Inspection on 04/12/07 for Limes Residential Care Home

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Limes Residential Care Home 14/08/06

Limes Residential Care Home 24/04/06

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

CARE HOMES FOR OLDER PEOPLE Limes Residential Care Home 11a Station Cresent Ashford Middlesex TW15 3JJ Lead Inspector Pat Collins Unannounced Inspection 4th & 7th December 2007 08:15 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 Limes Residential Care Home DS0000066830.V348872.R02.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. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limes Residential Care Home Address 11a Station Cresent Ashford Middlesex TW15 3JJ 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) 01784 240114 0208 5783890 elmbank@talktalk.net Elmbank Residential Care Home Ltd Mrs Alena Vivian Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The named service users (as detailed in letter dated 6th March 2006) currently accommodated in the home who fall within the category of `dementia - over 65 years of age` may only continue to remain in the home subject to a full care management review and re-assessment of their individual care needs. No further admissions may take place in respect of that category. 14th August 2006 Date of last inspection Brief Description of the Service: The Limes Residential Care Home is registered to provide accommodation and personal care for up to 16 older people. Situated in a quiet residential area, the home is within walking distance of Ashford town centre and is accessible by road and rail public transport systems. The building is a two- storey detached house that is domestic in scale and character. There is an attractive enclosed garden at the rear of the premises and limited car parking facilities at the front. Bedrooms are on the ground and first floor, accessible by stairs and stair-lift. These are all single occupancy, of varying sizes and shapes and fitted with washbasin and emergency call system. Facilities include an adapted assisted bathroom and walk- in shower. There is a large combined lounge and dining room on the ground floor beside the kitchen. A separate utility room is in an outbuilding and office facilities are in the attic. Fees are set at a flat rate of £450 per week. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection visits form part of the key inspection process, using the ‘Inspecting for Better Lives’ (IBL) methodology. They took place over two full days and were conducted by one regulation inspector. The home’s manager, who is unregistered, was present throughout. The registered providers were present in the late afternoon and evening of the second day of the inspection. Judgements about how well the home is meeting the national minimum standards for older people are based on the cumulative assessment, knowledge and experience of the home since its key inspection in August 2006. The required Annual Quality Assurance Assessment (AQAA) completed by the manager was used to inform the inspection process. A partial tour of the building was carried out and records, policies and procedures were sampled. Other information was obtained through practice observations. Discussions took place with the registered providers, manager, deputy manager, care staff, cook, domestic assistant, a general practitioner, five visitors and a volunteer. Five people using services, referred to as ‘residents’ in the report, were also consulted. The term ‘resident’ is used in accordance with the expressed wishes of those able to state their preference. Feedback from some residents was limited owing to communication difficulties. Observations of their body language and appearance, the content of their care records also information from staff and visitors, was used to form judgements about their well-being. The content of survey questionnaires received from four staff and two residents also informed the inspection process. The inspector wishes to thank all who contributed information; also the residents, the home’s management and staff for their time, hospitality and assistance throughout the inspection visit. What the service does well: The personal appearance of residents’ was overall good, demonstrating due care and attention to this area of personal care. Individual residents described staff as “nice” and “kind”. Residents’ consulted including those who completed survey questionnaires, felt they usually received the care and support they needed. A resident commented, “ Staff are always cheerful and very helpful”. Visitors were positive about most aspects of the home. The atmosphere was welcoming and whilst calm, it was also stimulating. Two residents were observed to exercise control over where and how they spend their days. The environment was warm and comfortable, also clean and tidy throughout. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There are significant shortfalls in the home’s management and administration. This is not in the best interest of residents’ who are not safeguarded by the home’s admission practices, standards of record keeping, policies and procedures including those relating to safeguarding adults incidents and complaints. Staff recruitment and vetting procedures are unsafe and induction and training for staff is inadequate. Staffing levels have not been maintained and some staff felt these were inadequate. Attention is necessary to risk assessments and hazards in the environment. Care practice does not always respect residents’ rights to privacy or dignity. Their health, safety and welfare is not always promoted by infection control practices or arrangements for medication administration. Unsafe practice was observed in the use of the stair-lift and this was in need of repair. The emergency call system also requires repair or replacement. Relationships between managers, the providers and the manager and the providers and some staff were poor, affecting communication within the home and with external management. Staff morale was low and it was of concern that the manager, a former employee and two existing employee reported inappropriate, offensive language used towards them at times by the responsible individual. There has not been a registered manager since just after the registered providers purchased the home in February 2006. Since then, a manager was in place between April 2006 and December 2006, without submission of an application registration. The manager in post at the outset of this inspection was the home’s former deputy manager. She has managed the home Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 7 informally since the previous manager’s dismissal and accepted the post of ‘trainee manager’ in May 2007. She has a qualification in health and social care at NVQ Level3. The deputy manager’s post was vacant from that time until very recently. An application for the manager’s registration has not been received. Directly prior to the inspection visit, the manager verbally notified the CSCI of her resignation. At the end of the second day of the inspection visit the manager left without working her notice, at the request of the registered providers. This information was not communicated to the inspector who met with the providers twice after this had taken place. The deputy manager was also on leave. Seven immediate requirements were made as a result of this inspection. These relate to improvements that must be made to staff recruitment and vetting procedures, staff induction and training and to infection control practice and systems. This action is essential for the health, safety and welfare of residents’. A total of twenty-three requirements were made, three of which are repeat requirements from the last inspection. The law expects there always to be a registered person managing a registered care service. Other requirements include the appointment of a competent individual to manage the home that is ‘fit’ to do so and has the necessary qualifications, skills and experience. The name of the person appointed and date on which the appointment is to take effect must be notified to the Commission for Social Care Inspection (CSCI). Written information must also be supplied to the CSCI to enable the register to be updated in respect of the