CARE HOMES FOR OLDER PEOPLE
Ludbourne Hall South Street Sherborne Dorset DT9 3LT Lead Inspector
Rosie Brown Unannounced Inspection 10:50 31 January 2006
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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 DS0000026838.V281397.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. DS0000026838.V281397.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ludbourne Hall Address South Street Sherborne Dorset DT9 3LT 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) 01935 816382 01935 815901 Scosa Ltd Mrs Denise Lesley Bevan Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000026838.V281397.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One of the following bedrooms may be used at any one time for shared occupancy, not exceeding a total of sixteen (16) residents: Bedrooms 7 & 11. 13th October 2005 Date of last inspection Brief Description of the Service: Ludbourne Hall is a registered care home offering both long and short-term places to a maximum of 16 people over the age of 65. The home is owned by Debra and Phillip Scott, under the title of SCOSA Ltd; the registered individual (RI) is Debra Scott and the registered manager is Denise Bevan. Ludbourne Hall is situated a short level walk from the centre of Sherborne and is within easy access of the towns facilities including the railway station, gardens and Abbey. Parts of the building date back to the 18th century. Extensions have been added to create the present accommodation comprising 16 bedrooms, a ground floor lounge and separate dining room. Residents’ accommodation is on the ground and first floor. There are assisted bathing and toilet facilities on both floors. The home has a stair lift fitted on the main staircase. Care staff are on duty at all times and include wakeful night staff. In addition to personal care and support the service provided includes all meals, laundering of clothes, and all housekeeping. A range of social and leisure activities are provided and the manager and staff ensure residents’ attend healthcare appointments when necessary. A variety of professionals visit the home including chiropodist, optician, hairdresser, GPs and community nurses. The home has an enclosed sheltered patio at the rear of the building and a small parking area is situated at the side of the house. DS0000026838.V281397.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 31st January 2006 and was undertaken by inspector Rosie Brown: it was the second of two statutory unannounced inspections planned to take place within a year. The inspection commenced at 10:50am and was concluded by approximately 3pm. The inspector assessed 13 of the National Minimum Standards and the requirements and recommendations set out in the report of the previous inspection. The communal areas and a selection of bedrooms were viewed: residents’ care and medication records, staff records and certain policies and procedures were examined. The inspector used observation skills to assess the interactions between staff and residents, spoke with the manager Denise Bevan, two staff that were on duty and three residents. Four comment cards supplied by the Commission were received from service users; the views expressed within them have also been used to inform this inspection report. It is recommended that the previous inspection report be read in conjunction with this report to gain a more complete ‘picture’ of the home. What the service does well:
The home has a comprehensive statement of purpose and service user guide that is supplied to prospective residents and is also readily available in the home’s entrance hall. Before moving into the home each resident has a pre-admission assessment of care needs to ensure that the home can meet the person’s needs prior to admission. Care plans and care related risk assessments are in place for each resident and contain detailed guidance so that staff can meet identified needs. Visitors are always welcome in the home and links with the local community are maintained. Residents’ social care provision is central to care provision and forms a very positive part of life in the home and a friendly atmosphere was apparent in the home on the day of the inspection. Residents are supplied with a variety of wholesome home baked food that is served in the home’s comfortable dining room or in residents’ rooms if requested. The menu is displayed and alternatives are supplied.
