Inspection on 16/07/08 for Lime Tree House

This inspection was carried out on 16th July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lime Tree House 09/01/09

Lime Tree House 14/02/08

Lime Tree House 04/09/07

Lime Tree House 12/10/06

Lime Tree House 17/05/06

Lime Tree House 14/12/05

Lime Tree House 07/06/05

Lime Tree House 19/10/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Lime Tree House Chantry Green, Main Street Upper Poppleton York YO26 6DL Lead Inspector Stevie Allerton Key Unannounced Inspection 16th July 2008 09:45a 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 Lime Tree House DS0000061499.V369464.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. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lime Tree House Address Chantry Green, Main Street Upper Poppleton York YO26 6DL 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) 01904 795280 Dinka.rch@gmail.com Roseville Care Home Ltd Manager post vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Random inspection 17th April 2008 Brief Description of the Service: Lime Tree House provides personal care and accommodation for up to 26 older people and is owned and managed by Roseville Care Homes Ltd. The home is a large detached property set in private gardens in the village of Upper Poppleton on the outskirts of York, off the A59 York to Harrogate Road. There is parking to the front and side of the home. The village offers amenities within walking distance. Each resident and prospective resident is given information about the home in written documents called the statement of purpose and the service user guide. The fees for the home range from £415 to £515 per week. This information was provided on the day of the inspection. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection was carried out without prior notification and was conducted by one inspector over the course of one day and evening. A pharmacy inspector was present for 3 hours at the start of the inspection. Before the visit, accumulated information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection. This information was used to plan this inspection visit. Unfortunately, the Annual Quality Assurance Assessment (AQAA) was not returned in sufficient time to allow surveys to be carried out in advance. People living at the home, relatives and members of staff were spoken to either on the day of inspection or subsequently by telephone. Three people were case tracked, and other files were looked at. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, all twenty-one key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit, were able to be assessed. What the service does well: People feel they are well looked after by the staff and are treated with respect. Relationships between people and the carers looking after them are warm and friendly. People said, “The staff always treat me well”, and “The staff are very kind and try to do their best”. Staff have shown that they are willing to advocate on behalf of people with high dependency needs, in order that the proper equipment is provided to look after their needs. The home is ideally situated in the centre of the village, and there is a lot of community input, from relatives, friends, and former neighbours. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 6 There was evidence that staff are flexible in their approach to peoples’ personal preferences, for example, coming to an agreement about altering the timing of a particular medicine, which was highlighted as an example of good practice. The person currently managing the home is demonstrating that she has the skills and ability to improve and develop systems to ensure the smooth running of the home. This will improve outcomes for people living there. She is aware of what work is still needed. What has improved since the last inspection? What they could do better: There were a number of areas of concern regarding safety of the premises or equipment, where action needs to be taken. These are included in the requirements section at the end of the report. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 7 At certain times of the day, there are not enough staff on duty to enable people’s needs to be met. This severely restricts the ability of the service to deliver person-centred care, or provide activities that people want, and could place people at risk. People were observed having to wait a long time for staff attention, two staff attending to someone with high physical dependency needs, whilst individuals with cognitive impairment were growing increasingly distressed. One person said, “The staff try their best but they are always pushed for time”. Staff are not skilled in dementia care, despite a high number of people identified with dementia living in the home. This could mean that their care needs are not being properly met. Staff have also raised concerns about how to access management support and advice out of hours, as there is no clear process or structure for this such as an on-call support rota. Record keeping, policies and written procedures need to be improved, so that peoples’ rights, best interests and well-being are safeguarded. The provider regularly calls in to the home, but there was no evidence that she looks at the things that the Care Homes Regulations say that she must look at, and no written reports are made about the running of the home. The provider is reactive to inspections from CSCI and other statutory bodies, rather having a pro-active approach that continually looks to develop and improve the service. This reliance on other methods of assessing quality means that the home is not being run in the best interests of the people living there. 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. Lime Tree House DS0000061499.V369464.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 Lime Tree House DS0000061499.V369464.