resignation of the registered manager and for an amended registration certificate to be issued. The former registered manager’s name is on the current certificate displayed in the home and in the services users guide, which is the book that states how the home works. This is misleading and prevents prospective residents’ from making an informed decision about the suitability of the home. The home’s statement of purpose, the book that tells people who the home is for, must contain all required information and the service uses guide must be updated. Requirement has been made for the home to operate within its conditions of registration. Though a full needs assessment is undertaken prior to admission, on two occasions since the last inspection, admissions had taken place outside the home’s categories. The placement of one of these two people broke down less that two weeks following admission, culminating in a serious incident that staff did not have the skills or training to safely manage. A review of staffing and staffing levels must take place. The increase in staffing levels put in place after a safeguarding adults investigation prior to the last inspection, had not been sustained. This was concerning considering the circumstances of an increase in residents’ number from eleven to sixteen. Also the new manager’s self-acknowledged limitations in respect to her management knowledge and skills. There was evidence of inadequate support systems for the manager compounded by the vacant deputy manager post for the past year. Current staffing levels detract from available management hours to be able to manage the home effectively. Staff turnover was high, totalling thirty-one since Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 8 January 2006. The high and continuing turnover in staff was a further constraint to the manager spending time in the office on management and administration tasks. Not only was she integral to staffing levels but also it was crucial she maintained a presence in the care environment to ensure effective staff direction and supervision and continuity of care. The frequent changes to the staff rota made by the responsible individual were a significant problem for the manager in the management of staff. Some staff were working excessive hours without a day off, and staff rotas and other staffing records were either not in place or maintained up to date. The manager advised there were staff on the rota she had not met and had not been involved in their appointment. Failure to evidence the qualifications and training of new staff created difficulties in staffing to ensure competent staff on duty and support and supervision for new and less experienced staff. The practice of redeployment of domestic staff in the delivery of care for which they are not trained, must cease. It is essential for care staff for which English is not their first language to be able to communicate verbally with residents’ and colleagues and comprehend training and care plans, to be competent to perform their role. It is required that care plans and risk assessments be reviewed and for staff to follow care plans. Action must also be taken for medical assessments of residents’ found to have significant weight loss. Care practice must be monitored to ensure residents’ rights to privacy and their dignity is respected and staff’s approach towards residents must be ageappropriate. Staff administering medication must be trained and competent to do so. It is required for improvement to be made in catering arrangements. Food stocks at times run low and during the inspection visit this was a barrier to providing a wholesome and substantial meal on one occasion, at lunchtime. Records of food consumed must be accurately maintained and the menus reviewed in consultation with residents, to ensure their preferences are accommodated. Residents’ must have opportunity to have the cooked breakfasts that are recorded on menus and a choice of a cooked evening meal must be available. A resident commented in a survey questionnaire, “ The meals could be better, more edible and more taste”. The activities programme must be further developed to be inclusive of residents with visual impairments. A resident who returned a survey questionnaire commented, “ “ I have no one to talk to, I cannot join in most activities because of my poor eyesight”. A redecoration and refurbishment plan must be produced with timescale for redecoration and replacement of bedroom carpets and addressing malodour in four bedrooms. Staff and residents must have suitable facilities to wash their hands to promote good infection control. It is important for management to consider the impact of the environment on residents’ currently accommodated with dementia and for this to be reflect in their assessments and the home’s refurbishment programme. The complaint procedure needs to be more robust. The investigation and recording of complaints and concerns and process for complainants’ to receive feedback must be improved. Residents are not Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 9 adequately protected from abuse or neglect by the home’s policies, procedures and arrangements for staff recruitment, induction and training. Other requirements include the need for improvement in record keeping relating to accidents and for notification of all significant events to the CSCI. A number of other health and safety hazards were identified. 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. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 10 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 Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 11 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): Standards: 1, 3, 4, 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have access to written information about the home however this does not give the reader fully accurate information. Whilst a full needs assessment is undertaken prior to admission, this does not always result in admissions being within the home’s conditions of registration, to be assured needs can be met. Service provision does not include intermediate care. EVIDENCE: The statement of purpose, which is the book describing who the home is for, does not include all required information. This information is instead incorporated into the service users guide, which is a book stating how the home works. This book was not maintained up to date and was misleading about management arrangements, referring to the registered manager who left prior to the last inspection. The outcome is that prospective residents are unable to make an informed decision about the home’s suitability based on full, clear and accurate information about the home’s day- to- day management. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 12 It was good to note the practice of placing copies of the service users guide in residents’ bedrooms, however these were also out of date. They refer to the former registered manager and contain inaccurate contact details for the home’s regulator, the Commission for Social Care Inspection (CSCI). The manager stated that prospective residents or their relatives/representatives, if unable to visit personally, are encouraged to read these documents when they visit to view the home. It was noted however that one of the two residents’ who returned surveys felt they did not receive enough information about the home to enable an informed decision about whether it was right for them. It was suggested to the manager that she review procedures for giving access to the information in service users guide to prospective residents who are unable to view the home themselves. The pre-admission needs assessment tool used by management includes all activities of daily living. This enables needs to be identified including diversity, cultural and religious needs. Community care needs assessments and other assessments carried out by professionals, where these exist, are sought prior to deciding whether to offer a place at the home. A visitor consulted during the inspection visit said she had visited the home several times before finally deciding on the home’s suitability. She complimented the manager on her management of pre-admission arrangements. Her relative, who is now a resident, also visited. The manager had carried out a comprehensive needs assessment for this individual before admission. The home’s admission policy and procedure could not be located at the time of the inspection. The manager stated that a non-discriminatory admission policy was in operation. She was also fully aware that the home’s registration conditions excluded admission of prospective residents with either a primary condition of dementia or mental disorder. Evidence was found however of the admission of residents’ within both these categories since the last inspection. The placement of one of these individuals broke down less than two weeks after admission following a serious incident that staff did not have the skills or training to safely manage. This person was admitted prior to the manager taking over the management of the home. The manager confirmed the responsible individual makes the decision on who is admitted to the home. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 13 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): Standards: 7,8,9,10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Though the home has a plan of care that residents’ or someone close to them have been involved in making, these do not fully address residents’ needs and risks. Additionally action is not being taken to refer residents’ experiencing significant weight loss for medical assessment. Care practice does not respect residents’ privacy and dignity or protect them from cross-infection. Staff administering medication are not all suitably trained and supervised. EVIDENCE: Residents’ personal appearance was generally good. Residents’ with capacity to express their views described staff as “nice” and “kind”, indicating general satisfaction with their care. All visitors consulted were pleased with most aspects of care and the home in general. The concerns of two residents about care are being followed up by another agency and are not addressed in this report. Two questionnaires received from residents’ confirmed they usually received the care and support needed. All residents are registered with a general practitioner (GP). The GP recently completed the home’s quality survey and the content indicated his satisfaction with arrangements for meeting residents’ health care needs. The same GP was Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 14 consulted during the inspection and confirmed he visited the home at least once a week. He did have some concerns about the continuing staff turnover and the potential impact of this on care. He referred to the loss of core staff that had been knowledgeable about residents’ needs. He evidently held the manager in high regard. The home does not provide nursing care and is supported by the local district nursing service. District nurses are currently treating two residents twice a week. Arrangements were in place through the district nursing services for the prevention and treatment of pressure sores. Records are maintained of all input from health and other professionals. The care plans sampled afforded a holistic view of residents’ needs. A resident and a relative confirmed their involvement in the care planning process. Though care plans were underpinned by some risk assessments to enable independence and ensure needs identified, these must be further developed. Suitable weighing scales have been purchased and residents’ weights are now regularly monitored. Significant weight loss however had not been discussed with the GP and was not addressed in care plans. Use of validated assessment tools was recommended for undertaking comprehensive nutritional screening, which is not the current practice. A care plan was examined for a resident with a history of falls prior to admission. Though a care plan was in place for minimising risk of falls this did not fully address all risks. The home does not use a validated falls risk assessment and it was suggested this be considered to ensure all risk factors are identified. Practice observations confirmed staff were not following the care plan for this individual to reduce risk of falls. Examples included their failure to ensure this person’s walking aid was accessible to him by his chair in the lounge. The inspector twice had to draw staff’s attention to this person walking with an unsteady gait without his walking aid. The need to monitor practice to ensure a resident who wears hearing aids is assisted in fitting the same was discussed with the manager. On the first day of the inspection visit he wore one and had difficulty in engaging in conversation with the inspector. On the second day both hearing aids were left on his bedside table. The home has an infection control policy and procedure. The manager confirmed receipt of the Essential Steps Tools from the Department of Health, for reducing healthcare associated infections, though this is not being used. On sampling staff’s records it was not evident that they were all trained in this area or had received infection control instruction since taking up post. It was stated that the manager, three care staff and the cook were nearing completion of an infection control course. Observations confirmed poor infection control practice at the time of this inspection. Examples include disposable aprons and gloves worn by staff in multiple episodes of care when dealing with bodily fluids instead of single episodes of care. Staff then walked around the home without removing gloves and aprons or hand washing, assisting residents at breakfast tables. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 15 Medication procedures and practices were examined. A monitored dosage medication system is used and medication record keeping was satisfactory in the records sampled. Most medication is stored in a locked medication trolley kept in the kitchen when not in use. A metal medication cabinet with controlled drug storage is also available in the home. A record of staff trained to administer medication was not found though a letter was on file from the home’s pharmacist confirming medication training had take place. The manager stated most of the staff that had received this training were no longer in post. She was unable to confirm which of the new staff were trained and competent to administer medication. The manager had carried out an assessment of competence for medication administration for some but not all new staff. It was found that a new care assistant identified to require medication training had administered medication on at least one occasion when in charge of a shift. Though most staff were responsive to residents and interacted with them in a friendly and cheerful manner, the care practice observed did not respect residents’ rights to privacy or their dignity. Staff spoke loudly and indiscreetly to each other, exchanging information over the heads of residents’ about their personal intimate care. This was humiliating for residents and disrespected their feelings and rights. A senior staff member’s approach towards residents’ was infantile, for example, loudly asking one person whilst walking with her across the lounge towards the toilet, if she wished to go for a “wee- wee”. On another occasion this staff member was observed singing nursery rhymes to a resident whilst walking her from the breakfast table to her chair. Staff were also noted to walk in and out of a resident’s bedroom whilst sat in his room, where he chooses to spent his day, without the courtesy of first knocking and waiting to be invited in. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 16 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): Standards: 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Though an activities programme is available the programme needs to be inclusive of residents’ with a sensory impairment. With support of families and staff, individual residents’ participate in community activities. Though the cook works hard to provide balanced lunches, arrangements for purchasing food can be a barrier and food stocks were low at the time of the inspection visits. Most residents’ are not offered varied breakfasts in accordance with the menus, and do not always have a choice of a cooked meal option in the evening. Accurate records are not maintained of food consumed by residents to be able to judge the nutritional content diets. EVIDENCE: At the start of the inspection visits the majority of residents were up and dressed and sat in the lounge, some having already eaten their breakfasts. Others were sat at the dining table eating cereals, a slice of toast with jam and a cup of tea one morning and porridge, toast and jam and tea on the second morning. One resident was observed eating a cooked breakfast in his bedroom both mornings whilst watching the television. Staff were busy assisting the remaining residents to get up, washed and dressed, seating them at dining tables for breakfast when ready. The home’s atmosphere on both mornings was calm, the radio was softly playing in the lounge/dining room and the Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 17 manager was administering medication. A night care assistant consulted stated that only residents who were awake were assisted in getting up and dressed by night staff. Visitors consulted confirmed their experience of the atmosphere in the home generally being welcoming. Two residents were observed to exercise control over where they spend their days and how they spend their time. One prefers to spend his time in his bedroom and the other person evidently derives a great deal of satisfaction from time spent tending the home’s garden. The manager confirmed five residents to have a diagnosis of dementia. Areas of discussion with the manager included the needs to consider the impact of the environment on these individuals to enhance their quality of life. For example the new carpet is patterned which is not ideal for these individuals’ and minimal suitable orientating information is provided. Consideration could be given to displaying information about the day, date, weather, and topical news events, names of staff on duty as well as the day’s menu, which is displayed at lunchtime. Cues to aid orientation could include additional signage and colour coding. A programme of planned activities is on a notice board in the lounge. This informs residents of available activities and was stated by staff to be flexible, enabling residents’ choice. This includes opportunity to participate in a church service on Sundays. On both days of the inspection visits a group of residents were observed playing a game of cards with staff and there was much laughter and fun. Another group were making Christmas cards. The atmosphere in the lounge was stimulating both mornings. Visitors were present or had already been in early, others were seen in the late afternoon and early evening. A resident stated he regularly goes out with his family, enabling him to attend a club, which he very much appreciates. In the questionnaires received from two residents, one stated there were activities this individual could usually take part in. The other resident stated there was no one to talk to and this person could not join in most of the activities because of a visual impairment. A volunteer who popped in with a clock he had repaired for a resident, stated he and his wife, who live locally, have been coming to the home for many years. They provide social activities on a voluntary basis. The ethnicity of all residents is White British and effort has been made to meet their cultural needs through routines and menu planning. A new cook had been appointed since the last inspection. The cook has previous catering experience and is aware of the need to update her food hygiene certificate and for this to be at intermediate level. A recent satisfactory inspection has taken place at the home by the Environmental Health agency. The cook attended a training event this year recommended by the Environmental Health Officer, ‘Safer Food Better Business’. The kitchen was clean at the time of this inspection and food storage was hygienic. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 18 The menus had not been reviewed since the former manager left twelve months ago. Though it was stated that there is a four- weekly rotating menu only two weeks could be located. Observations confirmed the content of the menus to be misleading. For example, the cook stated that a record was maintained of food served where this differed from the menu. The menu referred to cooked breakfasts daily and the alternative breakfast given to all but one resident was not recorded in this record but on a separate list pinned on the kitchen wall. It was not demonstrated that regularly consultation takes place with residents about menus and meals. Those residents stated to prefer a light breakfast did not appear to be afforded opportunity to occasionally choose a cooked breakfast, in accordance with the menu. Reference in the menu to lunches of roast beef was established to be not quite all it appeared. The manager stated the responsible individual insisted she purchase frozen slices of beef that was then served in gravy. The responsible individual disputed the accuracy of this information. The manager and another staff member described this meat, as “tasteless”, stating residents did not enjoy it as much a joint of beef. The manager advised she sometimes went against instructions and purchased a joint of meat, though only pre-packed sliced meat and one small chicken was in the freezer. On the second day of the inspection, which was a Friday, the main meal of the day was frozen fish fingers or fish cakes and oven chips. The manager stated that most residents enjoyed fish cakes and fish fingers and were sometimes served white fish in sauce. It was suggested residents’ be consulted to clarify if the might prefer a different type of fish which is culturally more traditional to fish fingers or fish cakes. These could still be available as a cooked meal option in the evenings. Information from other sources confirmed fish in batter or breadcrumbs was never purchased and when residents had recently had battered fish purchased from a fish and chip shop, they had thoroughly enjoyed the same. A male resident who did not like either fish fingers or fish cakes was offered fried egg and chips for the main meal of the day during the visit. The evening meal served both days of the inspection was soup, sandwiches and cake and this featured most days of the week on the menus viewed. It was good to note feedback that the manager takes time to bake cakes and sometimes involves residents in this activity. The cook also stated that residents enjoy multi-cultural foods. Feedback from residents who completed survey questionnaires confirmed one person always enjoyed the meals; another commented, “the meals could be better, more edible, more taste”. Food stocks were low at the time of both inspection visits. The manager confirmed that the responsible individual and herself carry out a bulk purchase of food provisions every two weeks. She advised that owing to the extraordinary circumstances of the week of the inspection, this had been delayed. The manager was stated to have access to money to be able to purchase items of food, fresh vegetables and fruit in between the main shopping trip. On both inspection visits there was no fresh fruit available and Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 19 on the second visit all residents were given a very small portion of jelly for dessert at lunchtime with no accompaniment. The cook confirmed she had no tinned fruit or cream to serve with the jelly. The meal served at lunch- time on day one of the inspection appeared wholesome and offered an alternative main course. The desert that day was cake and custard. It was suggested that the dietician be consulted about the routine provision of half fat milk. It was noted that a dietician had had sight of previous menus and had offered guidance to ensure good management of nutrition. Dining tables were nicely presented and the cook wore a clean tabard. Care staff wore blue plastic aprons when handling food at lunchtime but as previously stated, not at breakfast time. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 20 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): Standards: 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaint procedure needs to be more robust in the investigation and recording of complaints and ensure complainants’ receive feedback. Residents are not adequately protected from abuse or neglect by the home’s policies, procedures and arrangements for staff recruitment, induction and training. EVIDENCE: The home’s complaint procedure is displayed in the lounge. This had been updated with new contact details for the Commission for Social Care Inspection (CSCI). The responsible individual agreed to ensure the complaint procedure in service users guides in bedrooms is also updated. The CSCI has received one complaint about the home since the last inspection. This relates to shortfalls in the home’s response to a serious injury sustained by a former resident. This complaint was referred to the home by the CSCI for investigation under the home’s complaint procedure. Observations of records relating to this complaint again identified inadequate record keeping practices for complaints. An audit trail of this investigation was not found and recordkeeping practice for complaints was fragmented. The manager was unable to locate correspondence demonstrating the outcome of this complaint or to verify this had been communicated to the complainant. It was reiterated again, as at the time of the last inspection, that the home must have a process in place for recording the investigation and outcome of complaints. According to information provided by the manager there had been four complaints in the Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 21 last twelve months. These were said to have been investigated and resolved under the home’s complaint procedure. The complaint file however referred only to one other complaint and record keeping in respect of the same was incomplete. Evidence of the outcome being communicated to the complainant was not demonstrated. The home has a copy of Surrey’s safeguarding adults procedure. Since the last inspection the manager has attended Surrey’s safeguarding adults training. The responsible individual stated she attended this training in 2006. The home’s internal safeguarding procedures were noted to not follow Surrey’s procedures. A safeguarding adults incident notification was received by the CSCI from a relative since the last inspection and referred to the safeguarding adults team. The home’s records confirmed a full investigation carried out in this matter by this resident’s care manager. The outcome identified shortfalls in the hospital discharge practices on admission to the home also in the home’s admission procedure. The manager stated the admission procedures had since been reviewed and strengthened though unable to locate the same. Records confirmed a complaint was made by the home to the hospital. An explanation and apology was received from the hospital. The inspection process identified failure to follow Surrey’s safeguarding adults procedures in response to two separate allegations recently made by residents. An investigation was in progress into these allegations by Surrey’s Safeguarding Adults Team having been referred by the Commission for Social Care Inspection (CSCI). The home’s whistle blowing procedure is available in the home’s policy manual in the office. This would be improved by including contact details of the other agencies referred to in the policy. Other observations identified insufficient information in the home’s restraint policy and procedure and missing persons procedure. Observation of staff personnel records confirmed a number of new staff had no induction or evidence of training to enable them to recognise and respond to abuse and neglect. Additionally it was not evidenced that all staff had received moving and handling training, though this was recorded in the diary to be planned. Improvement had been made to systems for safeguarding residents’ money since the last inspection. This was securely stored and records maintained of transactions with receipts. The homes recruitment procedures and practice does not protect residents from abuse or neglect. Details regarding these findings are recorded in the Staffing section of this report. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 22 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): Standards: 19, 22, 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The replacement of carpets in ground floor communal areas has enhanced the environment. Some bedrooms and other areas of the home are in need of redecoration and new carpets. The home was warm and comfortable, clean and tidy throughout. Odour control was ineffective however in four bedrooms and infection control practice and procedures were poor. Attention is necessary to hazards in the environment. EVIDENCE: A tour of the premises included all communal areas, bathrooms and toilets, kitchen, utility room and a sample of bedrooms. All areas viewed were clean and tidy. The home was warm and the lounge and dining area well lit, adequately ventilated and comfortably furnished. A redecoration and refurbishment programme is in place and remedial work had been carried out to address shortfalls in maintenance identified at the time of the last inspection. Carpets have been replaced in the combined lounge and dining area and ground floor corridors. Seating has been rearranged in this area and Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 23 new tablecloths purchased. Suitable equipment has been purchased for monitoring weights. Suitable adapted bathing and shower facilities are available and grab rails and raised toilet seats provided, maximising residents’ independence. The home has a hoist however this was stated not to be in use or necessary to meet the needs of current residents. The bedrooms viewed were clean, tidy, and most were personalised. The garden was observed to be secure and to be well maintained, with seating and sunshade for residents’ safety. A programme for improving the décor of bedrooms and for replacing further carpets was said to be planned. The registered providers advised of their intention to apply for planning permission for a new extension to provide a separate activities room. Longer-term it is their intention to install a fourperson passenger lift. Meanwhile, the stair lift on the main staircase is used and is regularly serviced. On the day of the inspection a fault was noted with this equipment, specifically the footrest did not automatically move into position when in use and needed to be manually positioned. The manager had reported this fault to the registered provider. A senior staff member was observed transporting a resident from the first to the ground floor without using the footrest. This unsafe practice was immediately drawn to the attention of the manager who was requested to ensure all staff instructed in the safe use of this equipment. Additionally she was asked to follow up progress for repair with the registered providers. The main staircase is steep and the stair tread narrow. The manager said all residents’ accommodated on the first floor are required to use the stair lift to ensure their safety. An injury recently sustained by a resident to her leg however was said to be caused by a fall whilst climbing the stairs. It was agreed that risk assessments would be carried out for all residents in respect of their access and use of both staircases in the home. Other environmental safety hazards identified were the faulty emergency call system; also a ground floor bedroom window not fitted with a restrictor. This window is low and opens wide posing a potential security and missing persons’ hazard. A programme of routine maintenance was evidenced however the record not checked off to demonstrate which work had been undertaken. Odour control in four bedrooms was poor and though these carpets were shampooed at the time of the visit, and stated to be shampooed every weekday, an unpleasant odour remained in two of the rooms. The washing machine has a sluice cycle to enable the hygienic management of soiled and infected linen. A care assistant was observed sorting soiled linen and personal clothing when loading a washing machine, without wearing gloves. There was no soap in the laundry room and without washing her hands she then directly joined in a group activity with residents, in the lounge. The home was stated to have a contract for a yellow bag clinical collection service for disposal of Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 24 incontinence pads. It was good to note that since the last inspection residents now had access to their own incontinence aids and towels in bedrooms. No soap was available in communal toilets and bathrooms and paper hand towel holders were empty. Bars of soap were available in bedrooms for residents’ personal use and hand towels. No soap was available in bedrooms for staff’s use however and paper towel holders in bedrooms, where these exist, were also empty. Areas of discussion included the need to carry out a risk assessment with a view to making provision of liquid soap dispensers in toilets, bathrooms and bedrooms, to promote good hygiene practice. In the event that this would pose a risk to residents alternative solutions must be found. Noting the responsible person’s long - term intention to include dementia care in the home’s service provision it is important to be aware of research findings to create a positive physical environment for people with dementia. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 25 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): Standards: 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels at the time of the last inspection had not been sustained. Current staffing levels detract from management time to the detriment of the home’s management and administration. Staff recruitment and vetting procedures, induction, training and records are not in compliance with regulations and do not protect residents or ensure their welfare. EVIDENCE: Though staff were observed to be caring and kind in their approach towards residents, as previously stated, all except the manager and ancillary staff at times did not respect residents’ dignity and privacy. Feedback from two residents who completed survey questionnaires confirmed their experience that staff always listened to them and acted on what they say. One resident added, “ staff are always very cheerful and helpful”. Relatives consulted during the inspection commented positively on the kindness of staff. Staff wear uniforms and were smart and neat in their appearance. The home has not sustained the increase in staffing levels put in place following a safeguarding adults issue, prior to the last inspection. This is despite the increase in residents’ numbers from eleven to sixteen. Two staff that completed surveys felt staffing levels were inadequate. This was observed to be detrimental to the home’s management because the manager is essential to staffing levels and has limited time available to attend to management and Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 26 administration duties. Since taking over the manager’s role she has worked without a deputy manager until very recently. Staff turnover, a total of thirty-one since January 2006, was acknowledged by the registered providers to be exceptionally high. This situation has compounded difficulties for the manager in fulfilling her management role and responsibilities. It has been essential for the manager to maintain a presence in the care environment to direct and supervise new staff and ensure continuity of care and routines. The reason received for this continuous staff turnover differs from the manager and registered providers. The providers’ account is they had terminated the employment of some new staff based on feedback from the manager of their unsuitability. They added that some new staff had voluntarily left, stating they were unwilling to work with the manager. It was stated that other staff had their employment terminated on grounds of misconduct. The manager advised she had no control and mostly was not consulted about the employment of new staff. She referred to the appointment of staff that was incompetent. She stated some former staff had very limited command or comprehension of the English Language to the degree they could not communicate with residents, follow care plans, be trained or read or maintain essential records. Others had left or had their employment terminated for a variety of reasons, including refusal to sign a new contract which changed the terms and conditions of employment, disadvantaging existing staff. This information was corroborated by an ex employee and other existing staff who expressed concerns also about arrangements for payment of salaries. The manager stated a recently appointed care assistant left after working three shifts because she had felt unsupported when working with the deputy manager and had concerns about his care practice. A record was not available for inspection to confirm the date staff took up post or left. Exit interviews were not carried out to establish the facts of the high staff turnover. No disciplinary records were maintained for staff that had been dismissed. The staff contract states the home is not obliged to follow its own disciplinary procedures for staff employed less than one year. It was stated the staff dismissed had met this criteria. The staff files sampled demonstrated unsafe recruitment practices. Shortfalls included failure to always evidence work permits, obtain a full employment history, probe gaps in employment dates, obtain two references ensuring these are relevant and to pick up on discrepancies between information supplied in application forms and supplied by referees. References had not been obtained for some staff for their last period of employment when working with vulnerable adults. A care assistant was noted to have taken up post prior to receipt of the outcome of a POVA check. Three care staff employed at the home in the past had left for a period, then had been reinstated without repeating POVA and CRB checks, as required. Agency staff had been recently used however no evidence found to verify the agency ensures POVA and CRB Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 27 checks are carried out for these staff or to confirm their training. CRB Disclosures were not recorded, stored or disposed of in accordance with CRB guidance. There was no record to demonstrate that new staff had produced training certificates at the time of interview. The manager advised they were asked to bring them with them when they took up post. Observation of personnel files confirmed some new staff had not done so. The manager stated the deputy manager, who took up post in November, did not produce his certificates until after working at the home for two weeks. A number of new staff had not received an induction and others had received a basic induction that did not cover the common induction standards. A number of care staff was employed for whom it was not possible to evidence they have had the necessary statutory training to demonstrate competence to perform their duties and role. The manager confirmed some staff training was in progress, however this was not evidenced. Training records were not produced to verify information in the Annual Quality Assurance Assessment (AQAA) which was completed in August 2007 that three staff held NVQ level 2 qualifications eight were working towards the same. It was not known how many of these staff remained in post. The manager was noted to have little control over the staff rota to ensure more experienced staff with relevant training and experience supported new and less experienced staff. The responsible individual was stated to be changing the rota almost on a daily basis without discussion or communication with the manager. The rota was not being maintained up to date to reflect the hours worked by staff. For this reason the manager had commenced a system of maintaining duplicate rotas. The rota and daily records identified a shift when the home’s domestic had undertaken care duties for which she was not trained. A care assistant on duty during the inspection visit was unable to communicate with the inspector or residents in English and had minimal comprehension of the language. It was established that she had formerly worked at the home in the capacity of domestic, had left then reinstated as a care assistant. No evidence was found on her file of an induction or training to enable her to competently provide personal care. A relative spoke to the inspector about the ethnicity of the team not reflecting that of the resident group. The home employs a multi-cultural staff group. This relative had anxieties about those staff with limited command of the English language and the impact of this on communication with residents. There was no evidence of diversity training for staff and information received from some staff highlighted racial tensions within the team. Shortfalls in employment practice included the employment of a student for hours exceeding the conditions of her Home Office work permit. Also working in advance of receiving a POVAFIRST check. The deputy manager and a care assistant were noted to be working excessive hours some weeks without a day off. The cook was not always able to take her days off. Observation of staff files and discussions with staff confirmed they were not informed their rights under the European Union Working Time Directive regarding hours of work. