Inspection on 12/11/08 for Littledene House

This inspection was carried out on 12th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Littledene House 16/12/09

Littledene House 23/07/09

Littledene House 30/05/09

Littledene House 05/05/09

Littledene House 08/04/09

Littledene House 30/04/08

Littledene House 16/05/07

Littledene House 06/09/06

Littledene House 17/02/06

Littledene House 08/08/05

Littledene House 17/12/04

Littledene House 30/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Littledene House 54 Bushey Grove Road Bushey Watford Hertfordshire WD2 2JJ     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Patricia House     Date: 1 7 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 41 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 41 Information about the care home Name of care home: Address: Littledene House 54 Bushey Grove Road Bushey Watford Hertfordshire WD2 2JJ 01923245864 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : m.ang@btopenworld.com Ms Margaret Ang care home 12 Number of places (if applicable): Under 65 Over 65 0 12 dementia old age, not falling within any other category Additional conditions: 1 0 If the names service user ceases to be accomodated at the home then the variation to the category shall cease. The home may accommodate one named service user under the age of 65 with Dementia. The manager must inform CSCI if the service user permanently leaves the home for any reason. Date of last inspection Brief description of the care home Littledene House is a care home providing personal care and accommodation for twelve elderly people who may also have a dementia. Littledene is privately owned and the proprietor also manages the home. The property is a large detached house, which has been converted to provide single room accommodation. Six of the bedrooms have en-suite toilets. The house is well Care Homes for Older People Page 4 of 41 Brief description of the care home presented and provides residents with comfortable surroundings in a homely atmosphere. There is a passenger lift for easy access to the upper floor and an enclosed garden to the rear. The frontage of the property is attractively paved and allows for the parking of several cars. A single storey extension at the back of the house provides living accommodation for three members of the care staff. Littledene is situated in a quiet residential road in the village of Bushey and is approximately two miles from the village High Street and also about two miles from the extensive amenities of Watford Town. There are local shops a short walk away. There are nearby bus and rail services and the home is close to several major roads and motorways. Current charges for the home range from £495.00 to £609.00 per week. Further information can be found in the homes Statement of Purpose and the Service Users Guide, which are displayed in the entrance hall together with the last CSCI inspection report. The home also has an internet web site. Care Homes for Older People Page 5 of 41 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection on this service was completed on 30th April 2008. Since that time information received from a Local Authority Reviewing Officer raised concerns about the care provided at the home and so this further inspection took place. Issues raised and comments included in the Reviewing Officers report are included in this inspection report and are identified in quotation marks. As a result of the concerns raised by the Reviewing Officer, Hertfordshire County Council Adult Care Services called a strategy meeting under the joint agency safeguarding vulnerable adults procedures, to consider the findings. At this meeting we saw a further report completed by a second Reviewing Officer about the care provided in the home. Findings from this second report are also included in this inspection Care Homes for Older People Page 6 of 41 report. This information was also shared with the provider at the meeting. The information in this report is based on an unannounced inspection of the home, which took place on two separate days by two regulation inspectors carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as we. The inspection began on the afternoon of the 12th November and continued on the early morning of 17th November. The manager was present on both days. The home was full at the time of the visit although one resident was in hospital. Residents were spoken with and the interaction between them and the staff was observed. We spoke with staff and visitors. We visited all areas of the home and examined a selection of relevant documents. We also removed specific documents from the home under the Commissions legal powers. These documents set out, hour by hour the duties of staff on each working shift. Information from these documents has been referred to in this report. We have also reviewed any other information we have received about this service between inspections. What the care home does well: What has improved since the last inspection? What they could do better: A considerable number of requirements have been made as a result of this inspection. Despite residents being looked after by caring staff, services provided at the home have not kept up with current guidelines for good care provision and the dementia care provided is particularly poor. Written information about services at the home must accurately reflect what can be provided. Person Centred Planning has yet to be implemented in this service. Residents need to be seen as individuals and given choices about how they live and Care Homes for Older People Page 8 of 41 written evidence to show appropriate care takes place must be completed. Families should be involved in care planning and regular reviews of care should be adequately recorded to show the up to date situation. The current procedures for administering medication in the home are unsafe and must be improved to safeguard residents. Residents must be treated with respect and dignity at all times and should be provided with more choices about how they spend their days and how personal care is provided. Residents should have their own toiletries available in their own bedrooms. Fresh milk and fresh fruit juice must be provided to ensure a balanced and nutritious diet is provided and enjoyed by residents. Staff must receive training in and must be able to demonstrate an understanding and awareness of Safeguarding Adults and Whistle Blowing procedures to ensure residents are safeguarded from abuse. Guidelines for good infection control in the home must be followed and essential supplies of appropriate paper towels, liquid soap and toilet rolls must be available at all times. Residents must not be put at risk of harm through fire doors being wedged open or through residents having easy access to dangerous substances. We made some Immediate Requirements at the time of the inspection and subsequent to the inspection the manager has confirmed that these have been complied with. The manager states that appropriate medication procedures and storage now take place and that a fridge for medication storage is now in place. The manager also states that all care staff except one have received accredited training for administering medication. The manager states that toilet rolls, paper towels and liquid soap are now in place and that residents have their own supplies in their bedrooms. The manager states that call alarms are now accessible in all toilets but that only two residents can use call alarms so where these are not in use in peoples bedrooms care plans have been updated accordingly. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 41 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 41 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the home is provided in writing and on the internet. This assists peple to make an informed choice about becoming a resident. Written assessments are completed for all prospective residents but this does not ensure that all the specialist needs of individuals will be met by staff in the home. Evidence: We were provided with a copy of the homes Statement of Purpose and Service Users Guide at the last inspection and found the information was detailed and enabled prospective residents to make an informed choice about entering the home. During this inspection we found that, despite some residents having been assessed as needing particular exercise this was not being provided. Individual mobility requirements were not being met as described later in the report. Care Homes for Older People Page 11 of 41 Evidence: The home is also registered to provide specialist services for people with a dementia. Evidence detailed later in the report, however, will show how that current procedures in the home have resulted in choices being unavailable to some people. For example, people are given the same breakfast each day as staff feel they know what they want and do not provide a choice and in some bedrooms call alarms are not available as staff say the residents concerned would not know how to use them. At the last inspection the manager stated that training for staff in dementia care was being booked. We saw records that a Dementia Care Awareness training course took place in September this year. However care staff told us during this inspection that the course only lasted for part of one day and was therefore fairly basic. No member of staff has completed any specialist dementia training and the manager was unaware of the current information and guidance, available from a wide variety of sources, which providers of dementia services are expected to use to meet the range of needs of confused people. At the last inspection the manager also said that she would pursue training to enable one member of staff to specialise in providing activities for those residents with dementia. This has not happened and no special stimulation is provided for confused people. We saw no dementia appropriate signage in the home and no visual, or any other equipment, which is recommended for those with dementia to enable them to remain stimulated and remain as independent as possible. Since the inspection, we have seen a copy of a second report completed after a visiting professionals review of a resident in the home. The officer completing the review said that they felt that the manager of the home did not understand the need for dementia specific activity/stimulation. The report adds the manager of the home said that the staffing ratio in the home would not support the option of providing potential memory stimulating activities. Findings from the review indicate that the lack of stimulation may result in a deterioration of the residents mental health, especially as the basic human needs of contact and socialisation were not being met in this case. We reported to the manager at the end of the inspection that it was our judgement that the specialist needs of the many confused people in the home were not being met. The information provided for those people considering using the service must accurately reflect current services provided for people with a dementia, so that people are given full and accurate information on which to base their decision to enter the home. Care Homes for Older People Page 12 of 41 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents individual care needs are generally set out in care plans but resulting actions are not always put into practice in the home so that not all residents needs are met. Procedures in operation in the home do not all promote respect or peoples dignity and the system for administering medication leaves residents at risk of harm. Evidence: We spoke with or observed all residents over the two day inspection. We then tracked a selection of the corresponding care plans. The care plans contained information about peoples individual needs and, since the lat inspection, the manager has completed a falls risk assessment for each resident. However, the reviews of individual needs were not adequate and in all cases they consisted of a list of dates with no comments or signature to show that reviews had actually taken place or the outcome of the review. This means that the inevitable changes that people in the home experience over time may not have been identified or assessed. Handling assessments and transfer planning had been completed but we found evidence that these were not being followed in practice. The relative of one resident told us that staff transferred Care Homes for Older People Page 13 of 41 Evidence: their relative on a shower chair and we saw a shower chair in the lounge on the first inspection day. There was no detail of this means of transfer in the residents care plan. One care plan gave information that the resident should undertake stretching exercises and should be mobilised daily. This need was further confirmed by the individuals relative. However the relative said that no exercises took place. During a review of this resident, undertaken by a visiting professional we have been told that the homes manager said that staff numbers were not sufficient to ensure that the daily mobilisation, required in the care plan took place. In addition the manager told the reviewing officer that she did not recognise that a care plan is prescriptive or binding. Care planning is an important means of ensuring that all residents needs and the means of meeting these needs, are identified and that this information is available for all staff in the home to follow consistently and must be kept up to date. Furthermore care plans must be person centred to ensure that people are assisted in a manner of their choosing so that they are shown respect and have their