Inspection on 11/04/06 for Longdean Lodge

This inspection was carried out on 11th April 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

Longdean Lodge 04/07/07

Longdean Lodge 17/10/06

Longdean Lodge 07/11/05

Longdean Lodge 09/06/05

Longdean Lodge 13/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Longdean Lodge Hillsley Road Paulsgrove Portsmouth Hampshire PO6 4NH Lead Inspector Clare Hall Unannounced Inspection 11th April 2006 09:00 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 Longdean Lodge DS0000044492.V288717.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. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Longdean Lodge Address Hillsley Road Paulsgrove Portsmouth Hampshire PO6 4NH 023 9238 3021 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) www.portsmouthcc.gov.uk Portsmouth City Council Mrs Rita Mangeolles Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability over 65 years of age (8) of places Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Longdean Lodge provides accommodation and personal care for up to thirtynine older persons and is owned and run by Portsmouth City Council and managed by the Health and Housing Directorate. Longdean Lodge is arranged over three storeys and is broadly divided into five units, one providing intermediate care to older persons returning to live independently in the community. All bedrooms are single occupancy. Each wing of the home has a dining and sitting area, and there is a large communal lounge in addition to this, and a specified smoking area. Service users have their meals in the dining rooms in the designated units, or elsewhere if they choose. There is recreational space outside, with seats, and a patio off the rehabilitation wing. Gardens surround the home and consist of shrubs, trees and some plants to the front of the home; there are lawned areas also, and new boundary fencing has recently been installed to improve security, as well as CCTV. Service users who use frames and wheelchairs are able to access the garden. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook the visit over two days. During this visit the evidence on which this report is based was sought from discussions with 16 staff, individually and in groups, and discussions with service users individually and in groups. An audit was also undertaken of records and procedures and observation of staff practice. Input was also provided by an accumulation of evidence recorded by the Commission in respect of Regulation 37 reports, regulation 26 visits, service histories, complaints and reported issues over a period of twelve months. A full tour of the premises was undertaken and the registered manager and deputy/duty managers also contributed to the outcomes. Five relatives’ views were also sought in respect of the service provision. What the service does well: Service users and relatives reported that “The team are fantastic, it’s like an extension of our family home. “We are included in every aspect of my father’s life”. “The staff are caring and compassionate and the care at Longdean is exemplary”. “All the staff are wonderful and friendly and keep you informed of what is going on”. Thank-you notes received by the home stated “Thank you for getting me on my feet again, thank you for the laughter and thank you for all the kindness and support. Records did indicate that staff have made significant efforts to improve the care planning process. The team at Longdean demonstrated verbally motivation and commitment during the visit for improving the services provided. The home was clean, the atmosphere chatty, happy and friendly. All staff were helpful and demonstrated compassion and a commitment to the core values of dignity and rights of service users. Staffing levels appear appropriate for the clients needs and all clients and relatives spoke positively in respect of the service. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 6 All service users spoken to where happy and satisfied with the service provided and felt their expectations have been met. What has improved since the last inspection? 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. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 7 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 Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 8 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): 2,3,4,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all the service user’s written contract/statement of terms and conditions with the home contain the information required. The assessment procedure is not robust and does not ensure the needs of prospective service users can be met. Longdean Lodge is not the most appropriate placement for a number of clients currently residing there. EVIDENCE: Five service user records were audited. Some lacked details pertaining to fees, rooms to be occupied and signatures of clients. New service users are not always admitted on the basis of a full assessment identifying suitability with the homes intended purpose and details of registration. The registered person does obtain a summary of the Care Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 9 Management (health and social services) assessment and a copy of the Care Plan produced for care management purposes. Evidence through records and discussions with staff have identified that on this and previous occasions the home has admitted service users whose needs are not being met. There are currently four clients demonstrating needs outside that of which the home states it can meet. This concern has been identified on a previous visit and there is an outstanding requirement