Inspection on 17/01/06 for Lisnaveane Ltd

This inspection was carried out on 17th January 2006.

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

Lisnaveane Ltd 28/06/07

Lisnaveane Ltd 07/08/06

Lisnaveane Ltd 12/05/06

Lisnaveane Ltd 19/09/05

Lisnaveane Ltd 12/01/05

Lisnaveane Ltd 14/06/04

Lisnaveane Ltd 16/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Lisnaveane 790 Longbridge Road Dagenham Essex RM8 2AA Lead Inspector Ms Rhona Crosse Unannounced Inspection 17th January 2006 11:00 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 Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lisnaveane Address 790 Longbridge Road Dagenham Essex RM8 2AA 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) 0208 592 0022 0208 491 8424 Mr Alfred Henry Gilmore Waddell Mrs Fiona Foo Siang Waddell, Miss Julia Patricia Waddell Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2005 Brief Description of the Service: Lisnaveane is a residential property that has been converted and extended over time to provide a care home for 19 older people offering 24 hour care. The home is situated on the corner of a busy road with good transport links. There is parking in the street to the side of the property. There is limited space to the side of the building for parking in the homes grounds. The home comprises of single and shared bedrooms. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection therefore the home did not know the inspector was coming. The inspector arrived at approximately 11.00 am. This inspection was to look at compliance with requirements set at previous inspections therefore service users were not spoken with at this inspection. At the last unannounced inspection in September 2005 there were serious concerns about the operation of the fire doors within the home. The inspector called in the Fire Officer who visited the home at the time of the inspection. A report from the Fire Authority set the home various tasks to comply with as a result of this visit. The Commission served and Immediate Requirement Notice on the home due to the concerns about fire safety. At this inspection it was observed from the fire file that although the staff have been carrying out the weekly alarm call tests (as required by the regulations) and reporting in the fire file and to the proprietor, that fire doors are not closing when the fire alarm is activated. No action had been taken by the proprietors to get repairs carried out to ensure the fire doors closed appropriately. The inspector called the Fire Officer to the home again due to the concerns about the safety of service users and staff, should there be a fire at the home. The fire officer visited at the time of the inspection and a separate report will be written by the Fire Authority to the proprietors detailing the concerns and what action the proprietors must take to meet the Fire Regulations. Due to the ongoing failure of the home to ensure that fire doors are operable the Commission served a Statutory Notice on the proprietors. This is to ensure that the proprietors take action to rectify the problems of the fire doors not closing when the fire alarm was activated. If action is not taken they would face prosecution for their failure to operate the home within the Care Homes Regulations 2001 as a result of the serving of this notice. Requirements in relation to staff training and staff employment records (4 staff do not have CRB disclosures and staff have not had lifting and handling training) were not complied with from previous inspections. This has resulted in the serving of a Statutory Notice after this inspection. The manager who put forward an application for registration with the Commission has now resigned. It is an ongoing concern that this home and the ‘sister’ home operated by the same proprietors is unable to keep managers in post. The above failures and the associated risk this places for service users wellbeing, reflects on the fitness of the proprietors to continue to operate a registered establishment. The Commission will be seeking legal advice about Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 6 further action that may be taken as a result of the continued failure of the proprietors to meet the National Minimum Standards and comply with the Care Homes Regulations 2001. What the service does well: What has improved since the last inspection? Care plans have improved since the last inspection. Although there was thorough information about each service user the plans of care were not working care plans therefore the changes in need and the reviewing system was not evident at that time. The recruitment and selection information that the manager was responsible for was found to be in order. Staff have been offered a 12 week training course and this is taking place this includes basic first aid training. Staff have been trained in the ‘theory’ of lifting and handling by the manager who is trained to provide theory training only. Repairs to the property have been carried out. There was no odour of stale urine in the building at the time of this unannounced inspection. After an Immediate Requirement Notice was served on the home at the last inspection in September 2005, the providers are now providing Regulation 26 visit reports on the operation of the home. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 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 Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These core standards were inspected at the last inspection and were met therefore they were not inspected at this inspection. EVIDENCE: Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 The documentation relating to the needs of service users was deemed appropriate at this inspection with improvements made, this benefits the care and wellbeing of service users. Medication practice needs to be monitored more closely to eliminate any risk to service users. EVIDENCE: Care plans inspected at random were observed to have been updated and were also reviewed, with information readily retrievable. Visits by health professionals were documented and the outcome of visits also documented. Medication practice was inspected. The storage and administration was appropriate, however the recording showed from the medication administration recorded for the 29/12/05 – 19/1/05 that some areas had not been documented as required. For one service user the medication Cefadroxil syrup was prescribed. The amount of Cefadroxil syrup received by the home had not been entered onto the medication administration sheet. For another service user the medication Frusemide had been signed as being administered but this tablet remained in the blister pack. For a further service user the medication Quetapine had been prescribed part way through the month and the remaining Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 11 amount of medication was not documented as being carried forward to the next medication administration sheet, therefore a clear audit trail of this medication was not possible. Although there is a monthly audit of medication recording the manager will have to monitor this more closely. The pharmacy who provides the medication to the home makes visits and checks the storage, administration and recording of medicines in the home. A visit took place on the 14/12/05 there were no problems noted at that time. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These core standards were inspected at the last inspection and were met therefore they were not inspected at this inspection. EVIDENCE: Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 These standards are well managed. EVIDENCE: The home has policies and procedures for dealing with any complaints. There is a record of all complaints made. There have been 2 complaints made since the last inspection. These were documented with the action taken to ensure that there are no recurring instances of the same complaint. Both were substantiated. The home has policies and procedures to deal with abuse. Staff have received training in the protection of vulnerable adults. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of the standards in this section were inspected at the last inspection in September 2005. Requirements set at the last inspection, in relation to standards 19 and 21 (environment) have been addressed by the home which benefits service users. EVIDENCE: The home was clean and tidy, odour of urine was apparent in the home at the time of the unannounced inspection. Repairs that were set at the last inspection have been complied with. Clinical waste was appropriately stored at the time of the inspection. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 These standards are not met and have implications for the wellbeing and safety of vulnerable service users, in that they have failed to provide adequate lifting and handling training placing service users and staff at possible risk of injury. As the home have failed to take up CRB disclose checks the home has no evidence that the staff are fit to work with vulnerable adult thus placing them at risk. EVIDENCE: Staff employment files were inspected at random. Newly appointed staff had the appropriate documentation. However for 4 staff who have worked at the home for some time, no CRB disclosure forms have been received by the home. The staff members have all completed the CRB forms to be sent off for processing these forms were given to the proprietor. Due to non-compliance with regulations, a Statutory Requirement Notice was served on the proprietors as a result of these findings. Since the last inspection staff have been trained by the manager in the ‘theory’ of lifting and handling (she is not qualified to teach the ‘practical’ part of manual handling). Staff have not had any ‘practical’ lifting and handling training which is needed to ensure they are capable of carrying out this task. Or had training in the use of lifting equipment (portable hoist). This is a requirement that was not Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 16 complied with from previous inspections. This has also resulted in the serving of a Statutory Requirement Notice after this inspection. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Due to non-compliance with regulations these standards 31,33, 35 and 38 have implications for the appropriate operation of the home, as well as the wellbeing and safety of service users and staff. The owners are failing to secure an appropriate registered manager for the home. These failings may also compromise the homes insurance policy. EVIDENCE: The acting manager has resigned prior to her final interview for registration as manager with the Commission. The home has failed to keep a registered manager who has put forward an application for registration with the Commission. Due to this legal advice is being taken as a result of this situation. The failure of the home to meet requirements set at inspections and work within the National Minimum Standards and comply with the Care Homes Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 18 Regulations 2001, evidences that the home is not being run in the best interests of the service users as they are being placed at risk due to non compliance with regulations. There