dignity upheld. The Care Homes Regulation underpinning the need for care planning also requires that the resident or their relative is involved in the care plan. During the inspection we were told by a visitor that they were not aware of and had never seen their relatives care plan. One reviewing officer who visited the home reported that the relative of the resident under review had said that they were concerned that the lack of mobilisation had led to a rapid decline in their relatives mobility. In the report shared with us it also states that care staff had said they were unable to encourage residents to mobilise regularly as there were not enough staff on duty to provide this assistance. As described in the report of the last inspection visit, the manager of the home clearly sets great store in keeping the residents clean and keeping their skin in a healthy condition. The manager is a registered nurse and also takes residents blood pressure and from the outcomes assesses whether to ask a doctor to visit. However, the home is not registered as a nursing home and in providing residential care the manager needs to be able to meet a wide range of needs and must ensure that care plans are more individualised or Person Centred. Plans must include individual histories and must record peoples individual likes and aspirations and the services provided must aim to meet these needs. Several residents have diabetes and care staff confirmed to us that they are involved in assisting with aspects of blood glucose testing and insulin administration. Assistance with insulin administration is a specialised medical technique for which care staff must receive individual training. There were no risk management plans in place and no records to show if care workers had been trained to provide assistance or to show what the administration procedure should involve. Care Homes for Older People Page 14 of 41 Evidence: We saw records of the residents weight, recorded at regular intervals. However, care staff confirmed that the weighing scales we saw were the ones used for this task and these were large bathroom scales. Care staff also confirmed to us that most residents had to be held when standing on these scales therefore the accuracy of weight records could not be guaranteed and this could put residents at risk if a serious weight change was not accurately identified. Scales should be appropriate for the people using the service and should therefore be sit-on scales or wheel chair scales. During the previous inspection we observed the lunch-time medication round and were satisfied with the system. However, at that inspection we reminded staff that nonblistered drugs should have the date of opening written on the packaging and that totals of medication not returned to the pharmacist should be carried forward to the new record sheet. This is so that accurate audits can easily take place. When we checked the medication store on this occasion there were packets of drugs with no opening date recorded. Medication without opening dates on may mean that medication is used past its use by date, meaning that it may be clinically ineffective. The reviewing officer who raised concerns about the home with the Commission had also expressed concerns about the medication procedure which took place in the afternoon. We visited in the afternoon on the first inspection day and found that at 4pm care staff had already set out the medication, which was to be administered at 5pm. All drugs had been removed from the blister packs and from any packaging and had been placed into egg cups, all together on a tray, with residents names written on pieces of paper attached. The record sheets for administration of these drugs had already been signed in advance by staff, indicating that the medication had been taken, although it had clearly not been. Care staff confirmed this was normal practice in the home. This procedure is not only illegal but puts residents at risk of drug error. It also demonstrates again that care staff assume that residents will all accept their medication and does not recognise that people must be empowered to refuse medication if they choose to. The care workers we spoke with also confirmed that all staff administer medication but the only medication training they had received was to watch a short video in the home. Guidelines for the safe administration of medication in care homes require that only staff who have completed an accredited training course and have their competency checked regularly should administer medication. On the second inspection day the manager confirmed that an accredited medication training course had now been booked for staff to attend. The manager must also provide storage for controlled drugs, which complies with pharmacy regulations and must provide a dedicated fridge for medication needing to be stored at low temperatures. At the time of the visit there was a considerable amount of medication stored amongst food in the fridge in the kitchen. This does not comply with guidelines for the storage of medication and puts people in the home at risk as the fridge is not Care Homes for Older People Page 15 of 41 Evidence: kept locked. During the inspection we also saw prescribed creams and prescribed Immodium left accessible in a glass fronted cupboard in the dining room. There were also prescribed blood glucose test strips and lancets in this cupboard, which could not be locked and could be easily accessed by residents, putting them at risk of harm. We checked the homes written medication policy during the inspection and this was very old, out of date, did not provide staff with information for proper procedures and was totally inadequate. We spoke with some residents who indicated that they were happy with the arrangements for personal care in the home. The relative we spoke with praised the care staff and said they always treated residents with respect as well as kindness. However, we noted on both inspection days that people mostly did not have their own toiletries in their own rooms and that there was a general community store of soap, toothpaste and shampoo in a cupboard. Care staff also confirmed that not many residents had their own toiletries and we also noted that, after people came out of the ground floor bathroom, there was one hairbrush in the hall, which care staff said was used for each person in turn. This practice does not afford people who live in the home respect or dignity. In the laundry there were named storage boxes containing residents washed clothing. We also saw residents toothbrushes in each of these boxes, meaning that teeth cleaning was also a procedure which did not take place in private in peoples own bedrooms. We saw this procedure as a further example that residents were kept clean but were not treated as an individual and given the dignity of