DS0000026838.V281397.R01.S.doc Version 5.1 Page 6 The home has a complaints procedure and information in this regard is provided in the home’s hallway and residents’ notice board. The home continues to be well maintained, pleasantly decorated and furnished in a homely manner: it is clean throughout. The home operates a quality assurance system that includes residents’ views and it was evident that action had been taken to address findings and necessary improvements. Care records comment cards and conversation with residents’ revealed that staff actively promote each resident’s independence, privacy and dignity. As stated in the previous report, residents’ views are respected and acted upon appropriately and this is demonstrated in the minutes of residents’ forum meetings. Maintenance records are well kept and show that arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. What has improved since the last inspection? What they could do better:
One of the two good practice recommendations that remain outstanding from the previous report has been changed to a requirement: the registered persons must ensure that induction for new staff includes the five mandatory health and safety topics and be supplied within the first six weeks of employment. The homes’ medication storage arrangements should be relocated to a place other than the kitchen. All Controlled Drugs (CD) must be stored in double
DS0000026838.V281397.R01.S.doc Version 5.1 Page 7 locked cupboard and a CD registered must be obtained and used to ensure proper recording practice. Residents’ medication administration record (MAR) charts should include all details of prescribed medication, eg no more that 8 tablets to be taken in 24 hrs or to be taken with food. The home’s medicines policy should be updated to include reference to the use of homely remedies and an audit trail should be established for those medicines not supplied in the monitored dosage system. Although the protection of vulnerable adults (POVA) training has been supplied to care staff, the manager must undertake the local two-day awareness course provided by the Social Care & Health Department to ensure she familiar with local processes. Some night storage heaters are protected and the hot water supply to baths is supplied close to 43degrees as recommended. The inspector acknowledges that the resident group is relatively independent and feel their rights are being infringed by the use of radiator covers. However, this report recommends that a programme of protecting the homes’ night storage radiators and the governing of the hot water supply to washbasins and baths in residents’ ensuites be progressed using a risk-assessment process. The home’s recruitment and ‘Whistle blowing’ policies should be updated to make reference to the POVA guidance as previously recommended. 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. DS0000026838.V281397.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000026838.V281397.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home has a statement of purpose and guide in place to ensure that a prospective resident or their representative can make an informed choice, before moving into the home. Standard 3 was assessed as met at the previous inspection. EVIDENCE: The home’s manager reviews the statement of purpose and guide on an annual basis. A copy of this information is readily available in the entrance hallway of the home as is a copy of the home’s inspection report. The manager explained that all prospective residents are supplied with a copy of the guide when enquiries are made initially made about vacancies. One resident confirmed that they had been given information about the home before moving into the home. DS0000026838.V281397.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, 9 and 10 Each resident has an individual care plan with care related risk-assessments in place to ensure that staff have up to date guidance on their care needs. The home’s medication storage and administration arrangements are satisfactory with all residents’ medicines cared for by the home. Service users confirmed their privacy is protected and that their known wishes are respected. Standard 8 was assessed as met at the previous inspection. EVIDENCE: Two resident’s care records were examined and demonstrated that care plans are in place and reviewed each month. Daily care reports describe the personal and health care being given to residents by staff. A number of care related risk-assessments are also in place and these include the prevention of falls, personal hygiene and dignity, mental health issues, vulnerability to burns from night storage heaters and the hot water supply.
DS0000026838.V281397.R01.S.doc Version 5.1 Page 11 One resident said that they feel well cared for by staff and confirmed they are regularly consulted about their care needs. The home has a documented medication policy that provides guidance to staff that handle and administered residents’ medicines. This should be improved to make reference to the use of homely remedies and describe how medication not contained in the monitored dosage system is trail audited. The manager evidenced that staff training concerning the safe handling of medicines has been arranged for 22nd February 2006. Residents’ medicines are stored in a locked facility, but it is not ideally situated in the home’s kitchen. In the longer term the medicine storage cabinet should be relocated to a more suitable place other than the kitchen. In the meantime, staff record the temperature of stored medicines on a daily basis to ensure that medication are stored appropriately. The controlled medication for one resident was not properly stored in the Controlled drugs (CD) cupboard within the cabinet, as required: the home must also obtain and use a CD registered. Each resident has a monthly Medication Administration Record (MAR) chart. Staff must ensure that MAR charts contain all the details of prescribed medication, eg take with food or do not take more than 8 in 24hrs. Comment cards confirmed that residents feel their privacy and dignity is protected and that staff treat them with respect. One resident said, ‘staff are helpful and kind here, I go out to the to town when I feel able’. DS0000026838.V281397.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Visitors are welcomed by the home and social activities are creatively organised to ensure that residents maintain community contact. Standards 12, 14 and 15 were assessed as met at the previous inspection EVIDENCE: The daily care records for two residents demonstrated how the home encourages and enables resident to keep in contact with their relatives and friends. For example, daily care records evidenced that one male resident is taken regularly to visit his wife in another home. A visitors’ record book is kept in the entrance hallway and evidenced that the home receives visitors on a daily basis. Comment cards noted that visitors are always welcome in the home. One resident said, ‘my son and daughter in-law visit and take me out’ while another said that they enjoy going out to the town in their mobile buggy. The social activities programme is decided with residents at their monthly forum meetings and includes taking part in local events, eg a recent Christmas carol concert.