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): 2 and 3 (Standard 6 is not applicable in this service) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have opportunity to visit and to get written information about the home, which helps them to make a decision about whether to live there. However, contracts were not available on site, so it was not possible to assess whether people understood these and were aware of their rights and responsibilities. Assessment of needs is being carried out more thoroughly, but the staff team is still under-resourced, so people cannot always be sure that the home will be able to meet their needs if they decide to move there. EVIDENCE: We looked at the care records for the newest person to be admitted. There was a full assessment of needs, service user plan, evidence that the plan had Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 10 been reviewed and daily records of the person’s care. There was evidence of the persons involvement in their own care plan, and they had signed it. There were no contracts/statements of terms & conditions in evidence – the manager said that families were given one copy and the other was at the provider’s house. People spoken to could not remember whether they had been given a contract. The Statement of Purpose was available and was informative, although was in the process of being updated, after consultation with people living in the home and the staff. Lime Tree House DS0000061499.V369464.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 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The care planning system that is now in place should provide staff with the information they need to provide a good standard of individual care, but staff need more training in how to use the care plans as workable documents. Documents are not always updated as changes occur, so there is a risk that people are not getting the care they need. The providers slow response to changes in care need also places people at risk. Medication is managed more safely now. EVIDENCE: Three people were case-tracked, their care records looked at in depth and evidence triangulated by way of observation, discussion with the person and/or their relatives, discussion with staff, etc. One persons care plan showed that they had been assessed as low risk in all areas such as falls, pressure areas, mobility, etc. However, none of these Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 12 documents were dated so it was not possible to tell how long they had been in place or when they would need reviewing. The person had been risk assessed for keeping their own medication but the assessment documents in 2 files did not say the same things, making it difficult to determine which version was relevant. One person was being cared for in bed. There was evidence of District Nurse involvement, their notes stating that manual handling had become unsafe and expressing concern that there wasn’t an appropriate bed in place for the Nimbus pressure-relieving mattress that had been ordered. However, the provider had recently secured a height adjustable hospital bed from another home and the person was being nursed on the Nimbus mattress at the time of inspection. This person’s relatives said they felt more reassured with the care now that the right equipment was in place. There was evidence of good advocacy on behalf of the staff, in bringing the person’s condition to the attention of the provider and insisting that action be taken to enable them to look after her correctly. The risk assessments for pressure and nutrition found in the care plan were out of date and needed updating, however, an up-to-date Waterlow risk assessment was seen in the District Nurses notes. Although this person was only taking very small amounts of food, and staff said they were encouraging her to drink fluids, there were no records in her room to show how much fluid she had been drinking. The only record that could be found was in the care plan daily records, and these had not been completed since the day staff had come on duty. It was therefore not possible to see how much fluid the person had taken during the day of the inspection visit. A CSCI pharmacist inspector again attended on this visit and conducted a pharmacy inspection of the systems in place for managing medications at the home. The pharmacist inspector found evidence of improved practice but some areas of concern remain. Since the previous pharmacy inspection a lot of time and work have gone into improving the way medication is handled. This improvement helps to make sure people are getting their medication correctly, which in turn helps to improve their health and well being. The current and previous month’s Medication Administration Record (MAR) charts were looked at. There is now a record of staff authorised to administer medicines. This means it is possible to identify who was involved in administration if a problem or error was to occur. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 13 There are now photographs of people on the dividers between each MAR chart. This means there is an extra check for staff to make sure medication is given to the correct person. The recording and administration of Warfarin has greatly improved. Warfarin is now supplied in original packs and a copy of the most recent blood tests and dose is kept with the MAR. A check of the records of administration showed that the Warfarin was being administered as directed by the Warfarin clinic. This means that the person is now receiving the correct amount of Warfarin, and that the medical condition is being treated as prescribed. The administration and recording of antibiotics is poor. For example one person was prescribed a course of 10 antibiotics at a dose of 1 to be taken twice a day. At the time the course was completed 12 signatures of administration had been recorded. This means that on two occasions a record of administration had been made but none given. Antibiotics must be accurately given to make sure the infection they were prescribed for is treated properly. The code ‘O’ was used on one MAR chart to record administration of a cream. It was explained that the carers administer the medication after helping the person wash themselves and the code ‘O’ was a record of that taking place. Using this system means there is no way to identify who administered the medication. A signature of the person who administered the medication should always be recorded. There is inconsistency in the recording of the quantity of medication supplied and the date received. The quantity of medication from one monthly cycle to another is not recorded on the new MAR. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. At the time of the inspection there were no controlled drugs requiring storage in a controlled drugs cupboard. The pharmacist inspector was informed that a cupboard was on order. It is now a legal requirement for all care homes to store controlled drugs in a cupboard that meets the specific legal requirements. The recording of controlled drugs has improved, a register that meets the recording requirements has been obtained. This means that accurate records of the use of these medicines within the home can be made and kept securely. One person self-administers their medication but a risk assessment has not been done to check that they can take their medication correctly and are happy to do so. Medicines not stored in the trolley and medication that is waiting disposal is kept in a separate locked cupboard in the office. This means that access is Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 14 limited to staff involved in medication administration and helps to maintain the security of medicines. A good record is kept of medication sent for disposal. A number of people have had their medication changed in light of their personal preferences. For example one person who feels dizzy on waking asked if the medication prescribed to help this, could be left by their bedside overnight so they could take it as soon as they wake to prevent the dizziness. An agreement on this has been made and detailed in the care plan and a copy kept with the MAR chart for this person. The agreement included the person’s GP and the person themselves. This is an example of good practice as it identifies individual’s choices and preferences and puts systems in place to help meet these choices. Some members of staff have attended training courses provided by the local Primary Care Trust. Other staff members will be attending at a later date. This training in addition to one provided by the supplying pharmacy will make sure staff are working to current best practice guidance and will understand how to handle and administer medicines safely. People in the home felt they were looked after well by the staff, although they acknowledged that sometimes they had to wait a while for attention. “The staff are very kind and try to do their best, but they are always pushed for time”. People said that they felt they were treated with respect. “The staff always treat me well”. Observations during the day showed that relationships between people and the carers looking after them were warm and friendly. Lime Tree House DS0000061499.V369464.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 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People have their social and recreational needs identified, but unless they are able to fulfil these themselves, staff have little opportunity to contribute to meeting these needs. This means that those who rely on staff as a source of social contact and activity, are not having their needs fully met. The quality of the food has improved, and people generally enjoy their meals, although further improvements could be made to the dining experience. EVIDENCE: The home is ideally situated in the centre of the village, and there is a lot of community input, from relatives, friends, and former neighbours. The new manager also has strong contacts with local schools and churches and is enabling the home to have a higher profile in the village. Those people who are independently mobile lead quite active social lives. Relatives are also a good source of social and recreational activity. When staffing allows, those who are less mobile are taken along to the local shops in wheelchairs. The home has a good stock of library books that are changed Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 16 regularly, and there is a volunteer befriender who comes in three times a week. Care plans did not provide much evidence of social care needs being identified and action taken to ensure these are met. There is a really nice garden area that is easily accessible. One of the people spoken to at the home, said that she likes to direct her own leisure activities she reads, knits, and does crosswords. She said that she did not get out much unless her son takes her, but that that didn’t bother her. Staff confirmed that there was little time to do one-to-one work with people, but if they were going along to the shops for an errand, they would take a resident with them in a wheelchair. The lunchtime meal was sampled. This was nicely presented and appetising. There were two choices of hot meal and three choices of dessert. The dining room is a pleasant area. There was no menu on display so people did not know what they would be having for lunch. People had mixed views about the food: some really enjoyed the dishes prepared by the new chef, but others said that they preferred plainer cooking. Lime Tree House DS0000061499.V369464.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 and 18 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People are more confident that their concerns will be taken seriously and acted upon, however, the current complaints policy needs to be reviewed. This is so that people can be encouraged to raise their concerns in a more informal way, and so that all staff know how to handle concerns and complaints in the absence of the manager. Staff should have more training in safeguarding vulnerable adults so that people can be sure they will be protected. EVIDENCE: Relatives that were spoken to said that they had had concerns about various aspects of the running of the home: the recent prosecution under Environmental Health legislation, the cleanliness and décor of the home, the lack of sufficient staff, the increasing care needs of someone whose condition was deteriorating. They felt able to approach the new manager, and now had confidence that their concerns would be listened to, and that she would try to address them. All of the visitors said that the manager was approachable. There is now a suggestion box in the hallway. A recent safeguarding issue was dealt with appropriately. The manager said that staff training in safeguarding was to be increased. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 18 The complaints policy was seen: this needs to be reviewed, with CSCI contact addresses updated, and the policy of only accepting complaints in writing looked at. Lime Tree House DS0000061499.V369464.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, 22 and 26 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The improvements made, both to the décor, and to the arrangements for keeping the premises in a hygienic condition, mean that people now live in a safer environment. Some of the recent adaptations to the premises, and the provision of specialist equipment such as hoists, have been carried out without properly assessing people’s needs. This means that people do not always have the specialist equipment that would best meet their needs. Some food storage and general health and safety practices are not safe, and could place people at risk. EVIDENCE: Since the last inspection, new floor coverings have been laid in the hall, corridor, dining and sitting rooms, and these areas have also been Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 20 redecorated. Radiator covers in the lounge and dining room are still loose and hazardous, but the manager informed us that new ones were being made. The bedrooms that were seen were all nicely decorated, and a rolling programme of redecoration is planned for those rooms that are not as well decorated. Some rooms were very personalised and some people had their own telephone installed. The new sluice room has now been created to separate this area from the laundry. Good infection control measures are in place and staff were seen wearing appropriate protective clothing. There were no unpleasant smells in any of the areas that were seen. There are now two hours a day designated for cleaning the kitchen. There were a number of areas of concern, where action needs to be taken: • In the ground floor bathroom, the unguarded towel rail remains in situ. Although this has been switched off during the summer, it needs to be removed so that there is no temptation to turn it on again when the weather gets colder. There was damage to the tiles surrounding the bath. The shower attachment switch was also broken. • Attention is needed to all of the internal fire doors, to prevent them from banging loudly on closure. The temptation could be for staff not to close them at night in order not to disturb people with the noise, which would be unsafe practice. • There was confusion as to whether or not fire extinguishers were up-todate with servicing, as the labels were illegible. The manager said that these had been done one month ago and thought that the invoice would be with the provider. There was no record in the home to confirm this. • There was poor food storage seen in the fridge, with raw and cooked food stored on the same shelf (this was immediately dealt with by the manager when it was pointed out). The raw meat was also not dated. • There was a hoist in use in one persons bedroom, but it could not be determined when it was last tested. The staff said that this had come from the providers other home. It was a different type to the one already in use, and staff had not been trained to use this model. • The other hoist in use, had a label on saying it was last tested in 2006; staff had already contacted the suppliers to get this serviced at the earliest opportunity. Lime Tree House DS0000061499.V369464.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 People who use the service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. At certain times of the day, there are insufficient staff on duty to enable peoples needs to be met. This severely restricts the ability of the service to deliver person-centred care, or provide activities that people want, and could place people at risk. Recruitment procedures are sound and protect people from those who may be unsuitable to work with them. Staff are provided with some training to do their jobs, although the lack of clear records make it difficult to see whether all training is up-to-date. EVIDENCE: The staff rotas were looked at – they showed that there was one senior plus 3 care staff (or 2 Seniors plus 2) on the morning shift, and two or three staff on the afternoon shift. Staff were spoken to on the day of inspection or subsequently by telephone. All have concerns about the low staffing levels. There was evidence both from the rotas and from the staff information that some continue to have to work long hours, double shifts, etc., in order to cover for staff shortages. Staff records were looked at for the two people recruited most recently. These contained all of the documents required, including evidence of Criminal Records Bureau (CRB) checks. Induction records were seen, which showed Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 22 that fire training had been included when employment commenced. The manager has obtained Skills for Care Induction packs and has identified a need to improve the induction training given to staff. She is also currently getting a list together of which staff members need various elements of the mandatory training. Staff spoken to said that they had always had a reasonable level of training. Some were doing National Vocational Qualifications (NVQ) level 2. Not everyone has had Food Hygiene training yet. Training has been booked in Food Hygiene, First Aid, and Manual Handling over the next couple of months and fire training was booked to take place the following week. There was a new hoist in use in one persons bedroom and staff had not been trained to use this model. There is no evidence that staff have had training in dementia care, although 9 of the current 23 residents are identified on the AQAA as having dementia. Staff said they had seen a big change with the new manager’s way of going about things. Some said there was more structure, and they felt more settled as a result of that, and that morale had improved. Others are not responding well to her style of management and there is some resistance to proposed changes in the duty rota. A staff meeting was due to take place the following week. There are now some dedicated hours for kitchen duties around teatime, to enable care staff to concentrate on care for the residents. However, on the day of inspection, care