having their own things in their own rooms. During this inspection we also saw several bedrooms, which contained large stores of incontinence pads. Care staff told us these pads were not just for the resident concerned and one resident could not access their en-suite facility as it was full of pads. We told the manager that residents bedrooms must not be used as a store room and that doing so showed a lack of respect for the residents concerned. Care Homes for Older People Page 16 of 41 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are not provided with adequate stimulation to ensure their mental well-being and are not supported by the procedures followed by care staff to make choices about their lives and remain as independent as possible. Residents enjoy the meals provided but more consideration must be given to the choices available to those with dementia to ensure their continued good health. Evidence: In the last two reports we recommended that activity provision be improved in the home to provide more stimulation for the residents. We had received comments from relatives in the quality surveys they had returned to the Commission that they thought more stimulation could be provided for the residents in the home. At the last inspection the manager had said she might identify one member of staff who could plan weekly activities and would also pursue training to enable one staff member to specialise in dementia activities. During this inspection the manager confirmed that no specialist activity training had yet taken place or been researched and that no staff member plans activities in the home. The reviewing officer reported that staff on duty had told them they were concerned Care Homes for Older People Page 17 of 41 Evidence: about the lack of stimulation for residents and that a relative stated that they had never witnessed any activities taking place. We were told by a visitor during this inspection that they visited daily and that they had not seen any activities take place except a very occasional board game played with the manager and one particular resident. On the second day of this inspection visit, the television was already on at 7.40am although there were only three residents in the lounge and they were asleep. A second reviewing officer has reported that when they visited the television was on, at full volume, showing a childrens programme. Again none of the residents were watching this but a visitor told the officer this situation was always the case. During this inspection care staff confirmed to us that they have no time to provide activities for residents and in the written Littledene daily Shift Routine it is clear that no time is allowed for staff to provide activities. We found that there is no visual or sensory equipment available in any areas of the home as recommended for the benefit of confused people and none of the staff or the manager demonstrated an understanding of the mental and emotional needs of people with a dementia. The staff Shift Routine confirms that the managers priorities are to keep both the home and the residents clean and well presented, and there is a lack of any individual or Person Centred support. In all areas there is a lack of choice for residents. The staff Shift Routine lists named residents and their times for getting up and going to bed. There are also times listed for taking named residents to the toilet during the night. Therefore we must assume that residents have to be woken at these times if asleep to fit in with the homes routines. The Shift Routine also requires that between 9am and 10am the dinner and pudding is cooked and the 12 noon medication is prepared. This further confirms poor procedures take place for medication administration. There are more instructions on the plan telling staff to start washing named residents between 2pm and 4pm, presumably getting them ready for bed as they have already been washed in the morning, although staff are instructed not to put night clothes on at this time. Routines in the home appear rigid and do not allow staff to change their way of working to meet individual choices and wishes. Subsequent to the inspection the provider has stated that the written Shift Routine seen at the home at the time of the visit no longer corresponds to the current regime. Times for meals are also stated on the Shift Routine for staff and we were surprised that the mid-day meal is served between 11am and 12 noon, which seems rather early for dinner. The manager should ensure that this early time for the main meal is what all residents actually want. We saw the evening tea served on the first inspection day and the mid-day meal Care Homes for Older People Page 18 of 41 Evidence: served on the second day. Both meals looked appetising and well presented and the residents clearly enjoyed the food provided. One visitor told us that the evening tea has much improved since the recent visit made by the reviewing officer. However there are no choices provided for meals served in the home. The manager said that most residents were unable to make meaningful choices about food and that the staff know the individual likes and dislikes of residents. One reviewing officer has stated that their client could make choices with support and the manager was advised to research some of the guidelines for assisting residents to make choices, such as using pictorial menus. There could certainly be more choices made at breakfast time, when residents could sit down at a table and choose from a selection of breakfast food. On the second inspection day we found that breakfast had already been made for residents by the night staff and was ready for serving on trays. Some of these trays contained thin sandwiches made with jam and these were covered over with plastic covers but not with foil or cling film, so would be getting dry. Clearly there was little choice provided for this meal. One reviewing officer has reported that a relative has complained to them that residents were provided with no fresh vegetables, fruit, meat, milk or juice. We were told by the manager that fruit was offered. However we did not see any fruit left available for people in the communal areas in the home but there was fruit in the fridge on the second inspection day. The manager confirmed that the milk provided in the home was the long-life variety. The residents living in the home would almost all have been used to having fresh milk during their lives and we told the manager that this must be provided daily as a choice for residents. The juice provided is not fresh fruit juice but squash. We also told the manager that a choice of fresh juice must also be available, as listed on the displayed menus. We asked care staff preparing food in the kitchen how information about special diets was provided for those preparing food. We were told that