DS0000026838.V281397.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The complaints procedure is supplied to residents and they were confident that their concerns would be taken seriously and acted upon. The home has a policy concerned with adult protection to ensure that residents are protected and allegations of abuse properly responded to. EVIDENCE: The home has a complaints procedure that is supplied to resident and their relatives. One comment card noted that if there were any concerns they would approach the manager and felt confident she would ‘put things right’. The home has a complaints book but there have been no complaints since the previous inspection. The manager said that residents are encouraged to air their views at regular forum meetings and the most recent meeting record demonstrated that this is the case. For example, particular requests for meals. On the day the inspector heard one resident insisting that they did not want a birthday cake or present and ‘no fuss’ and the manager confirmed that staff would respect these wishes. The home’s adult protection policy has been shared with staff and most of the staff team have taken part in training concerned with the recognition and prevention of adult abuse. The manager has yet to attend training provided by the local Social Care and Health department in relation to ‘No Secrets’ and POVA guidance procedures and abuse awareness: both guidance documents are kept in the home for reference if necessary.
DS0000026838.V281397.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home is very clean and maintained to a good standard; it provides an attractive, comfortable and homely environment for the residents who choose to live there. Standard 26 was assessed as met at the previous inspection. EVIDENCE: As described in the previous report residents’ bedrooms are available on the ground and first floor of the home; there is a stair lift for people unable to independently use the stairs. All bedrooms are single and many have en-suite facilities: those without have bathrooms and toilets nearby. Bedrooms are highly personalised with residents’ furniture, pictures and other personal items. The home has a large furnished entrance hall where the ‘parakeet’ lives. There is a communal lounge where ‘Lily’ the home’s dog has her basket and a separate dining room, which also has comfortable armchairs offering an alternative room to sit and relax in. DS0000026838.V281397.R01.S.doc Version 5.1 Page 15 Since the previous inspection the entrance hall has been redecorated, as have bedrooms 12 and 15: bedrooms are routinely redecorated when they become vacant. Assisted bathing and toilet facilities are available on both floors. The home has night storage heaters and risk-assessments have been drawn up regarding residents’ vulnerability to hot surface temperatures. The manager explained that some heaters are protected but others are not and this is generally due to residents’ specific requests for the heaters in their rooms not to be covered. However, the home should implement a programme of protecting heaters and fitting fail-safe hot water temperature control valves to ensure that hot water is supplied close to 43 degrees using a risk-assessment process. The home is generally in good order, is well maintained and homely: some original features of the ‘old house’ have been carefully restored, thus enhancing the homely environment created. DS0000026838.V281397.R01.S.doc Version 5.1 Page 16 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): 28,29 and 30 The manager uses a company staff recruitment and employment procedure that incorporates proper checks to ensure residents are safe. The home provides care staff with NVQ training but staff induction training needs further development to ensure that each newly employed person has the skills necessary to care for service users. Standard 27 was assessed as met at the previous inspection. EVIDENCE: The recruitment, training and supervision record for a recently employed member of staff was examined. This evidenced that a POVA/CRB disclosure check was satisfactorily received before the person commenced work in the home. While the new staff member was taking part in the homes’ induction programme they worked alongside senior staff as in an additional capacity to the care team. Records contained certificates for basic food hygiene training and moving and handling training attained during previous employment while fire safety training had been supplied during induction by the manager. The induction programme must ensure that new staff are supplied with mandatory training in first aid, moving and handling, basic food hygiene, infection control and basis food hygiene within the six week induction training programme. There are 12 care staff employed to work in the home and five have achieved NVQ level 2 training certificates. The manager said the two more care assistants have been enrolled to commence NVQ2 in February 2006.
