Inspection on 07/02/06 for Libury Hall

This inspection was carried out on 7th February 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 no outstanding requirements from the previous inspection report, but made 4 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 31/07/06

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 Jeffrey Orange Unannounced Inspection 7th February 2006 08:50 Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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.V277821.R01.S.doc Version 5.1 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.V277821.R01.S.doc Version 5.1 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.V277821.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 3rd May 2005 Brief Description of the Service: Libury Hall comprises a large detached House and five cottages located to the rear of the main house. 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.V277821.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours and concentrated on monitoring the progress made in meeting those requirements made following the previous inspection of the 3rd May 2005. It was very positive to find that these had been addressed and that plans are under active consideration for the future development of this service, that would enable the environmental challenges, presented by the older parts of the current buildings to be overcome. Residents spoken to and observed appeared satisfied and well cared for and the standard of record keeping seen was generally good. In discussions with the manager and deputy manager, it became clear that policies and procedures, systems and records are under review and have already benefited from a period of development and change. The manager, her deputy and staff were very co-operative and open in facilitating this inspection, for which the inspector is grateful. Those key standards that have already been assessed during the inspection of the 3rd May 2005 have not all been assessed again on this occasion. Where that is the case reference should be made to the report of the inspection dated 3rd May 2005 for full details. What the service does well: What has improved since the last inspection? What they could do better: The fact that the future development of the home’s environment is being so actively considered recognises that in many ways, because of limitations of age and the configuration of existing layouts the home is far from ideal and makes the achieving of current national minimum standards problematic. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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.V277821.R01.S.doc Version 5.1 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.V277821.R01.S.doc Version 5.1 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): 3 Prospective service users are given an opportunity to visit the home and to stay for an initial trial period before any decision is taken about a more permanent arrangement. EVIDENCE: Details of the assessment, trial period, and process for determining a permanent move into the home for a recently admitted resident were seen and included strong evidence of the involvement of the resident and their family and professional advisors in that process. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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, 9 Service user care plan documentation and risk assessments have been reviewed and improved and subject to further refinement in the light of experience, now provide the required information to both inform the care of and reasonably assess risks to, the home’s service users. EVIDENCE: A sample of the new care plan documentation was seen and discussed with the Manager and the development and improvement of the home’s risk assessments, completed following the previous inspection, were also noted. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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, 16, 17 Subject to assessment, choice and practical restrictions caused by the relative geographical isolation of this service, service users are able to take part in a range of social and leisure activities based either in the home, the associated day centre or in the community. The rights of service users are recognised and respected and the manager and staff are aware of the need to challenge and review the routines and patterns of activity within the home to ensure that they reflect the wishes of service users and promote their independence and dignity. EVIDENCE: The day centre was visited (not inspected) during this inspection of the home, care plans were seen to include assessments and action plans in respect of activities for service users. Although the pattern of serving meals has not been fundamentally changed since comments were made at the previous inspection, a process of consideration and consultation was undertaken together with experimentation Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 11 with some alternative formats which did not however prove satisfactory or acceptable to service users. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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): 20 There has been a marked improvement in the standard of record keeping and practice in respect of medication and this should provide satisfactory safeguards for service users. No service users are currently assessed as able to self-medicate, the management of the home accept that where possible selfmedication, within a risk-assessment framework should be encouraged provided that it can be achieved safely. Some requirements are made in respect of the storage temperatures of medication, recording of variable doses and the storage of controlled drugs. EVIDENCE: A spot check was carried out on the home’s dispensary and medication records and the standard of record keeping was found to be greatly improved since the last inspection. In order to monitor the storage temperature of all medication, temperatures should be recorded for all medication storage. This is currently only done for medication held in the medication refrigerator. The exact amount of medication administered, where it is prescribed in variable doses should be clearly recorded as this is not always done currently. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 13 Controlled drugs storage must be of a suitable capacity for the needs of the home, this is not currently the case. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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): The key standard(s) were assessed during the inspection of the 3rd May 2005; please refer to the report of that inspection for full details. EVIDENCE: Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 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): The key standard(s) were assessed during the inspection of the 3rd May 2005; please refer to the report of that inspection for full details. (Action has been taken to address all requirements made following that inspection) EVIDENCE: Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 16 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): 34, 36 Although the recruitment file seen highlighted some potential areas of concern, the general standard and understanding of good recruitment practice found should mean that service users are adequately protected. Staff have either group or individual supervision and appraisal in line with the requirements of the National Minimum Standards. EVIDENCE: The one staff recruitment file seen did not include a photograph or health reference and there were considerable gaps in the employment history with references provided by people who had only known the applicant for a relatively short time. It also appears that following some questionable advice received, the applicant was allowed to commence work, albeit under very close supervision, before a POVA first check was received in respect of her. These deficiencies were due in part to the difficulty in obtaining information from abroad and delays experienced with the CRB process. A schedule of staff supervision was seen. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 17 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): The key standard(s) were assessed during the inspection of the 3rd May 2005; please refer to the report of that inspection for full details. (Action has been taken to address all requirements made following that inspection) EVIDENCE: Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 18 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 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X X X Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO 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 Timescale for action 07/02/06 2 YA20 13 (2) 3 YA20 13 (2) 4 YA34 19 & sch 2 Where medication is prescribed in variable dosages, the exact amount administered must be recorded on each occasion. The storage temperature for 07/02/06 medication held in the home must be monitored and recorded to ensure it remains within recommended levels. Suitable and adequate 07/02/06 capacity storage for controlled drugs must be provided. All required checks must be 07/02/06 made and information obtained in line with current guidance, before a person is allowed to commence employment. Libury Hall DS0000019448.V277821.R01.S.doc Version 5.1 Page 20 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.V277821.R01.S.doc Version 5.1 Page 21 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.V277821.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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