staff just know who needs a special diet. Although there are people currently living in the home with diabetes, subsequent to the inspection the provider has stated that no one is on a special diet. Staff also said there are no records kept at present showing what people in the home actually eat and this information should be recorded in line with the Care Home Regulations and Environmental Health guidelines and to demonstrate that each resident receives appropriate nutrition. The reviewing officer also reported that the bedroom doors in the home were kept locked in the day and that the heating was switched off and rooms were cold. Care staff had said that they were not allowed to put the heating on and that bedrooms were locked so that residents could not enter other peoples rooms. We found that the home was warm during both inspection days and a visitor told us that the home had Care Homes for Older People Page 19 of 41 Evidence: been cold but that it has been warmer since the reviewing officers visit. We found most bedroom doors locked on the first day we inspected and we advised the manager that doors must not be locked and that residents should be given the choice and opportunity to return to their rooms when they wished. We also said that all rooms should be kept warm so that visitors can see their relatives in bedrooms in private, and in comfort, when they want to. Little consideration appears to have been given to the wishes and choices of the people using the service. Overall we felt that the care provided in the home is not Person Centred and does not provide support for individuals to remain as mentally alert as is possible. Residents have to fit in to the homes routines and are not given sufficient opportunities to make their own choices. Times for getting up, going to bed appear prescribed and residents appear unable to choose where and how they spend their days. Residents who would have had preferences for their own toiletries now use communal supplies provided by the manager. Care Homes for Older People Page 20 of 41 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a written complaints policy so that people using the service and their relatives can raise any concerns with the manager of the home. Safeguarding policies in the home need updating and current procedures do not ensure that residents in the home are protected from abuse. Evidence: At the last inspection the manager said she was updating the homes Safeguarding policy. We checked this policy during the visit and found the information confusing. The old policy was still in the file and guidance conflicted with the current guidelines provided by Hertfordshire County Council Adult Care Services, which is followed by all services and agencies in the County. We asked one senior member of staff their understanding of Safeguarding reporting procedures and they were not aware of current procedures. The home has written policies covering Complaints and Whistle Blowing. We checked the Whistle Blowing policy and found this inadequate for giving staff clear information or for providing them with an understanding of the implications of the policy. We spoke with care staff who were not aware of the Whistle Blowing policy or procedures, or of their role in ensuring that all residents are protected from abuse at all times. There have been no complaints made to the home, or to the Commission, about the Care Homes for Older People Page 21 of 41 Evidence: home, since the last inspection, with the exception of that raised by the reviewing officers from Social Services. There is one Hertfordshire Safeguarding investigation taking place as a result of the concerns raised as explained in this report. An outcome has yet to reached. Care Homes for Older People Page 22 of 41 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained and kept clean for the benefit of the residents but procedures followed in the home do not promote good infection control and therefore could leave residents at risk. Evidence: We visited all areas of the home during the inspection and, as at previous visits, the home was generally clean and well decorated and maintained. There was however a broken toilet handle in one en-suite room and an unpleasant smell apparent in one bedroom. There is a passenger lift and stair lift in the house and ramp to the garden so that residents have access to all areas of the house and garden. At the last inspection we found there were fabric towels but no paper towels provided in communal bathrooms and toilets, although this provision is recommended in current guidelines for infection control. On this occasion we found that there was no liquid soap, no towels of any description and no toilet rolls in many of the bathrooms and toilets including in en-suites in bedrooms. The lack of toilet paper and appropriate towels is contrary to all guidelines for good infection control and could put residents, staff and visitors at risk. As already stated we saw stores of tablets of soap for general use and saw this soap left in the one bathroom which appeared to be used for all the people who live in the home. The laundry also had tablet soap and no paper towels in Care Homes for Older People Page 23 of 41 Evidence: place by the wash hand basin. Tablet soap is not recommended for communal use because of the risk of the spread of infection. We therefore advised the manager that liquid soap must be provided in all communal bathrooms and toilets and in the laundry where staff handle soiled bedding and clothing. In one area of the home there is one residents bedroom, and a bathroom, both at the top of a flight of stairs. There is no other room in this area but the bathroom is designated for the use of visitors only and is kept locked. Although it is acknowledged that this resident needs assistance, it means that the person in question cannot access a nearby bath or toilet but has to go down the stairs on a chair lift to use another facility. Subsequent to the inspection the provider has stated that the service user currently in the room is satisfied with the arrangements. These arrangements must however be kept under review if and when the situation changes. This bathroom also had no towel in place and had tablet soap in use. We checked the homes policy on Infection Control and this was extremely old and out of date. The manager has also not obtained copies of the current written guidelines recommended for use in all care homes for preventing and dealing with infections and thus for safeguarding residents. Care Homes for Older People Page 24 of 41 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents in the home are not supported by staff in sufficient numbers or by staff who are sufficiently trained to ensure all residents needs can be met. Procedures for recruiting staff in the home need improvement to ensure that residents