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 28 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): Standards: 31, 33, 35, 37, 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Significant shortfalls in the home’s management have been identified. Residents best interests are not safeguarded by admission practices, record keeping, policies and procedures, the operation of safeguarding and complaint procedures, staff recruitment, induction and training, staffing levels and elements of care practice. The health, safety and welfare of residents’ is not promoted in respect of infection control practice and systems, maintenance of the emergency call system and maintenance and practice relating to the stair lift. EVIDENCE: The home has not had a registered manager since just after the home changed hands in February 2006. Since that time a manager was appointed in April 2006 and dismissed in December 2006 without an application being received Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 29 for his registration. The current manager stated she has managed the home informally since the departure of the previous manager and formally since May 2007. Prior to this she was deputy manager at the home and has a qualification in health and social care at NVQ Level3. The manager is currently studying for NVQ Level 4 in management and the Registered Managers Award. She said these studies were at an early stage. She has not submitted an application for registration. At the time of the inspection the manager was working out her notice. She stated this was following a series of disputes with the registered providers. They advised of concerns about her conduct however. At the end of the second day of the inspection visit the manager left without completing her notice, at the request of the registered providers. The inspector was unaware of this situation at the time. The need to provide written notification to the Commission for Social Care Inspection (CSCI) of the proposed interim management arrangements and for appointment and registration of a competent, suitably qualified manager, was discussed with the registered providers. Also the requirement to conduct the home at all times in accordance with the conditions of registration that apply. The home continues to display the registration certificate with the name of the former registered manager and this information is replicated in the services users guide. In order to update the register the homeowners agreed to provide written confirmation to the CSCI South East Regional Registration Team that the registered manager is no longer in post. The management structure includes a deputy manager post though this has been vacant since December 2006 until recent weeks. The manager has had limited time to allocate to her management and administrative role and responsibilities, as referred to earlier in the staffing section of the report. The registered providers have defined areas of management responsibility which involved regular visits to the home. The manager stated however that there was no formal opportunity for her to meet regularly with the responsible individual to discuss the home and to receive guidance and support. Records of the manager’s supervision sessions with the responsible individual confirmed five sessions had taken place in the past twelve months. The responsible individual said she had arranged for the deputy manager based at the providers’ other home to spend time with the manager in the past, for support. Observations confirmed tense relationships and poor communication between the manager and deputy manager during the course of the first day of the inspection visit. Lines of communication were also poor with the home’s external management. This situation was not in the best interest of residents or the general management and operation of the home. It was concerning that although the manager had identified a number of shortfalls in the home’s operation and care practice she reported being disempowered by the registered providers to deal with them to safeguard residents. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 30 The inspection was protracted in time by the circumstances in which neither registered provider was available to take part in the inspection until late afternoon on day two of the inspection. Because the manager was working out her notice it was also necessary to ensure they received comprehensive feedback on the outcomes so as not to delay action for improvement. Other areas inspected included the home’s policies and procedures. Though some had dates indicating they had been reviewed since the last inspection, on examination it was found their content was not adequate. Record keeping for accidents was found to be incomplete. On 30th November 2007, two residents’ informed the manager they had fallen. The manager recorded this in the diary. It was said the staff on duty when these accidents occurred had no knowledge of the same. An entry had not been made in the care notes or accident records in this matter, only in the diary. The manager stated the responsible individual prevented her from following these accidents up with the staff concerned. Observations identified failure to always notify significant incidents to the CSCI as required. Health and safety audit records dated August and November 2007 were reviewed. Other records examined included the fire risk assessment, fire training and fire practices and service records for fire detection and fire fighting equipment, gas, electricity and the stair-lift. Risk assessments were in place for the storage of toiletries in bedrooms and lockable cabinets provided for these items. It was agreed with the manager that risk assessments would be carried out where furniture with sharp edges was positioned beside beds. Quality Assurance systems included quality audits carried out by key workers. Some of these were undated and on examination it was evident that staff carrying these out these audits were not trained and unclear about what was expected of them. Other quality systems include use of survey questionnaires for relatives, residents, staff (though only one had been returned and this person no longer employed), visitors and GP. It was good to note evidence that feedback from residents and relatives surveys was acted upon. Reports following monthly visits by the responsible individual were available to evidence only four visits since the last inspection. Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 31 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 1 x 3 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 1 x x 2 x x x 1 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 3 x 1 1 Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 32 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 OP1 Regulation 4(1)(a)(b) (c) 5(1) Requirement The statement of purpose must contain all statutory information. The service user guide must be updated to reflect current management arrangements. Previous timescale of 14/09/06 for updating the service users guide not met. To ensure care staff can competently communicate with residents and colleagues to be able to competently perform their duties and ensure residents’ health, safety and welfare. For the home to be managed with sufficient care, competence and skill to ensure admissions are within the categories of registration that apply. An admissions policy and procedure must be in place. The registered person(s) must ensure that a system is in place for recording, investigating and giving feedback to complainants about complaints received at the home. DS0000066830.V348872.R02.S.doc Timescale for action 07/01/08 2. OP4 18(1)(a) 09/12/07 3. OP4 10(1) 12(1)(a) 09/12/07 4. OP16 22 07/01/08 Limes Residential Care Home Version 5.2 Page 33 5. OP8 12(1)(a) 6. OP9 13(3) 7. OP12 16(2)(n) 8. OP15 12(1)(a) 16(2)(i) 17(2) Sch4 .13 9. OP18 13(6) Previous timescale of 14/09/06 not met. For appropriate action to be taken in response to the weight loss experienced by the residents’ identified, ensuring medical assessment and for this to be addressed in care plans, as necessary. Designated, competent suitably trained staff must administer medication. A record of staff designated this responsibility must be maintained also evidence of their training and copies of signatures. The activities programme must be further developed to address the needs and interests of all residents including those with sensory impairments. Records of food consumed by residents must be accurately maintained for all meals. Residents must be offered the choice of breakfasts on menus and have increased variety of evening meals including the choice of a cooked option. Arrangements for replenishing food provisions must be reviewed so that at all times the cook can prepare wholesome and substantial meals. The home’s management must ensure all allegations of abuse or neglect are referred to Surrey’s Safeguarding Adults Team in accordance with Surrey’s safeguarding adults guidance. The home’s abuse procedure must be amended to reflect this guidance and clarify responsibility for making safeguarding adults referrals. Action must be taken to ensure the staff induction enables new staff to recognise and respond to DS0000066830.V348872.R02.S.doc 24/12/07 09/12/07 07/02/08 07/02/08 07/01/08 Limes Residential Care Home Version 5.2 Page 34 10. OP26 16(2)(k) 23(2)(d) 11. OP26 13(3) abuse and neglect. A plan of proposed training must be developed for the team to ensure all staff to receive safeguarding adults training. A copy of this action plan to be supplied to the CSCI by this timescale. For a development plan to be produced for improving the décor of bedrooms and other areas of the home and replacement of carpets as necessary. Malodours must be eliminated in the four bedrooms identified. A copy of this action plan to be supplied to the CSCI by this timescale. The registered person(s) must ensure that suitable arrangements are in place to minimise the risks of infection in the home. Previous timescale of 15/08/06 not met. You must now carry out a selfassessment of infection control risks and practice at the home using a recognised assessment tool. A framework for improvement in infection control practice must be in place, including staff training. You must inform the CSCI of action taken and proposals for improving infection control procedures and practice and for quality monitoring by this timescale. Care staffing levels must be reviewed and remain under constant review to ensure numbers of staff are adequate without depleting management hours and adversely impacting on the home’s management and administration. Staff must not work excessive hours to ensure DS0000066830.V348872.R02.S.doc 07/01/08 12/12/07 12. OP27 18(1)(a) 24/12/07 Limes Residential Care Home Version 5.2 Page 35 13. OP29 19 (1)(a)(b) Sch 2 1-9 14. OP29 13(6) 19(1)(a) their health and safety and that of residents and for compliance with employment law. For all new staff to have the required recruitment checks as set out in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 (as amended). This includes ex-staff who have been re-employed. Advice must be sought from the CRB website regarding the correct procedure for recording, storage and disposal of CRB Disclosures. In respect of the three staff previously employed who left and then reinstated and any other staff currently working without a POVA First check, immediate action must be taken to ensure the safety and protection of people using services. The action taken must be confirmed in writing to the CSCI within the following timescale. 09/12/07 09/12/07 15. OP30 12(1)(a) 12(4)(a) 18(1)(a) (b)(c) (i) 16. OP30 18(1) (a)(b)(c) (i) 24/12/07 For improvement in care practice, ensuring care plans and risk reduction plans are followed. Staff must at all time respect residents rights to privacy and dignity and approach residents in an age-appropriate manner. Staff must ensure residents have opportunity to wear their hearing aids. Further risk assessments must be carried out addressing risks referred to in the main body of the report. For a skills audit to be carried 17/12/07 out for the staff team. You must tell us about measures you have taken and propose to take to ensure all staff in post and new staff, receive a structured induction and statutory and other training appropriate to DS0000066830.V348872.R02.S.doc Version 5.2 Page 36 Limes Residential Care Home 17. OP30 18(2)(a) (b)(i)(ii) their roles and responsibilities. A central record must be held of staff training. For the duration of a new worker’s induction training, a member of staff who is appropriately qualified and experienced, must be appointed to supervise the new worker and as far as practicable, be on duty at the same time. The law expects registered care services to have a registered manager. A suitably qualified and competent manager must be appointed to manage the home who is ‘fit’ to do so and notice given to the CSCI of the name of the person appointed and date this is to take effect. For the responsible individual or appropriate person delegated this responsibility, to carry out monthly visits to the home in accordance with this regulation and prepare a written report on the conduct of the home. This must be supplied to the manager and be available in the home for inspection. For the registered person(s) to give notice to the CSCI of any event at the home which adversely affects the well-being or safety of residents, serious illness of a resident and any allegation of misconduct by the registered person(s) or any person who works at the home. Any notification made orally shall be confirmed in writing. For a record to be maintained of all persons employed at the home in accordance with statutory requirements. This must include dates on which DS0000066830.V348872.R02.S.doc 07/01/08 18. OP31 8(1)(b)(i) 8(2)(a)(b) 24/12/07 19. OP31 26(2)(a) (b)(c) 26(3)(4) (5) 07/01/08 20. OP31 37(1)(2) 24/12/07 21. OP37 17(2) Sch4 .6 07/01/08 Limes Residential Care Home Version 5.2 Page 37 22. OP38 13(4)(a) (b)(c) 23(2)(c) 23. OP38 13(4)(a) (b)(c) 23(2)(c) they commence and cease employment and all other records in relation to their employment. An accurate copy of the duty roster must be kept and made available for inspection. All accidents must be appropriately recorded in accident records and care notes. For the stair lift to be repaired 07/01/08 and in the interim for staff to be instructed to manually position and use the footrest when transporting residents’ up and down stairs. For the emergency call system to 07/01/08 be repaired or replaced. 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 OP1 Good Practice Recommendations For prospective people using services that are unable to personally visit to view the home, to receive a copy of the service users guide in advance of admission. This will help them decide on the home’s suitability. For the home to use a validated assessment tool to enable comprehensive nutritional screening to be carried out admission and subsequently, on a periodic basis. For the home to use a validated falls risk assessment to ensure all risk factors are identified. For the home’s whistle blowing procedure to be displayed accessible to staff and include contact details of agencies referred to in the policy For the home’s restraint policy and procedure and missing persons procedure to be further developed. 2. 3. 4. 5. OP8 OP8 OP18 OP18 Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email:inspection.southeast@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 Limes Residential Care Home DS0000066830.V348872.R02.S.doc Version 5.2 Page 39 - 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. 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