staff were still in and out of the kitchen, trying to sort out peoples choices for tea and answer call bells. Care staff also have to cover the kitchen on the cooks day off. There was still a great deal of frustration expressed about the staffing levels, both from staff and from people living at home. On the evening of the inspection visit people were observed having to wait a long time for staff attention, two staff attending to someone with high physical dependency needs, whilst individuals with cognitive impairment were growing increasingly distressed. One person living at home had strong opinions about staffing and was concerned about the turnover rate of staff, although they acknowledged it seemed to be more settled of late. Staff have also raised concerns about how to access management support and advice out of hours, as there is no clear process or structure for this, such as an on-call support rota. Lime Tree House DS0000061499.V369464.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, 37 and 38 People who use the service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The person currently managing the home is demonstrating that she has the skills and ability to improve and develop systems to ensure the smooth running of the home. This will improve outcomes for people living there. She is aware of what work is still needed. The provider is reactive to inspections from CSCI and other statutory bodies, rather than having a pro-active approach that continually looks to develop and improve the service. This reliance on other methods of assessing quality means that the home is not being run in the best interests of the people living there. Record keeping needs to be improved, so that peoples’ rights, best interests and well-being are safeguarded. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager currently running the home is not yet registered. She has temporary management support, one person specifically to look at medication, and another person helping with administrative support. The manager has identified the need to continue to update all policies and procedures, making them relevant to the home, and therefore usable documents. She has also identified a need to promote accurate record keeping. Residents were due to have a meeting later that week. One person spoken to referred to this. This person holds strong views about how the home should be managed, particularly regarding staff slipping back into “old habits” (such as putting sandwiches out too early for tea), and stated that, “Management should insist on things being done their way.” It was clear that people had access to CSCI inspection reports, as they are on the noticeboard in the entrance hall. Some relatives asked questions about the last inspection report and said they had noticed some improvements in running of the home since then. The service user guide contains the policy on quality assurance. There are doubts about the validity of this, for example, “The management of the home is committed to providing services which conform to, or exceed the requirements defined by NCSC”, NCSC being the regulatory body prior to CSCI. The manager states that her priority has been to get all the systems in place correctly to operate the home safely, before quality audits can be carried out. There is no evidence of any thinking about equality or diversity issues, other than the responsibilities as an employer. The manager said that the provider regularly calls in to the home, but there was no record that the provider carries out visits as described by Regulation 26 of The Care Homes Regulations 2001, or prepares a written report on the conduct of the care home. The provider had a conversation with us during the visit and spoke about her aim to be an excellent three star service. There was evidence from care plans that staff had expressed concern to the provider about the correct use of a new hoist and sling; it was clear that staff were expected to teach each other how to use it. The staff are recorded as expressing concern about this and pointing out to the provider that training was mandatory. Residents’ financial records were not able to be looked at. The manager said that these had been a complete mess when she took over the running of the home and that she was still in the process of properly sorting these out into Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 25 individual records of personal allowances held on behalf of people. There was still a large bag full of receipts and odd bits of money, that were not traceable to individuals. Statutory and operational records looked at during the day included: • service user guide • care plans • accident records • kitchen cleaning schedules • records of fridge temperatures • medication records • policies and procedures • maintenance records • fire safety records • staff files • training records • minutes of staff meetings • staff rotas. There had clearly been some work carried out on updating records and getting them into some semblance of order. However, work is still required to archive old records and make sure that each file contains up-to-date and current information. Accident records were not being numbered as advised, and needed details adding of how a person was assisted to their feet or the chair following a fall. Kitchen cleaning schedules were not clear, as they were not dated. As noted under the Environment section of this report, there was poor food storage seen in the fridge, which the Manager rectified immediately this was brought to her attention. Many of the policies and procedures seen needed updating or revising, for example, CSCI details instead of NCSC. The fire safety file contained a lot of historical information and old procedures, which need to be removed. There were also no records in the file to show that weekly fire alarm testing was being carried out, although staff did confirm that this was being carried out. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 1 X X X 3 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X 2 1 Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) Requirement Care plans must be reviewed at least once a month, updated to reflect changing needs and current objectives for health, social and personal care. This is so that staff know at all times how to provide the right care for each person. Service user plans must be dated and signed. This is so that staff know what is current information and when it needs to be reviewed. Previous timescales 12/10/07, 7/4/08 and 07/07/08 not met. Timescale extended for 3 months in order for the work in progress to be completed. Risk assessments must be 16/10/08 completed in full. They must be dated and reviewed regularly. This is so that staff know how to keep people safe without removing their independence. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 28 Timescale for action 16/10/08 2. OP7 13 (4) 3. OP9 13(2) 17(1),Sch edule 3(i) Previous timescales 12/10/07, 7/4/08 and 07/07/08 not met. Timescale extended for 3 months in order for the work in progress to be completed. A safe system of recording and 16/10/08 safe administration of medication in the home must be implemented. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. Previous timescale 12/01/07, 04/09/07, 7/4/08 and 11/07/08 not met. Timescale extended for 3 months in order for the work in progress to be completed. The complaints procedure must 16/10/08 be reviewed and updated. This is so that people can raise concerns and complaints without having to formally put it in writing. Also, to let people know the correct contact details for CSCI. Attention is needed to all of the internal fire doors, to prevent them from banging loudly on closure. This is so that people are not unduly disturbed at night, but are kept safe from the risk of fire. Fire extinguishers must be kept up-to-date with servicing, and records kept in the home to confirm this. DS0000061499.V369464.R01.S.doc 4. OP16 22 (2) & 22 (7) 5. OP19 23 (4)(c) 16/10/08 6. OP19 23 (4)(c) 16/10/08 Lime Tree House Version 5.2 Page 29 7. OP22 23 (2)(n) This is so that people can be protected if fire occurs in the home. The registered person must 16/10/08 ensure that adaptations to the premises and items of disability equipment are only provided after an assessment by a suitably qualified person, such as an Occupational Therapist. This is so that any disability equipment provided has been recommended and meets the needs of people in the home. The tiled bath surround that is damaged must be repaired or replaced. This is so that hygiene can be maintained. Sufficient staffing levels must be provided to meet service users’ needs and to ensure the home is kept clean. This is so that care staff are available at all times of the day to meet peoples’ personal, health and social care needs and do not have to routinely do kitchen and domestic duties. Previous timescale 12/10/07, 7/4/08 and 07/07/08 not met. Staff must be provided with training that ensures they have the skills and knowledge to carry out their role competently and safely. This is so that people in the home are cared for properly and that care practices are safe. 8. OP26 23 (2)(b) 16/10/08 9. OP27 18 (1)(a) 16/10/08 10. OP30 18 (1) (c)(i) 16/10/08 Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 30 Previous timescale of 07/06/08 not met. Timescale extended to allow the action taken to address this to be completed. The registered provider must make arrangements to have a Registered Manager in place. This is so that the home can be properly managed by a person with the right skills, and achieve some stability for the people living there. A formal quality assurance system must be implemented ensuring the views of service users are taken into consideration. The results must be published as an annual development plan which should be made available to service users and the CSCI. Previous timescale 12/01/08 and 07/08/08 not met. Records must be maintained, be up to date and be accurate. This is so that the business runs smoothly and that people living in the home are protected and have their rights safeguarded. Hoists must be serviced at the appropriate intervals and records kept. This is so that equipment is maintained in safe condition. Staff must be trained in safe work practices, specifically the use of hoists and other equipment, with which they may DS0000061499.V369464.R01.S.doc 11. OP31 8 (1)(a) 16/10/08 12. OP33 24 (1) (2) and (3) 16/01/09 13. OP37 17 (3) 16/10/08 14. OP38 23 (2)(c) 16/10/08 15. OP38 13 (5) 16/10/08 Lime Tree House Version 5.2 Page 31 not be familiar. This is so that staff and the people needing this equipment are not put at risk of injury. 16/10/08 In the ground floor bathroom, the unguarded towel rail must be removed, disconnected or fitted with a protective covering. This is so that people are not put at risk of injury. This has been subject to a previous requirement but the timescale of 15/02/08 has not been met. Food storage must comply with the requirements of the Environmental Health Officer. 16. OP38 13 (4) 17. OP38 16 (2)(j) 16/07/08 18. RQN 26 This must be done so that people are not put at risk of food poisoning. The registered person must visit 16/10/08 the home, speak to people living there and working there, inspect the premises and the records and produce a written report on the conduct of the home, at least monthly. These reports must be sent to CSCI. This is to demonstrate that they know about the day-to-day running of the home, its’ problems and the views of the people it affects. Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 32 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. Refer to Standard OP9 Good Practice Recommendations A system should be in place to record all medication received in to the home and medication carried over from the previous month. This helps to confirm that medication is being given as prescribed and when checking stock levels. Care staff should receive formal supervision at least 6 times a year. This should cover all aspects of practice, philosophy of care in the home and career. Accident records should be numbered, and include details of how someone was assisted from the floor, eg, use of hoist, etc. The Jacuzzi bath should be appropriately cleaned to reduce any risk of Legionella. 2. 3. 4. OP36 OP38 OP38 Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Lime Tree House DS0000061499.V369464.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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