are protected from abuse. Evidence: On the first inspection day, in the afternoon, there were two care staff on duty and the manager was contacted after our arrival and arrived later during the visit. On the second day there were two care workers and the manager on duty. The home has eight permanent staff members and four of these live in accommodation in the grounds of the house. The manager said that agency staff are not used at the home. The reviewing officer who registered the concerns after visiting the home felt that there were insufficient staff numbers on duty on all shifts, to ensure that residents needs were met. During the inspection the care staff told us what duties they were expected to cover during a shift. Furthermore the staff Shift Routine confirms that the two care staff on duty have to complete all the cleaning, laundry, cooking, medication and personal care tasks throughout the day and during the night shift. Every hour is accounted for in this planning and it is easy to see why staff say they have no time to assist with any activities. In addition, some of the residents need two Care Homes for Older People Page 25 of 41 Evidence: staff to help them transfer and walk and two for some bathing assistance. This means that if two care staff are with one resident, all the other residents could be unsupervised at times. Similarly, when staff are cooking or cleaning there would be only one care worker at most to support the residents. The range of duties listed for the one night care worker to perform includes putting people to bed, toileting, preparing breakfast trays and cleaning duties. If some residents need two staff to assist them it is not clear how one care worker can safely manage to support them. Subsequent to the inspection the provider has stated that there is always a person available on-call on the premises. We observed that staff are currently provided with living quarters by the provider in out buildings in the homes garden. During the inspection the care staff we spoke with said they did not feel there were enough staff on duty at the home. Clearly more staff are needed to implement improvements to the activity provision in the home and to ensure residents receive more exercise, as already demonstrated. The first reviewing officer had also reported that some staff had difficulty communicating adequately when spoken with during the review. The report of another review indicated that two staff had difficulty communicating with one another and with the resident when performing a moving and handling manoeuvre. This could present a risk to a resident being assisted. One visitor told us during this inspection that most care staff could communicate well but one or two had difficulty at times. The visitor also praised all the care staff and said they provided a nice atmosphere in the home. The manager must ensure that staff have a sufficient command of English to ensure that residents are safely supported, especially at night when care staff work alone. We checked the staff files during the inspection and found that not all contained evidence that all necessary training had been completed. Some files contained certificates confirming attendance at training courses but there were some where attendance on essential courses such as Safeguarding and Infection Control was not evidenced. Care staff said that some in-house courses had consisted of them watching a short video and they felt this was not adequate training. The manager has confirmed that, since the inaspection, courses in the Administration of Medication, the Control of Infection and Safeguarding of Adults have now been booked. The manager should produce a training overview to demonstrate the training completed by staff and to show the training still needed. Care staff also told us that they are not paid for attending training sessions. Care staff should all have a training and development profile and should be provided with a minimum of three paid days training each year. This is required to meet current National Minimum Standards for employed care staff and to ensure residents are supported by a skilled and competent workforce. Care Homes for Older People Page 26 of 41 Evidence: As already demonstrated it is also essential to provide staff with activity and specialised dementia training in the near future. The senior care worker said that they have just completed NVQ 2 training but care staff told us that none of the remaining care staff have started this training. We also checked the recruitment records for the staff at the home during the inspection. Two application forms seen did not have full employment histories completed and one did not have a reference from previous recent employment in a care setting, both of which are needed to ensure a thorough and robust recruitment process is taking place to ensure the safety of residents. Evidence was also needed to confirm that two staff members have permission to work in the country. Care staff informed us during the inspection and had previously informed a reviewing officer, that they were paid considerably less than the minimum wage. The staff files we saw did not contain copies of contracts or staff Terms and Conditions. These documents must include the number of hours for which the individual is employed each week and the staff position held. Some of the care staff had expressed concern that there was confusion around payment for hours worked at the home and staff contracts must be clear about employment hours and rates of pay. The evidence we saw raised some concerns and so we have contacted the relevant agencies. Care Homes for Older People Page 27 of 41 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service cannot be sure that their views or those of the staff will be considered in the running of the home. Written policies in the home have not been kept up to date and procedures followed by the manager and the staff do not ensure that good health and safety practices are in operation or that residents are protected from the risk of harm. Evidence: The manager is registered with the Commission, has a management qualification and is a registered nurse. However as we have noted, the manager needs to keep up to date with current good practice findings and guidelines including those for dementia care and infection control. Although it is clear that the manager has set very high standards for personal hygiene and cleanliness she must also ensure that the care provided for people is less institutional and is Person Centred and reflects a more individual approach to supporting residents. Care Homes for Older People Page 28 of 41 Evidence: We saw no evidence that resident meetings are held in the home, to establish the views of the people using the service. Staff also confirmed to us that they do not have regular meetings. Care reviews with