is no quality assurance analysis of the home to enable prospective service uses and their relatives to know how current service users and professionals view the care being provided. The home must send out a quality assurance questionnaire to all relatives and professionals. Once these questionnaires have been returned an analysis must be drawn up from the information provided and be added to the Service Users Guide. The home does not hold any money for service users. Any expenditure is taken from petty cash should they wish to purchase anything or have the services of the hairdresser or chiropodist. However it was established that money is given to the home by relatives and this is then passed on to the proprietor. It is a requirement that any money held on behalf of service users is held in the home and appropriate records are kept of any expenditure. The system that is in place at present does not comply with the Care Homes Regulations 2001 as neither the records of money held or records and receipts of money spent on their behalf was available for inspection. The proprietors are required to hold all money and relating records and receipts at the home. These must be available for inspection at any time. Failure to act upon this requirement will result in formal action being taken by the Commission. At this inspection it was observed from the fire file that although the staff have been carrying out the weekly alarm call tests (as required by the regulations) and reporting in the fire file that fire doors are not closing when the fire alarm is activated. Also two emergency lights are not working these concerns have been reported to the proprietor. No action had been taken by the proprietors to get repairs carried out to ensure the fire doors closed appropriately and the two emergency lights are operating. The inspector called the Fire Officer to the home again due to the concerns about the safety of service users and staff should there be a fire at the home. The fire officer visited at the time of the inspection and a separate report will be written by the Fire Authority to the proprietors detailing the concerns and what action the proprietors must take to meet the Fire Regulations. The Commission served a Statutory Notice on the proprietors as a result of non compliance with regulations. Failure to act upon the requirements set out in the Statutory Notices will result in prosecution. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 19 The Gas safety certificate is now out of date. The proprietors must arrange to have this work undertaken and provide a copy of the new Gas safety certificate to the Commission. There is no current Legionella certificate to verify that the water storage system is safe. It is a requirement that an annual Legionella test is carried out by a qualified water treatment company. The proprietors are required to have this work undertaken and provide a copy of the new Legionella certificate to the Commission. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 20 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x X x X X X X 3 STAFFING Standard No Score 27 x 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 x x 1 Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP29 Regulation 13(2) 19 (7) Requirement All medication must be recorded and administered in line with prescribing instructions. The 4 staff who do not have CRB disclosures must have this check undertaken. A statutory Notice will now be served. Staff must have lifting and handling training by a qualified trainer. A Statutory Notice will now be served. All staff must be trained to use the portable hoist by a qualified trainer. A Statutory Notice will now be served. All staff must have food and hygiene training. A Statutory Notice will now be served. The home must put forward a manager for registration with the Commission who is suitably qualified as identified in the Care Homes Regulations 2001 & National Minimum Standards. The home is not being run in the DS0000027906.V278872.R01.S.doc Timescale for action 15/02/06 27/02/06 3 OP30 18(1)(c)(i )13(4) (c) 18(1)(c) (i) 27/02/06 4 OP30 27/02/06 5 OP30 18(1)(c) (i) 27/02/06 6 OP31 9 30/03/06 7 OP33 43 30/03/06 Page 22 Lisnaveane Version 5.1 8 OP35 17(2) 9 9 OP38 23(4)(c)(i v) best interests of the service users. Requirements set at inspections must be complied with to ensure the health and wellbeing of service users. A record of all money received and held by the home for use by service users must be available for inspection at any time. Failure to comply with this requirement will result in formal action being taken. The home must ensure that the fire alarm system is in working order at all times. Also that emergency lighting is working at all times. Repairs/replacements must be carried out without delays. A Statutory Notice will now be served. Provide written confirmation that the Legionella test has been carried out on the water system. Failure to comply with this requirement will result in formal action being taken. The Gas safety certificate is overdue. Have this work carried out and provide a copy of the certificate to the Commission. Failure to comply with this requirement will result in formal action being taken. 20/02/06 22/02/06 10 OP38 13(3) 15/03/06 11 OP38 13(4)(c) 15/03/06 Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 23 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 The manager must monitor the medication recording and administration more closely. Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lisnaveane DS0000027906.V278872.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!