Inspection on 18/04/07 for Libury Hall

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Libury Hall 31/07/06

Libury Hall 07/02/06

Libury Hall 03/05/05

Libury Hall 13/12/04

Libury Hall 29/06/04

Similar services:

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Libury Hall Gt. Munden Nr. Ware Hertfordshire SG11 1JD Lead Inspector Mrs Alison Butler Unannounced Inspection 18th April 2007 10:00 Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 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 Libury Hall DS0000019448.V336622.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 Adults 18-65. 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. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Libury Hall Address Gt. Munden Nr. Ware Hertfordshire SG11 1JD 01920 438 224 01920 438 887 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) Mrs A Schorr Angela Smith Care Home 37 Category(ies) of Learning disability (37), Learning disability over registration, with number 65 years of age (37), Mental disorder, excluding of places learning disability or dementia (37), Mental Disorder, excluding learning disability or dementia - over 65 years of age (37) Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2007 Brief Description of the Service: Libury Hall comprises a large detached house and five cottages that are located to the rear of the main house. Fees for the services are £472.50-£502.50 per week. Additional charges are made for newspapers, toiletries etc. (this was correct as at 18/04/07). Further information can be obtained from the home. The main house has been adapted and converted to provide 17 single bedrooms and two double rooms. There are four other bedrooms on the ground floor, with adequate bathrooms and toilet facilities provided on both floors. The main kitchen, laundry and offices are located on the ground floor. There are several large communal areas located throughout the ground floor. The cottages each provide a sitting/dining room, kitchen, bathroom, toilets and two or three bedrooms. The home is located in a rural position surrounded by farmland, with the village of Great Munden approximately half a mile away. Transport is provided on a daily basis for people who use the service who wish to go on shopping and social trips to Hertford or Ware. There is day centre situated within the grounds of Libury Hall to which all people who use the service are able to access if they so choose. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted with the deputy manager in the absence of the manager. Discussion took place with people who use the service and staff on duty. A tour of the building was taken with the maintenance person and care records were examined. Where information remains the same this has been brought forward from previous inspections. On arrival at the home there was a church service in progress and loud singing was taking place that demonstrated that all the people participating were very much enjoying the service (and it was a most delightful to hear). What the service does well: What has improved since the last inspection? Most of the requirements and recommendations made at the last inspection have been met. This included safe and appropriate recruitment practices. Medication procedures and storage have improved with the temperature between monitored and recorded to ensure it meets with the guidelines on the medication information. Pieces of furniture and equipment have been replaced and liquid soap and paper hand towels have been put into use, this aids in the prevention of cross infection. Some areas of the home have been improved, including the installation of a new bathroom and an addition of a new surgery to meet health needs of the Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 6 people who use the service (as it provides a private area to meet with healthcare professionals). Rooms 1-16 have had higher doors put in place, a new corridor carpet has purchased and the corridor has been redecorated (which provides a more homely area for the people who have rooms on this corridor). What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs assessed prior to admission to ensure the home are able to meet them. EVIDENCE: Examination of the newly admitted residents showed that the assessment process had been carried out prior to admission. They are able to visit the service prior to making a decision of whether to move in or not, in line with the admissions procedure. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service know their needs have been assessed and these are reflected in their care plan. EVIDENCE: Examination of the care plans show that they are each allocated a key worker to ensure that their assessed needs are met. Changing needs are continually assessed within the Care Programme Approach or Whole Life Review framework. Those spoken to were aware that a care plan is held and that staff refer to it to ensure that their needs are met. Risk assessments are carried out and enable the residents to take risks to create and promote an independent lifestyle as possible. These are reviewed as part of their quality assurance process. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although people who use the service are able to take part in activities of their choice this can at times be restricted due to the rural location. EVIDENCE: The home provides a day service within the grounds which most people who use the service access at various times. A new programme has been introduced through discussion with those attending the service. They have built a greenhouse at the back of the Centre and are now growing plants etc. The next project is to create a vegetable patch. Other activities include woodwork and painting. There is a display of paintings in the main dining area of the home and new paintings are being planned and will be hung in the new surgery. Service users are justifiably very proud of the work they produce. They can choose to come and go from the day centre although most prefer to stay and return to the house for their meals. They have access to drinks at the Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 11 day centre and spend time chatting and playing games for example darts, cards etc. The day service manger has got a plan of the individual preferences for activities which are reviewed regularly. Due to the rural location, transport is made available at Libury Hall to take the people who use the service into the local town. It is not possible for all to go to different areas at the same time and plans need to be made in advance. Menus are changed depending on the season; in 2006 the home received the Heartbeat Award, which is given for the provision of healthy food choices and a good understanding of healthy cooking methods. Staff were seen to eat with the residents and is very much a social occasion where lots of chatter goes on. They have plans to update the dining area as it a large room and surroundings could be made to feel more welcoming and homely. The people spoken to were very happy with the food provided and there is always a choice of two hot meals plus a selection of different salad options for example ham, cheese, fish etc. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service receive personal support in a way they prefer and the medication procedures are followed to protect them when staff are administering the medication. EVIDENCE: Personal and healthcare support records are well maintained. Good links are maintained with the local community mental health and psychiatric service teams. Since the last inspection, some building work has been undertaken to create a suitable venue for the use of the local GP’s who provide surgery to the people who use the service. The medication storage area is in a room adjoining the surgery. On the whole, records were well kept. A discussion took place with the senior member of staff to ensure that staff sign any changes that they have recorded. Where residents take medication ‘as required’ it would be useful if there was an instruction about when this should be given (for example a change in behaviour etc.). Labels should not be used on the recording sheet as the labels can become detached; only hand written information should be used. Where people who use the service administer their own medication, risk Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 13 assessments are place and a discussion took place to include further details around how to ensure that the risk is minimised (for example checking of the storage etc.). The storage and records of controlled were well kept and a spot check confirmed this. The room temperature is recorded to ensure it remains within safe limits as directed on medication instructions. A new care plan format is being introduced and these should be less bulky and will make it easier to record information. These should all be in place by June 2007. The next inspection will follow this up. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service feel safe and they are listened to. EVIDENCE: A complaint procedure is in place and is contained in the Statement of Purpose and Service User Guide. Those people spoken to during the inspection were very happy living at Libury Hall and felt the staff listened to them. Staff receive training on adult protection and as part of the quality monitoring staff receive updates as necessary. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are not living in a fully comfortable and homely environment. EVIDENCE: A tour of the building showed that a lot of work had been carried out. Liquid soap and paper hand towels have been placed in communal bathrooms and toilets. This will help prevent cross infection. One bathroom has been updated and includes a new Parker bath and resident who use it say that it is an enjoyable experience. Rooms 1-16 have new doors fitted to give extra height. The corridor carpets have been replaced and this area now looks a much brighter. All residents who access these rooms need to be mobile as they are not very wide and it would be difficult for wheelchair users or those using walking aids to manoeuvre. A bathroom on the ground floor is to be revamped next year. The home have applied for three grants; one for the smoking room to be revamped to become a no-smoking satellite TV room (this room also provides Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 16 access to the surgery and a conservatory will be built to create a smoking area), a second to revamp bathroom 153 to provide both a bath and a shower facility for those who are less mobile and the third grant is to replace the kitchen cupboards, which are looking very worn and tired. The blue lounge is having new blinds and is being redecorated later this year. Work has been carried out in the laundry area and a window has been put in to provide some much needed ventilation for staff It is to be redecorated in May 2007. The dining room is in need of updating and it is hoped that work will begin in the coming year. The toilets that are adjacent to the dining room were out of action as there were problems and it is hoped that this will be dealt with soon. These toilets will be included in the redecoration plan. The deputy manager confirmed that all other issues had been addressed in terms of replacement furniture and other equipment that had been subject to requirements the previous inspection. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff recruitment is robust with policies and procedures for recruitment are followed to protect the people who use the service. Staff are adequately trained to carry out their roles and responsibilities. EVIDENCE: Staff are knowledgeable about the needs of the people who use the service. There continues to be a good core of long serving and loyal staff. A training programme is in place and this is monitored through the quality assurance process. The staff team are supported through completing the NVQ awards in care. The pre-inspection questionnaire states that 90 of staff hold an NVQ level 2 or above and number of staff are in the process of working towards the award. Staff have undertaken various training course over the last year which include, mental health, infection control, dementia care, and administration of medicines. The staff and residents felt that adequate numbers of staff were deployed to meet the needs of the individuals at the home at the time of the inspection. They have no vacancies for carers. The home requires a weekend domestic and a day care worker both these are due to be advertise for shortly. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 18 Examination of three newly recruited members of staff show that all the relevant documentation had been obtained prior to commencing employment to ensure that the people who use the service are protected as far as is practicable. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run with a good management structure in place. A good quality monitoring system is in place. EVIDENCE: There is regular monitoring system in place to ensure that procedures and policies are being followed and checks are made to ensure the health, safety and welfare of anyone who lives, works or visits the home is promoted and protected. Appropriate risk assessments are carried out with regular reviews taking place, there is a maintenance person on site who can deal with minor maintenance work that is necessary and is also responsible for carry out health and safety checks, and fire system testing. A spot check showed that incident and accidents have been reported to the Commission for Social Care Inspection appropriately. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 20 Staff and the people who use the service concurred that there is an open and inclusive atmosphere in the home that it is well run and they confirmed that they are informed of any events that may affect them. The Commission has been informed of the plans to manage the home in the manger’s absence. These appear to ensure the people who use the service have a continuity of care. Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 22 Yes 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. Standard Regulation Requirement Timescale for action 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 Libury Hall DS0000019448.V336622.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area 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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