family involvement do not appear to take place and there is no evidence that any meaningful Quality Assurance is in operation. This means that the manager cannot demonstrate that the views of residents, relatives and staff are used to influence and underpin the running of the home. We were told by a senior member of staff that two or three residents have pocket money held for them at the home. The staff member also said that the manager kept some money and gave this to one resident when required. However the manager stated, when asked, that no one at the home held any money for residents and that families provided, or were invoiced for all extra expenses. The manager also said that she purchased communal toiletries for residents as many did not have these supplies provided by families. We reminded the manager that all residents were entitled to have the use of their personal allowance, one way or another, and that if a resident did not have toiletries and small items provided from this money it should be reported to the Local Authority as it could constitute financial abuse. Individual choice and independence is highly restricted by the approach adopted by the manager. During this inspection we found several areas where safety was a concern. On the first inspection day the lounge door was wedged open and one resident had barricaded their door almost closed from the inside. Both restrictions to door closure represent a fire hazard and we told the manager that alternative means of keeping the doors open or closed needed to be found. On the second inspection day the manager had already fitted a suitable door device on the lounge door but we found the laundry and another bedroom door wedged open. After the previous key inspection we wrote in the report that, We saw some door wedges being used to keep some fire doors open, during the visit. The manager removed these wedges before we left the building and said she would explain to residents why fire doors must not be held open as they would be put at risk in a fire. We were therefore disappointed to find during this inspection, that door wedges were still in use in the home. We also saw disinfectant and a chemical cleaning liquid left accessible in the laundry and saw disinfectant and a cleaning product accessible in a store cupboard, sited outside the conservatory, where the door was unlocked. All the accessible items presented a possible risk of harm to residents. In some bedrooms there were no accessible call alarms for residents to use in an emergency and the call alarm in one communal toilet was tied up out of reach. The manager said that the residents concerned were confused and could not use the alarms. This finding was not detailed in their care plan and must be reviewed and recorded. Care Homes for Older People Page 29 of 41 Evidence: We checked the written policies and procedures for the home and these were all very old and had not been updated. As already stated the Safeguarding, Infection Control and Medication policies are all inadequate and there are no general risk assessments for the home in the Health and Safety Policy. Risk assessments are needed for the two recliner chairs which residents are using as these can present a risk of injury. The risk assessments should give the rationale for the use of the chair, arrangements for its servicing, for its safe operation and detail any associated risks. Training must be provided and documented for all staff in the use of the chair. There had been two accidents since the last inspection where residents had sustained broken limbs. The manager said that the Commission had been informed of these incidents but no record was found of these notifications The manager was advised to keep copies of such notifications and advised that the funding authority should also be notified of such serious accidents. Staff are provided with accommodation in a three bedded outbuilding. This structure, although small, is adequately heated and reasonably comfortable. However, extra accommodation was also found in a cedar summer house at the bottom of the garden. The provider initially informed us that the accommodation was for meetings but late admitted it was where one member of staff lived. The staff living arrangements found at the time of the inspection have been reported to the relevant authorities. Staff confirmed to us that they pay for their accommodation. The provider must ensure that all relevant legislation is adhered to including Equipment and Health and Safety legislation. Care Homes for Older People Page 30 of 41 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 41 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 9 13 All care staff involved in 17/11/2008 administering medication in the home must have completed an accredited medication training course and have their competency checked and signed as satisfactory at least once a year. This is to protect residents of the home from unneccessary risk of harm. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 2 9 13 A safe system for the 17/11/2008 administration of medication must be maintained. Medication must not be dispensed into egg cups of containers in advance by staff and records must never be signed for prior to medication being administered. This is to ensure that residents are protected and that their health is not put at risk. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 3 9 13 Only care staff who have 17/11/2008 been individually trained and have their competency Page 32 of 41 Care Homes for Older People verified can provide medical assistance using specialist or intrusive techniques. A management plan must also be provided in all cases. This is to ensure that all care and support is safely provided. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 4 9 13 Appropriate storage must be 01/03/2009 provided in the home for controlled drugs, which complies with current legislation. This is to ensure the protection of all people in the home. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 5 9 13 All medication must be 17/11/2008 locked away when not being administered. This is to ensure the protection of all people in the home. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 6 38 13 Call alarms must be 17/11/2008 positioned within reach of residents in their bedrooms unless it can be demonstrated in care planning that this is inappropriate. This is to keep residents safe Care Homes for Older People Page 33 of 41 at all times. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 7 38 13 Hazardous substances must not be left accessible to residents. This is because this puts them at risk of harm. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 8 38 23 Fire doors in the home must not be wedged open or closed. This is to ensure fire safety in the home. This was required to be met by 17.11.08. The proprietor has responded to this requirement and has confirmed compliance. 