in respect of this. The decision to admit residents does not rest with the registered manager. The manager is able to clearly identify five service users with needs in relation to nursing and severe mental health issues who require other forms of appropriate placement, as the home is not meeting their needs. Staff do not collectively have the skills and experience to deliver the care, which the home offers to a number of service users currently residing there. There is evidence that this is placing service users and staff at risk. All specialized services are offered for those clients within the intermediate care facility but there are gaps in the support provided for clients with mental health needs and those demonstrating challenging behaviours. The registered person must ensure that prospective service users are not invited to undertake a probationary stay before a decision is made that their needs can be fully met. It was ascertained that one service users’ stay was agreed over the phone and by a member of staff other than the manager when it was clear that his mental health needs could not be met. The Victory unit demonstrates a good system of providing information to prospective service users in the form of a DVD. Longdean Lodge DS0000044492.V288717.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): 7,8,9, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not protected by the home’s policies and procedures for dealing with medicines, incidents and accidents. The care planning has improved considerably but further details are necessary for the recording of specific health care needs. EVIDENCE: The service user’s health, personal and social care needs are well set out in an individual plans of care but will require further expansion. The Victory unit care documents identify clear goals and support from the multidisciplinary team for the rehabilitation of clients in this intermediate care facility but the records lack a care plan, which addresses the health, needs of the clients. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 11 New documents in relation to care planning were audited and the homes’ system for care planning has improved. Plans indicated service user involvement. The plans must now be expanded to set out in detail the action that needs to be taken by care staff to ensure that all aspects of health needs are addressed. A client identified with diabetes must have the care and management of that condition clearly evident in relation to diet, medication, foot care etc. A client with arthritis and pain did not have this addressed in her care documents. Further development of care plans so as to demonstrate, wherever possible, the support given to service users to encourage their own capacity for selfcare, is strongly recommended. Service users identified with psychological /mental health issues must have an appropriate plan of care for the management of challenging behavior and it must clearly be demonstrated how their needs will and are being met. Assessment documents identified that nutritional screening is undertaken and this now needs to be communicated to the catering department, as the catering staff could not identify good documentary evidence that likes, dislikes and preferences of individuals are noted and details of specialist diets are recorded in appropriate detail. This will be expanded on in standard 15. Enforcement action has been taken in respect of medication within the home since the last inspection and this is being addressed further with Portsmouth City Council. The manager reported that an investigation following the incident has been conducted but she is not aware of the outcome. The manager was not aware that enforcement action in respect of this had been taken. A review of the organization’s practices and procedures has been undertaken by a Commission for Social Care Inspection pharmacist in conjunction with a review of the compliance evidence in respect of the above enforcement. This concluded that further work must be undertaken in respect of policy and procedure. This will be addressed with Portsmouth City Council separately to this report. The inspector did not want to audit further medication administration practice issues during this visit but did, on a tour of the premises with the manager, identify two tablets left on a service users’ table and a pot of prescription cream belonging to a service user in the bathroom. Records regarding the reporting of accidents and incidents under regulation 37 indicated a number of concerns regarding service users’ falls and other matters. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 12 Other identified concerns raised through regulation 37 reports were incidents when staff sustained injuries while assisting service users to mobilize. Discussion with staff regarding the recorded events identified the following: a) Staff have accident and incident recording forms, which they have to amend to suit its purpose. These forms are meant for reporting accidents and incidents to staff only. b) Staff are not provided with appropriate accident and incident recording tools. Staff reported they had been requesting new documents and forms at senior management meetings to allow the adequate reporting of incidents and accidents but this has not been addressed. c) An audit of incidents and accidents is not undertaken so the manager is unable to feed back trends, causes and outcomes. d) Two incidents discussed, where staff sustained injuries in relation to moving and handling of service users were case tracked to service users who have mental health issues and challenging behaviour. Review of the PCC guidance for