Inspection on 31/07/06 for Libury Hall

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Libury Hall 18/04/07

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 Key Unannounced Inspection 31st July 2006 10:00 Libury Hall DS0000019448.V306231.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.V306231.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.V306231.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 Mrs Annemarie Helene Hildegard 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.V306231.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Libury Hall comprises a large detached House and five cottages located to the rear of the main house. Fees for the services are £463per week. Additional charges are made for newspapers, toiletries etc. (this was correct as at 31/07/06). The main house has been adapted and converted to provide 17 single bedrooms and two double rooms. There are four further 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. The home provides transport on a daily basis for service users to go on shopping and social trips to Hertford or Ware. Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors conducted this unannounced inspection. The aim of this inspection was to assess all the key standards. The majority of the inspection was spent talking to residents, relatives and staff. Care and administrative records were checked. Where information remains the same this has been brought forward from previous reports. What the service does well: What has improved since the last inspection? What they could do better: There is still a lot of work to be carried out on the environment and the plan must include more prescriptive timescales not just years, further requirements may be considered to ensure the environment is brought up to an acceptable standard within reasonable timescales. Appropriate seating must be purchased to aid residents in bathing and showering. Appropriate infection control measures must be taken to protect residents and staff from cross infection. Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 6 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. Libury Hall DS0000019448.V306231.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.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the home. Residents have their needs fully assessed prior to admission to ensure the home are able to meet their needs. EVIDENCE: Full assessments are carried out prior to a resident being admitted to the home. Residents are involved in the process and are able to visit the home prior to admission, this is supported by the admission procedure, which includes a visit to the home. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the home. Residents are being encouraged and empowered to take risks as part of an independent lifestyle. Care plans have been improved to provide the information to staff on how individuals’ needs are to be met. EVIDENCE: An examination of three care plans showed that service users are allocated a key worker to support them. They are supported within the Care Programme Approach or Whole Life Review Framework to ensure changing needs are continuously assessed and reviewed. The individual owns their care plan and those spoken to were aware of this. Where a change in need is identified the care plan should be updated at the time and not wait until the next review. Risk assessments were completed on both an individual and generic basis and were found to have been reviewed and updated appropriately. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the home. Residents are able to take part in appropriate activities although this can be restricted due to the homes rural location. Residents’ rights are recognised and respected and this needs to be continually reviewed to ensure they reflect the wishes of the residents and promote their independence and dignity. EVIDENCE: The majority of the residents attend the day centre, which is located in the grounds. Although this is not inspected under the current legislations a visit to the service was carried out as part of the inspection process and talk with the residents. A tour of the day centre was conducted during which the staff provided details of what activities are offered and residents who choose to attend can take part in. The member of staff is due to retire which will be a sad loss to the centre as they have lots of ideas for the future and it is not sure if these will go ahead. The staff work with the residents to ensure that they have activities to meet their choice. A lot of arts and crafts products are Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 11 produced which are then sold to raise extra money at Bazaars held at the centre, to fund trips etc. for the residents. They are hoping to get the woodworking group running again but this is not definite due to the departure of a member of staff. The inspector feels this part of the service is very valuable to meeting the residents’ social health and provide a place to go and chat with others whilst achieving some excellent works of art. Residents spoken to during the visit really enjoyed attending the centre and were taking part in a darts tournament whilst others were playing cards. Menus are on a five weekly rota and change with the seasons, alternatives are offered if residents do not like the menu choices. Staff were seen to eat with residents and make it a social occasion and a time to chat. The recording of information is well maintained and a cleaning plan is in place. Although there is plenty of stock and it is rotated as appropriate it is not excessive so that items become out of date. The stock room and storage facilities are well maintained and organised. The home have also received the Heartbeat Award in June 06 which is given for the provision of healthy food choices and a good understanding of healthy cooking methods. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome is adequate. This judgement has been made using the available evidence including a visit to the home. The medication procedure is still in need of further improvement. Residents receive personal support in a way they prefer. EVIDENCE: The home maintains goods links with the local community mental health team and local psychiatric services. Records for maintaining residents physical and emotional health are well maintained. The medication administration and storage was examined and a number of issues raised, the requirement regarding the temperature of the storage area to ensure it remains within the recommended levels, had still to be actioned from the last inspection and a further requirement has been made. It is also noted that dispensing labels must not be added to the MAR (Medication, administration and recording) sheet and the information should be hand written copying the exact details from the dispensing label and ensuring the author then signs it. All medication must be signed in on entering the home. Where residents are able to self-administer a risk assessment must be in place. The individual must sign on the back of the MAR sheet when they take over responsibility for their medication as it has now left the custody of the home. The controlled drugs were well organised and a spot check showed they Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 13 reconciled. It is recommended that where District Nurse administer the injections and sign the MAR sheets a copy of their signatures are obtained alongside the homes staff so they are able to recognise it on the Mar sheet. There are plans to increase the size of the medication storage area. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome is adequate. This judgement has been made using the available evidence including a visit to the home. A complaints procedure is available to all residents. The residents felt safe and listened to EVIDENCE: There is a complaints procedure in place. Residents spoken to during the inspection felt happy and that they could to speak to staff and the manager if they were unhappy about any aspect of living at Libury Hall. Records showed that six staff attended Adult Protection training since May 06. This training is covered as part of probationary period and then updated every two years. See staff section for further information. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the home. There is still further decoration to be carried out and as such the residents continue to live in an inadequate environment. EVIDENCE: Whilst there has been some improvement in the overall environment there is still a way to go. A number of environment issues were raised during a tour of the building. A number of communal toilets/bathrooms have cotton hand towels in place and bars of soap; soft paper hand towels and liquid soap must be put in place to prevent cross infection. Paintwork needs repainting where it has been damaged by general wear and tear. A number of en-suite toilets have no toilet roll holders and these must be replaced. One bathroom had towels stored in an open unit, which looked unsightly, these should be placed in a cupboard and there is enough space within the bathroom for this to occur. Bathroom 153 is in need of decoration and there is a severe crack in the wall by the bath. The shower chair is in need of replacing, as it is rusting and very worn. Where seating is required for residents to use whilst in bathrooms/shower rooms more appropriate seating must be sought to allow Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 16 the furniture to be cleaned adequately as wooden and fabric seating is not easily cleaned. Room 17 en-suite flooring needs to be replaced. Toilet 118 needs attention, Room 11 the seating is torn and this needs replacing, Room 10 the headboard is badly stained and must be replaced. One resident who uses a urinal, which was in a very poor condition and must be replaced for the protection of health & hygiene. One ground floor residents bedroom door (that was a fire door) was not on a self-closure, the maintenance person dealt this with during the inspection. Work on the upper corridor was due to commence on replacing doors and then the flooring. A plan has been forwarded to the Commission For Social Care Inspection but only includes yearly timescales. Two very dusty black bin bags of clothing were discovered in a storage area which related to a previous resident who moved from the home over a year ago, the manager should arrange for these clothes to be returned to their owner or contact them to have them disposed of. One bathroom was in the process of being fully refitted; there was a large hole in the floor and no one around. A risk assessment must be completed and the area locked when no one is present to prevent any accidental injury to residents, staff and visitors to the home. The laundry room is in need of redecoration due to general wear and tear and is looking in a poor state of repair. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome is poor. This judgement has been made using the available evidence including a visit to the home. Recruitment of staff is not as robust as it could be due to the fact no photos were in place; no references had been obtained for one newly recruited member of staff. A training programme is in place. The numbers of staff are adequate to meet the needs of the residents at the time of this inspection. EVIDENCE: Staff spoken to during the inspection felt that the atmosphere of the home was friendly and they were knowledgeable about the needs of the residents. There is number of long-standing and loyal members of the team. There is a training programme in place and staff must all attend the mandatory training courses. Staff felt they were supported in attending other training such NVQ 3. Moving & Handling training has been arranged for September with 12 staff booked to attend. This training should be updated yearly not two yearly as per the current frequency programme. The rotas showed that adequate numbers of staff are available to meet the needs of the residents at the time of this inspection. Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 18 Examination of three staff files showed that no photographs were in place and for one member of staff no references had been obtained, although there appeared to be some evidence that attempts had been made, the individual should not have commenced employment until satisfactory references had been sought. A Protection of Vulnerable Adults check had been carried out, but all other information must be in place prior to commencing employment. An immediate requirement letter was issued to address this shortfall. The recruitment procedure was highlighted at the previous inspection and a requirement was made to ensure the appropriate checks are carried out as per the regulations prior to a member of staff commencing employment. Any further non-compliance may result in further legal action being considered. Libury Hall DS0000019448.V306231.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome is adequate. This judgement has been made using the available evidence including a visit to the home. The management of the home appears effective in the ensuring the home is well run. There is a good quality assurance system in place and records well maintained. CSCI are not appropriately informed of incident and accidents. EVIDENCE: A quality assurance process is in place and a look through some of the responses received which stated that they were made to feel welcome, good food with variety, felt a newsletter would be good idea to inform relatives of forthcoming events, or the use of a notice board, good social programme. A report must be completed on the findings, including an action plan which must be sent to the Commission For Social Care Inspection. A examination of the accident and incident records that have occurred within Libury Hall demonstrated that a number of these should have been reported as they Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 20 affected the wellbeing of the residents. Discussions with staff felt that the management of the home created an open and positive atmosphere. Residents felt that the home was well run and they were very happy at Libury Hall. A risk assessment must be put in place for the work that is being carried out on the bathroom and the resident who self medicates. Libury Hall DS0000019448.V306231.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 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 1 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 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Libury Hall DS0000019448.V306231.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. 1. Standard YA20 Regulation 13 (2) Requirement Where information is to be included on the record sheet this must be hand written and copied exactly from the dispensing label and signed by the author. Labels must not be attached to the record sheet The storage temperature for medication held in the home must be monitored and recorded to ensure it remains within recommended levels. All medication must be signed in on entering the home. A risk assessment must be carried out on any resident who self medicates to ensure the risk is minimised. All required checks must be made and information obtained in line with current guidance, before a person is allowed to commence employment. This has Timescale for action 31/08/06 2. YA20 13 (2) 31/08/06 3. 4. YA20 YA20 YA42 13 (2) 13(2) 31/08/06 31/08/06 5. YA23 YA34 19 & sch 2 & 17(2) sch (4) 31/07/06 been brought forward from the previous inspection. An immediate requirement was made. Further non-compliance may result in enforcement action being considered. Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 23 6. YA24 YA42 23(2)(b) & (d) 7. 8. 9. 10. 11. YA24 YA24 YA24 YA30 YA30 23(2) (d) 16(2) (c) 16 (2)(c) 13 (4)(b) 13(3) 13(3) 12. 13. YA30 13(3) 37 YA42 The manager must include in the plan more prescriptive timescales on the overall décor of the home to ensure that it is brought up to an acceptable standard within reasonable timescales. The main lounge carpet must be replaced. The head board in room 10 must be replaced. A risk assessment must be completed for the refurbishment of the bathroom. The urinal for an individual resident must be replaced. Soft paper hand towels and liquid soap must be available in all areas where staff need to wash their hands. The seating that residents use to aid them whilst bathing/ showering must be replaced. The manager must inform the Commission For Social Care Inspection of any incident that affects the well being or safety of a resident. 30/09/06 30/09/06 31/08/06 31/08/06 31/08/06 31/08/06 30/09/09 31/08/06 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. 2. Refer to Standard YA24 YA24 YA30 YA30 Good Practice Recommendations Toilet roll holders should be replaced in all toilet facilities within the home. The clothing of a previous resident should be returned or disposed of. Storage should be made available for the towels in the ground floor bathroom. Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 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 Libury Hall DS0000019448.V306231.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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