17/11/2008 17/11/2008 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 4 12 Specialist training for one or more members of staff at the home must be provided in dementia care and activity provision. 01/02/2009 Care Homes for Older People Page 34 of 41 This is so that appropriate stimulation and comfort can be provided for confused people in the home. 2 4 12 Improvements must be 01/02/2009 made to the environment and appropriate equipment must bre provided which will benefit people with a dementia. This is to benefit people with a dementia and to meet current guidelines for providing good dementia care. 3 7 15 The service user or their representative must be consulted and involved in the written care plan whenever possible. This is to ensure that all parties are clear about the care to be provided. 4 7 15 The care for each resident must be regularly reviewed and documented in detail in their care plan. This is to ensure that all staff are aware of the current needs of the resident and aware of how these needs are to be met. 5 7 15 All residents in the home must have a written plan which details all their needs and shows how these needs are to be met in a Person Centred way. 01/02/2009 01/02/2009 01/02/2009 Care Homes for Older People Page 35 of 41 This is so that all residents are supported by staff in a way that reflects their personal wishes and goals. 6 8 12 Appropriate weighing scales for the use of all residents must be provided for the home. This is so that accurate weight checks can take place and any serious weight loss can be identified and acted upon. 7 10 12 All residents must be 01/01/2009 provided with their own toiletries and these, together with their own toiletries must be left in their own bedrooms. This is to ensure the dignity and privacy of residents is maintained. 8 10 12 Communal hairbrushes must 01/01/2009 not be used for people living in the home. This is to ensure the dignity and privacy of residents is maintained and their personal hygiene promoted. 9 12 16 A suitable range of activities must be provided for residents in the home on a daily basis. This is to ensure that adequate stimulation is provided. 10 14 12 Efforts must be makde to provide residents with 01/02/2009 01/02/2009 01/02/2009 Care Homes for Older People Page 36 of 41 choices in their daily lives so that they can decide the time they get up and go to bed, choose what food to eat and have the option of going to their room in the day. This is to ensure that residents dignity, privacy and right to make choices is maintained. 11 14 12 Bedrooms must be kept 01/01/2009 warm and residents must be able to access them at all times. This is to ensure that residents dignity, privacy and right to make choices is maintained. 12 15 17 Records must be kept of the actual food eaten by residents. This is to ensure that individual diets are satisfactory. 13 18 13 All staff at the home must complete up to date training in Adult Safeguarding and Whistle Blowing and must demonstrate their understanding of these topic. This is to ensure that people living at the home will be protected from harm and abuse. 14 26 13 All communal bathrooms and toilets must contain liquid soap, soft paper 01/01/2009 01/01/2009 01/01/2009 Care Homes for Older People Page 37 of 41 towels and toilet paper and individual bedrooms must contain appropriate soap, towels and toilet paper. This is to ensure that good infection control is maintained in the home. 15 27 18 Staffing numbers in the home must be reviewed. This is to ensure that enough staff are on duty at all times to ensure that all the needs of residents can safely be met and so that appropriate stimulation and exercise can be provided. 16 29 19 A signed record must be 01/02/2009 kept in the home of the Terms and Conditions agreed with each member of staff including the hours they are employed and paid for each week and in what position they are employed. This is to ensure that staff are clear about their duties and responsibilities and can provide appropriate care for people in the home. 17 29 19 All staff must provide details 01/02/2009 of all employment histories and two appropriate written references must be obtained before new staff start work. This is to help protect residents from risk of abuse. 01/02/2009 Care Homes for Older People Page 38 of 41 18 30 18 All staff in the home must be 01/02/2009 provided with assistance, including time off, for training. This training must be planned with staff. This is to ensure that staff have the necessary skills to meet the needs of residents. 19 31 13 The manager must ensure 01/02/2009 that appropriate written policies and procedures are in place and that these are reviewed and kept up to date. Policies must be updated quickly for Safeguarding Adults, Whistle Blowing, Infection Control and the Administration of Medication. This is so that staff especially are aware of procedures to be followed for the benefit of all parties in the home, and to ensure the safety of residents. 20 31 10 The manager must 01/02/2009 undertake periodic training and must keep herself informed of current research and guidelines for the provision of care. This is to ensure that residents in the home receive the best support in meeting their needs. 21 33 24 A formal quality assurance 01/03/2009 system must be in operation at the home. This is to ensure the views Care Homes for Older People Page 39 of 41 and wishes of the residents and their families are used to improve services at the home and to affect the running of the home. 22 38 13 The homes Health and 01/01/2009 Safety Policy and Statement must include appropriate general risk assessments for the use of two recliner chairs in the home. These must then be identifiedin the individual persons file with appropriate detail to ensure the people are kept safe. This is to protect residents from any unnecessary accidents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 Information in the Statement of Purpose and Service User Guide must accurately reflect the current service provision in the home. This is to ensure that people receive appropriate information about the home. Evidence should be recorded to show that the care plan for each resident has been put into practice. This is to demonstrate that individual needs are being met or reasons are given where they are not. This would include where the need for a particular exercise has been identified as a need. 50 of care staff in the home should be retrained to NVQ level 2 to ensure that the needs of residents can be met by a professional workforce. NVQ training should be made available to all staff in the care home. 2 8 3 28 Care Homes for Older People Page 40 of 41 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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