accident and incident reporting states: Accident reporting and recording is an essential part of effective management of health and safety at work. It provides managers with information regarding suitability of risk assessment and protective and preventative measures are put in place and any other further control measures, which may be needed. It is important that each reporting team /unit has a nominated person responsible for ensuring the procedure has been followed and the correct forms are completed fully and forwarded promptly to the various authorities. This policy and procedure is undated, has no review date and does not reflect current practices. In summary, during the visit the records and discussions with staff identified that the actions taken for the reporting of incidents and accidents is inadequate, the procedures unclear and there was no in house monitoring of events. One service user seen during the visit had facial injuries. When the injury was case tracked it was found that this was related to a fall, which was recorded in the contact sheet. This event was not recorded as an accident or incident and there was no notification made under the provision of regulation 37 received by CSCI despite medical attention being sought and injuries sustained. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 13 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users stated that their expectations regarding social activities were being met. Considerable improvement is necessary with regards to the provision of food. EVIDENCE: Service users were observed participating in flexible mealtimes and undertaking daily living tasks in small kitchenettes. Records identified that service users have the opportunity to exercise their choice in relation to: • leisure and social activities and cultural interests; • mealtimes; • religious observance. Further expansion though is necessary for the provision of choices for food. Currently the menu does not identify that a choice is available or offered. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 14 When asked service users stated if you don’t like it “you don’t eat it “ and “No we don’t choose what we have, it’s on the menu and we all get the same”, which was confirmed by kitchen staff. On the day of the visit everyone was having liver and potatoes with vegetables. Daily food records did not identify choice. When discussing choices with kitchen staff gaps were identified in the record keeping of client’s likes, dislikes, preferences, food offered and consultation with service users regarding that day’s menu choices. It will be required that internal audit must be undertaken in respect of standard 15 and good practice initiatives recently identified by the Commission are acted upon. Of thirteen residents sitting in the lounges one could tell me what she would be having for lunch and only one had a drink of water beside her. Five stated they would like a drink, three stated they had just had one and the remaining did not particularly mind or elicit a response. Conversations with staff, records and training records indicated a lack of training in nutrition and providing special diets. The catering records for food and the cleaning and maintenance of the kitchen are well below practice standards identified in the home’s policies and procedures manual and this was also identified in the comments made by catering staff in the meeting held in February 2005. It was also identified however that over the two-day period the standards applied were dependent on the staff which were on duty. This inconsistency was attributed to the lack of procedures. The PCC Food safety manual regarding kitchen cleaning, kitchen hygiene, cleaning procedures, nutrition is not being implemented and the standard of record keeping is poor. Current practice does not reflect PCC guidance and procedures. It was established through training records and discussion that there were serious deficits for the provision for role specific training. One staff member employed for a considerable number of years who was handling food and undertaking domestic duties has received no formal training to undertake these roles. This staff member was identified in supervision as having specified learning and development needs which have gone unaddressed and unsupported. Some service users have had their preferences noted regarding food in the residents meeting records. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 15 Good evidence was available to identify that service users are provided with suitable activities and the home promotes ongoing contact with community groups. Service users and relatives were very complimentary regarding the provision for events and outings and this was observed during the visit. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 16 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): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The current process for the monitoring of complaints by the registered manager is not adequate, nor is there adequate record keeping and audit trail for the investigative processes attached to allegations of abuse. Financial systems within the PCC are currently undergoing changes requiring continuing audit and further clarification. EVIDENCE: The registered manager was unable to easily access details of complaints made regarding the service. The registered manager did not know the outcome in relation to an outstanding issue raised during a previous visit. It was reported that the PCC complaints and customer relations department does not keep the registered manager abreast of all issues/complaints raised in relation to the home