DS0000026838.V281397.R01.S.doc Version 5.1 Page 17 Two staff confirmed they regularly receive fire safety training during staff meetings while other records demonstrated that the manager provides formal one to one supervision sessions. One staff member said how much they enjoy the training offered and that they were looking forward to safe medicines training. DS0000026838.V281397.R01.S.doc Version 5.1 Page 18 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): 35 and 38 Residents’ finances are protected because the home does not handle resident’s money and bills each person for any transactions undertaken on their behalf. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. Standards 31 and 33 were assessed as met at the previous inspection. EVIDENCE: The home prefers not to handle residents’ money they either manage their personal allowances themselves or are assisted in their financial affairs by family, friends or solicitors. When small amounts of money are held there is a suitable storage and recording system in place: policies and procedures are in place in this regard. DS0000026838.V281397.R01.S.doc Version 5.1 Page 19 Training certificates for nine members of staff indicated that they had received update training in health and safety on the 24th January 2006. The inspector was shown a number of records and certificates to demonstrate that the homes’ equipment and service facilities are regularly serviced. The homes’ fire records demonstrated that regular in house checks and tests of the fire precautionary system are undertaken. The home has a fire safety riskassessment and was approved by the Fire Safety Officer in April 2005. The homes’ stair lift was serviced in June 2005. The boiler was replaced in April 2005 and is Corgi Registered. A clinical waste collection contract is in place. The electrical certificate is dated November and is valid for 5 years. Staff keep written records of accidents and incidents that occur in the home and report any untoward events to the Commission and other agencies as required. An independent company undertook a risk-assessment and the certificate issued is dated August 2005: recommended improvements were undertaken in the home, eg the new boiler was installed. The home is subject to an improvement programme but while central heating radiators remain unprotected in rooms and the hot water supply to washbasins and some baths in en-suites this means some residents may be at risk. Although risk-assessments are in place they must continue to be reviewed each month and at times of significant change, eg following a fall or deterioration in health or mobility and remedial action taken where identified. The manager explained that the home’s policies and procedures are reviewed on an annual basis: the recommendation that the recruitment and ‘Whistle blowing’ policies should be updated to make reference to the POVA guidance is repeated in this report. A quality assurance survey is also undertaken annually, this includes the views of residents and there was evidence to demonstrate that outcomes are actioned, eg the home now has a dog, and some radiators are not guarded at residents’ request. DS0000026838.V281397.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 DS0000026838.V281397.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement All Controlled Drugs (CD) must be stored in double locked cupboard and a CD registered must be obtained and used to ensure proper recording practice. The manager must undertake the local two-day POVA awareness course provided by the Social Care & Health Department to ensure she familiar with local ‘No Secrets’ and adult protection processes. The registered persons must ensure that induction for new staff includes the five mandatory health and safety topics and be supplied within the first six weeks of employment. Timescale for action 31/03/06 1. OP9 13 (2) 2. OP18 18 31/03/06 3. OP30 18 31/03/06 DS0000026838.V281397.R01.S.doc Version 5.1 Page 22 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 Residents’ medication administration record (MAR) charts should include all details of prescribed medication, eg no more that 8 tablets to be taken in 24 hrs or to be taken with food. The home’s medicines policy should be updated to include reference to the use of homely remedies and an audit trail should be established for those medicines not supplied in the monitored dosage system. A programme of protecting the homes’ night storage radiators and the governing of the hot water supply to washbasins and baths in residents’ en-suites should be progressed using a risk-assessment process. The recruitment and Whistle blowing policies should be updated to make reference to the POVA guidance. 1. OP9 2. 3. OP19 OP38 DS0000026838.V281397.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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