten additions or alterations were made to the computer printed medication administration record charts, supplied by the pharmacy, these were not signed and checked for accuracy. Residents had their medication given to them by designated trained care staff. One carer was watched giving medicines to some residents during the site visit. She was seen to given medication to several residents by handling the tablets without washing her hands in between, the medication trolley was left unattended in a communal area whilst medication was given to residents in a dining area, medication was assembled for several people at once and the records that they had taken the medication were signed before they had done so. These practices carry a serious risk of medication error and unacceptable infection control standards. An immediate requirement notice was served to make sure residents are protected by being given medication safely and that the records are completed properly. The cupboards where medication is stored were secure but the key to the cupboard where the medication fridge is, along with some other medication, hangs on a hook and chain at the side of the door. This is outside the bedrooms of 3 residents who could easily gain access to the medication unsupervised. No temperature records are kept of the medication storage rooms, which were at the high end of acceptable limits at this inspection. The failure to store medicines at the proper temperature could result in residents receiving a treatment that is ineffective. Daily refrigerator temperature records were kept. Controlled Drugs were being stored in a locked cupboard but this does meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 (as Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 14 amended). The usage of Controlled Drugs was being recorded in separate books but these were not as stated in the regulations. The balances recorded of the controlled drugs did not tally with what was in stock. On this key inspection of 06/02/08 a sample of care plans and care review documents were seen and found that the care plans were incomplete and did not provide enough details for the care staff to refer to and provide appropriate services. There was no evidence to suggest that the service users or their representatives were engaged in the care plan preparation and they had agreed to the planned care services. For example one service user was risk assessed for falling as high and ½ hourly checks in place. This changing need was not reflected in the care plan. Also, under diet weight and dietary preferences, it was recorded that they are diabetic and tablets control this. The home had not carried out nutritional assessment, to support the food provided was a balanced diet. The weight record for another person detailed that between February and August 2007 their weight had dropped from 8 Stones to 5 stones 8lbs, the latest record was dated 07/01/08 which recorded that the person was non weight bearing. It appears that, the home had not made any efforts to find out the reasons for weight loss and had not carried out a nutritional assessment. For another person a preadmission assessment was carried out on the 28/11/07 and the date of admission was on 30/11/07. However, in the absence of a detailed care plan being in place, it was difficult to understand on what basis the care was being provided by the home. The risk assessment rated high, for falling and there was no plan of action in place, to address this. Another person had difficulty eating food; we were told that every day her husband visits the home for lunch and dinner to feed her. On the day of inspection, her husband had not come to feed her lunch and she did not eat her lunch. This was confirmed by her daughter visiting on the day, who said ‘today dad has not come for lunch and she did not eat’ this was further confirmed by the daily report maintained by the home which recorded ‘ate her breakfast but not her lunch – very unsettled trying to leave lounge’. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The quality and amount of suitable activities provided by the home was unsatisfactory resulting in people who live at the home having little opportunity to pursue interests or activities. EVIDENCE: The home was unable to provide recorded evidence of a plan for daily activities. There was no evidence to support what activities have taken place that were meaningful, suitable, or stimulating and always suit the service users expectations, preferences, or capacities. For example, the television was switched on the ground floor lounge and most of the users were seen to be sleeping. One service user said I do not like TV, but I like audio music. However, there was no music being played in the ground floor lounge. On both the floors, there was very limited interaction among the staff and people using services. Most of the day the people who live a the home were seen to just sit on the their chairs. During the inspection staff members were found to be sitting in the dinning area of the ground floor with service users’ records and for more than an hour there was no interaction whatsoever with the people who live at the home There was no evidence that any staff had attended any specialist training to support them to deliver suitable activities. There was no Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 16 activity schedule for staff to follow, and no evidence to demonstrate that service users had been consulted about their interests. Evidence suggested that service users were able to maintain regular contact with their relatives and friends without restrictions and were supported to maintain contact if they wished, by the home. Relatives who were spoken to during the inspection said they felt welcomed by the home when visiting and knew that they could visit at any time. There was evidence that service users were encouraged to bring personal possessions with them into the home. Menus examined found that there was no evidence to suggest that people using services were consulted and offered choice regarding a nutritious and wholesome diet, with a balanced and varied selection of foods. Nutritional needs assessments and corresponding balanced diet had not been introduced by the home. As detailed in the previous section of this report one person had lost a significant amount of weight and there was no evidence that this had been investigated or followed up. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have satisfactory complaints or safeguarding adult procedures, which ensure that complaints are listened to and service users safeguarded. EVIDENCE: During the random inspection of 24/09/07, the then trainee manager stated, that she was not aware prior to the previous key inspection, of the process to reports incidents at the home to the safeguarding team, and was dependent on the head office. However, at this inspection the current trainee manager said she feels confident of handling safeguarding issues and in reporting to the appropriate offices as required. Evidence seen demonstrated that the trainee manager had made appropriate referrals. On this key inspection of 06/02/08, it was found that the home did not have a satisfactory safeguarding of vulnerable adults (SOVA) policy or procedure to deal with complaints. The statement of purpose and the service users’ guide did not include the current information about complaints procedure. Some staff had not attended SOVA training. Relatives spoken to were not aware of the home’s complaints procedure and were not confident that they would be listened to. Since the previous inspection the home had made 15 SOVA referrals to the social services and there was no evidence to suggest what follow-up actions Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 18 and preventative measures had been taken regarding the incidents, which led to these referrals. For example, one person had a fall on 10/01/08 whilst being assisted out of an armchair and dropped to the floor sustaining superficial injuries; there was no record of any action taken. For the same person the records detailed that after being found on the floor in the bedroom they were to have extra checks during the night, there was no evidence that this had happened. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 19 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, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was maintained clean without any offensive odour. The outcomes from risk assessment of the premises were not actioned, which could place people using the service at risk. EVIDENCE: During the random inspection carried out on the 24/09/07 it was found that the home had made arrangements with regards to the clinical bin being emptied twice weekly, and all the staffs have been informed to empty as and when required with in their shift. The clinical bins were inspected in the home and in the car park, the arrangement was found appropriate. During the key inspection of 06/02/08,a partial tour of the premises was undertaken and a sample of relevant documents were seen and found that the home was maintained clean with out any offensive odour. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 20 The risk assessment carried out by the home for bathroom, shower, and nurse call recorded severity risk – 9 on a scale of 1-10. There was no evidence to suggest what actions have been taken to rectify the situation. Also, the service user bedroom – 3 sink water temperature risk assessed as severity – 8 on a scale 1-10. There was no evidence of any action taken to rectify the situation. The situation appeared to be the same for most of the bedrooms. The responsible individual agreed to review this urgently. Emergency lighting, fire drills, and water temperature checks were carried out monthly. However, the water temperature checks were not carried out after December 2007. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff are generally sufficiently trained in mandatory subjects however the recruitment practices of the home are not robust to ensure that people who use this service are always properly supported and safeguarded. EVIDENCE: During the random inspection of 24/09/07, 3 staff members’ references were seen and found that, there are still outstanding issues with regards to the recruitment process as practiced by the home. For example, staff member –1 had not received the reference from the original referee as mentioned on the job application, therefore the home had written a note on the staff file that ‘ Staff reference not returned and 2nd reference from the employer received’. member – 2-job application had incomplete employment history and the name of referees’ section was blank. The references received by the home do not match with the previous employer. Staff member –3-job application had incomplete employment history and the references received do not match with the previous employer. On this key inspection of 06/02/08 a sample of staff records were seen, it was found that for one staff member their job application was completed in respect of a ‘sister’ home dated 22/07/05, there was no evidence of a previous employers reference being obtained, the CRB dated 03/06/05 had employer as Best Care Employment 2000 Ltd. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 22 For another person there was no evidence of the action taken following receipt of a positive CRB report. The employment contract that was signed was left blank in the space provided for the employee surname and forenames. For another person the application form referred to a senior care assistant and the contract as care assistant. However, the supervision record of 11/11/07 and 11/01/08 referred to this person as trainee manager. The responsible individual confirmed verbally during the inspection, that this person is a trainee manager of the home and would amend the recruitment records. There was no information made available with regard to this person’s qualifications and experience to support her role as a trainee manager of the home. Lady Spencer House DS0000014923.V358650.