nor update the staff on possible allegations referred to adult protection. Staff confirmed they are not kept informed of investigative actions or outcomes. Evidence to confirm the difficulties experienced by the homes staff in seeking this information was evident during the visit. The PCC complaints procedure and guidance within the home clearly states Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 17 • • • • • “For all agencies involved in investigating cases of suspected abuse of vulnerable adults in residential homes a requirement is for detailed recording of all aspects of the issue in question and that systems are in place to support the establishment throughout the investigation and following it. It also states, Owners, managers, of residential homes have the right to Be informed, involved and included in accordance with the wishes of the vulnerable adult and needs of investigation. Be supported Be informed of the outcomes of the investigation. The senior staff within the home stated they have not been involved or kept informed of what was the outcome of these events have been and there are no records in the home to establish that these issues have been recorded contrary to the PCC own guidance. The PCC complaints procedure of 23/3/04 states that where possible complaints should be resolved locally and informally,if the complainant thinks that matters cannot be resolved locally or do not wish to approach local staff they may go direct to the complaints office. This is contrary to the stage 1 identified in the service user’s complaints information leaflet produced by the PCC. The PCC complaints procedure which includes the stages and timescales for the process, issued to service users and other share holders identifies the first stage of the complaints process is to inform the PCC customer relations and complaints dept of the concerns. It was first reported by the organization’s complaints department to the manager that there had not been any events in relation to complaints or adult protection issues which was identified in the pre inspection questionnaire, but on further request to establish issues two were then identified. Unfortunately this by passes the registered manager, who it has been identified, is not aware of issues and outcomes of complaints allegations made and therefore cannot have any direct influence on improving areas of practice, which may be identified. Records regarding an event of an allegation of abuse made in November 2005 could not be monitored and audited to identify whether it was followed up promptly and the appropriate action taken is recorded. It will be required that the registered manager must be aware of all stages of and steps taken in relation to allegations regarding the staff /processes in the home and all complaints and that adequate records are kept. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 18 It has been identified that the home’s policies and practices regarding service users’ money and financial affairs do not ensure service users’ access to accrued interest as the monies have been pooled. Evidence in respect of the above indicates individual accounts have now been set up but it is unclear how the service users accumulative interest has been estimated and or re-paid. It is also unclear what happened to monies held by the PCC for service users who may have passed away without any will. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It was noted during the visit that there was a high standard of cleanliness throughout the home but improvements need to be made within the kitchen. Service users are very happy with the improvements made to the fabric of the building. Staff are not given the training necessary to support their role. EVIDENCE: During the visit the premises were mainly clean, hygienic and free from offensive odours. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 20 and do not intrude on service users. Unfortunately the dirty linen is carried through the clean area. This needs to be addressed in relation to infection control. It was reported that staff have not received an update and training on recent changes to the PCC procedures regarding infection control. This must be undertaken. Washing machines have the specified programming ability to meet disinfection standards with a sluicing programme. PCC cleaning documents and guidance for the kitchen were not being followed. Manuals giving clear instructions and guidance did not reflect current practice. Through discussions and records it was demonstrated that kitchen staff have not had appropriate training to support them in their role. Knowledge regarding diets, calorie requirements and support for residents with diabetes was not indicated. The kitchen appeared messy and cleaning records inadequate. Records identified that the environmental health officer has recently visited and recommendations have been made but not yet addressed. During a tour of the premises improvements were identified for the fabric, maintenance and internal redecoration of the building. Further improvements were noted for the replacement of a number of the windows and bathrooms within the home. Discussions with staff and service users identified the pleasure of having such improvements made to the fabric of the building. Residents on the top floor were proud and pleased with the new colours and décor of the dining areas corridors and bathrooms. Staff were also pleased with the improvements that have been made. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are not provided with the training necessary to support the needs of service users. Despite there being a vacancy factor, which has led to 158 hours of bank/agency staff being required, staff and service users feel there are sufficient staff. Records in relation to recruitment and selection of staff are now held on the premises. Records do not show that supervision is undertaken regularly. EVIDENCE: Records and discussion indicate there is a vacancy factor of 72 hours per week. Records indicate that there is a ratio of 75 trained members of care staff (NVQ level 2 or equivalent). This is considered good practice. There is a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users and this was evidenced through records and discussions. The home’s training records need significant improvement. Records indicate that staff have not been provided with the necessary training to support their Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 22 role. Supervision records also identify that training and development needs have not been addressed. The staff supervision records indicate that staff have not received regular supervision in the preceding twelve months. Staff reported that they were to attend manual handling training on the day of the visit. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Current practice with the PCC homes is not in line with best practice or PCC guidance. Despite the registered manager not having full day-to-day control of the home in relation to meeting all the standards, staff feel supported. The PCC must strive towards self- audit and quality assurance of its own homes and services as poor practice issues are still being identified by the regulator. This is not in line with the expectations of CSCI. The current standard of practice would indicate that this is a poor service. EVIDENCE: Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 24 The registered manager of the home is the acting manager and has been in this post for approximately 18 months and is currently undertaking an NVQ 4. It has been identified during discussion that a job description would be of significant benefit for the registered manager so to enable her to take responsibility for fulfilling her duties. The registered manager does not appear to be in full day-to-day control of the home in relation to meeting all the standards applying to the registered manager. Discussions in relation to issues regarding complaints, incident and accidents, inappropriate admissions and addressing concerns in relation to the inspection processes would be improved with clear lines of accountability within the home and with the external management. Staff reported that they had noticed significant improvements this past two years. They felt that the management supported them and that their opinions were considered. Staff felt the management team in the home has improved. Service users felt a team of caring considerate staff whom work hard was meeting their needs and that “things could not be better’’. Considering CSCI initiatives and moves towards Inspecting for Better Lives (2) the home is not yet applying processes to monitor quality of services. Effective quality assurance and quality monitoring systems, based on seeking the views of service users must be improved to measure success in meeting the aims, objectives and statement of purpose of the home. An internal audit must be undertaken annually, and visits made under the provision of regulation 26. The registered manager must be aware of the homes/organizations annual development plan and demonstrate a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. There are no current adequate quality systems in place. Systems must be improved to enable feedback to be accessed actively from service users about services provided through e.g. anonymous user satisfaction questionnaires and individual and group discussion, or taken as evidence from records and life plans. Service users and relatives do have meetings where opinions are sought but the process needs to be incorporated into a more developed process. It was also acknowledged through discussion that the views of family and friends and of stakeholders in the community (e.g. GPs, chiropodist, voluntary organisation staff) are not actively sought on how the home is achieving goals for service users. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 25 A significant concern identified during audit of staff based practice in relation to PCC procedures is that the current policies, procedures and practices are not regularly reviewed in light of changing legislation and current practice in the home does not reflect the organizations procedures. The records did not support that care and ancillary staff receive formal supervision at least 6 times a year but discussions indicate this may be happening informally and not recorded. It was identified that issues raised for the support needs of staff in relation to training and supervised practice had not been undertaken. There were significant gaps noted for the record keeping in relation to incidents accidents, kitchen procedures, complaints and staff supervision and training. Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 1 1 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 2 2 2 2 2 Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation CSA 2000 (Section 24) Requirement The registered persons must ensure that adequate assessment is carried out as part of the admission procedure to the home to ensure that the resident may be admitted legally within the categories and conditions of registration, in order to ensure that the needs of the resident can be met at the home. The registered persons must make application to vary conditions of registration, and this must be sanctioned by the CSCI prior to the home admitting residents outside of the current registration categories. This requirement has not been met and has been raised again. Further action will be taken in respect of this. 2. OP35 20 The home must not pay money into a bank account on behalf of a resident unless that account is in the name of the individual resident concerned. This requirement remains DS0000044492.V288717.R01.S.doc Timescale for action 14/05/06 14/05/06 Longdean Lodge Version 5.1 Page 28 outstanding from previous inspections. Clarification in respect of the processes will be required from PCC finances department before it can be evidenced that this has been fully met. 3 OP2 5(1) Terms and condition provided to all service users (including the Victory unit) must have all information in respect of that described in standard two. You are required to inform CSCI in writing by the given date of the action taken to ensure the needs of all service users are being met/with needs associated with their mental health and nursing needs. All staff must have the training to support them in their role. This includes ancillary, domestic catering and care staff. Please submit a training plan by the given date. The manager must comply with regulation 37 in full. Mandatory training must be provided and a matrix identifying how this will be met forwarded to the Commission. All service users care documents must identify the needs and actions necessary to meet health needs of clients. (Including the Victory Unit) Care plans must identify clear goals in relation to person centred planning and demonstrate the promotion of self care especially in relation to the promotion of continence. Mental heath support and provision must be clearly identified in the care planning of clients with challenging behaviours. DS0000044492.V288717.R01.S.doc 12/07/06 4 OP3 14(1)(2) 30/04/06 5 OP30 12(1) 18(1) 01/06/06 6 7 OP33 OP30 37 1291) 12/05/06 12/07/06 8 OP7 15(1)(2) 12(1) 12/07/06 9 OP7 15(1) 12/07/06 10 OP8 12(1) 13(1) 12/05/06 Longdean Lodge Version 5.1 Page 29 11 OP15 12(1) 12 OP9 13(2) 13 OP38 12(1) 14 15 OP38 OP38 12(1) 12(1) 16 OP38 13(4) 17(2) 17 OP38 17(2)(n) 18 OP38 17(2) 19 OP16 22(1) The manager must address standard 15 and ensure the minimum standards are being met. Service users must have their nutritional needs addressed, recorded and provided by appropriately trained staff in relation to the PCC procedures and Commission initiatives. Medications in any form must be securely stored and not be left on table tops/ and or in communal areas. The registered person must address deficiencies in the PCC practices and procedures in relation to medications. The registered person must ensure staff adhere to policies and procedures. The organisation’s procedures must reflect best practice, be updated and identify when they were reviewed. The reporting, recording, monitoring of all accidents and incidents must be in line with legislation and organisational procedures. Staff must be aware of the above and have the tools and guidance to do this. Records must indicate what food has been provided to service users and record when alternatives have been provided for. The process for the reporting, investigation and outcome of all complaints must include the involvement of the registered manager. The registered manager must have records pertaining to all complaints. The PCC complaints procedure must be consistent with guidance issued in leaflet form to allow the manager to be involved DS0000044492.V288717.R01.S.doc 12/07/06 12/04/06 12/07/06 12/07/06 12/07/06 12/07/06 12/07/06 12/07/06 12/07/06 Longdean Lodge Version 5.1 Page 30 in the complaints process. 20 OP16 22(1) The manager must be aware as 12/05/06 appropriate of the issues in relation to reported incidents and accidents and referrals to AP regarding the home and their outcomes. The progress and outcome in 12/05/06 respect of individual service users accounts being provided for service users and their monies must be forwarded in writing to the Commission. This must also address how the interest owed to service users has been reimbursed and the funds of service users who have been deceased whilst their monies were held by PCC and they were without living wills must be accounted for. Steps must be taken to ensure 12/07/06 cross contamination of clean laundry does not occur. The commission must be informed of what action will be taken to address this. Staff must be provided with training regarding the recent updates in the policy and changes to PCC procedures regarding infection control. Issues raised by the environmental health officer must be addressed in full. The acting manager must be provided with a clear job description identifying her role and responsibilities. Lines of accountability within the home and its relationship to external management must be clear in relation to admissions, complaints, accidents, incidents and standards in relation to the NMS for care homes and to DS0000044492.V288717.R01.S.doc 21 OP35 20(1) 17(2) 22 OP26 13(3) 23 OP26 13(3) 12/07/06 24 25 OP38 OP31 13 12(1) 12/07/06 12/07/06 26 OP31 12(1) 12/07/06 Longdean Lodge Version 5.1 Page 31 27 28 OP33 OP33 26 10(1) 24 ensure the manager is authorised to manage the home. Visits made under regulation 26 must be undertaken monthly as required. Effective quality assurance and quality monitoring systems and self audit must be in place. The PCC must inform the Commission how they will address this by the given date. 12/05/06 12/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Longdean Lodge DS0000044492.V288717.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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