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): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have appropriate management systems and practices. Non- compliance with previous requirements indicates that the safe running of this home continues to be compromised and not in the best interest of the service users. EVIDENCE: The home does not have a registered manager. During the random inspection of 24/09/07 it was found that the home had made some progress with regard to the application to the commission for registration as manager. On the key inspection of 06/02/08, it was found that the home has a new trainee manager working since November 2007. As stated in the staffing section of this report there was no information provided with regard to her qualifications and experience to match the suitability of her role as a trainee Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 24 manager or evidence of how she had been recruited to this position. The trainee manager informed us on this inspection that, she has completed NVQ level 3 on the 07/08/07 and had enrolled for the RMA, which was scheduled to begin on the 03/10/07, she also said she has received the application pack from the commission for registration. When the trainee manager was asked about her knowledge of the random inspection in September 2007 she said she was not aware of this inspection and had not seen the report. As part of the quality assurance, the home had received feedback from the people using services in the month of March 2007 and there was no evidence provided to show the feedback was analysed and the recommendations were actioned on time. The quality assurance policy of the home stated to carry out at least one quality audit on an annual basis and there was no evidence found that this has been done. The home had not provided information with regard to regulation 26 visit reports. At the last key inspection there were concerns regarding the conduct of this home and requirements were made. At this inspection there was little evidence of improvements and CSCI has concerns regarding the willingness and ability of the registered people to comply with the requirements of the law. Following this inspection, feedback was provided to the responsible individual and the trainee manager, who said they would provide an action plan for improvement. Failure to comply with the Care Homes Regulations 2001 and the National Minimum Standards will result in CSCI taking enforcement action to ensure compliance. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 25 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 2 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 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 1 17 X 18 1 2 X X X X X 1 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 2 2 1 Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 12(1) 13(2) 13(3) Requirement Ensure medication is administered safely and appropriately to residents and records of medication are completed at an appropriate time. An immediate requirement notice was served. 2. OP9 12(1) 13(2) Investigate why the named 08/02/08 resident was not administered medication as prescribed by their GP. An immediate requirement notice was served. 3. OP9 13(2) 17(1)(a) Complete and accurate records must be kept of all medication 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 not met. Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 27 Timescale for action 08/02/08 29/02/08 4. 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. Residents must be protected by having clear guidelines for the use of medicines prescribed on a “when required” basis. 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 home must have a registered manager to run the home and meet its stated purpose and objective. Unmet from previous timescale 31/01/07 and 31/08/07 29/02/08 5. OP9 13(2) 15 28/02/08 6. OP33 24 (1) (2) (3) 15/03/08 7. OP31 8 and 9 15/03/08 8. OP1 4, 5, and 6 9. OP2 5 (b) (c) schedule 4 (8) 15 schedule 3 (1) (b) 10. OP7 The home must ensure that the 15/03/08 statement of purpose and service user guide contains all the relevant information as per the regulation, are reviewed, and updated. The home must evidence that 28/02/08 each person using the service is provided with a statement of terms and conditions as per the regulation. The home must evidence that 15/03/08 each person using service has care plan which sets out in detail the action which needs to be taken by care staff to ensure DS0000014923.V358650.R01.S.doc Version 5.2 Page 28 Lady Spencer House 11. OP7 15, 13 (4) ( c) 12. OP7 15 (2) 13. OP7 15 (1), (2) (a) (c) (d) 14. OP12 12 (3) 15. OP15 13 (1) (b) Schedule 3 (3) (m) Schedule 4 (13) 16. OP16 22 17. OP18 13 (6), 17 (1) (a) 12 (1) (a) 13 (4) (a) 18. OP25 that all aspects of the health, personal and social care needs are met. The home must evidence that each person’s care plan meets relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, with particular attention to prevention of falls. 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 and actioned. The home must evidence that each person’s care plan is drawn up with the involvement of service user; agreed and signed by the service user whenever capable and/or representative if any. The home must evidence that each person using the service had the opportunity to exercise their choice in relation to leisure and social activities. The home must evidence that each person’s care plan must identify diet required, health care professionals advice received where necessary and details of any plan relating to the service user in respect of nutrition is provided. The home must evidence that each person using service and their family members are enabled to easy access of current complaints policy and procedure. The home must evidence that all allegations and incidents of abuse are followed up promptly and action taken in recorded. The home must evidence that DS0000014923.V358650.R01.S.doc 28/02/08 15/03/08 15/03/08 15/03/08 28/02/08 28/02/08 15/03/08 28/02/08 Page 29 Lady Spencer House Version 5.2 19. OP29 appropriate actions have been taken to prevent risks from Legionella and to prevent from scalding. 19 (4) ( c) The home must evidence all staff have two written references are obtained before appointing and any gaps in employment are explored. Unmet from previous timescale 31/12/06, 30/06/07 The home must evidence all staff are confirmed in post only following completion of a satisfactory police check. The home must evidence that all staff have received all the mandatory trainings and including for the job roles they perform. (c) 28/02/08 20. OP29 Schedule 2 18 (1) (a) (c) 28/02/08 21. OP29 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Lady Spencer House DS0000014923.V358650.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!