Inspection on 13/10/06 for Lychgate House

This inspection was carried out on 13th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lychgate House 18/06/08

Lychgate House 20/07/07

Lychgate House 11/01/06

Lychgate House 14/09/05

Lychgate House 05/01/05

Lychgate House 01/07/04

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

CARE HOME ADULTS 18-65 Lychgate House 145 Shrub End Road Colchester Essex C03 4RE Lead Inspector Marion Angold Key Unannounced Inspection 13th December 2006 10:10 Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 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 Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lychgate House Address 145 Shrub End Road Colchester Essex C03 4RE 01206 500074 01206 510916 mar.doobay@ntlworld.com 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) Doobay Care (Lychgate) Limited Mrs Natascha Hill Care Home 12 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number disorder, excluding learning disability or of places dementia (12) Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a mental disorder (not to exceed 12 persons) Two named people, over the age of 65 years, who require care by reason of dementia The total number of service users accommodated in the home must not exceed 12 persons The manager must undertake NVQ Level 4 in management and care by the end of December 2006 11th January 2006 Date of last inspection Brief Description of the Service: Lychgate House is a detached property, situated in a residential area, close to a range of community activities and Colchester town centre. Accommodation is provided on two floors, with the upper floor being accessible via a passenger lift. Most bedrooms are single occupancy and there is a choice of communal areas. There is a good-sized garden to the rear. This home provides care in a homely and comfortable environment for twelve adults, of varying ages, with mental health problems. The weekly charge for a room ranges from £550 to £650 per week. Residents pay extra for toiletries, chiropody, transport and social activities. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of Wednesday, 13 December 2006. During this visit the inspector • • • • • • talked with the person in charge as the manager, Natasha Hill was off duty talked with staff talked with residents watched how residents and staff got along together looked around some of the home looked at some records The inspector returned to the home on the mornings of Tuesday, 9 and Friday 19 January 2007. These visits were to • • speak with the manager look at some records, which only the manager or owners could show the inspector In writing this report, the inspector also used records she already had about the home, including information sent in by the people in charge and comments made by residents’ relatives, in response to the Commission’s survey of views about Lychgate House. Before the inspection took place a member of staff made an allegation about the way another member of staff had treated a resident. The way this was handled by the home has been covered in this report. Over all, 26 Standards were inspected. • • • 11 Standards were ‘met’. These are the things the home does well for residents. 10 Standards were ‘nearly met’. These are the things that need a little improvement. 5 Standards were not met. These are the things that gave cause for concern. What the service does well: These are some of the comments the inspector received from residents: • • I’d like to live to old age here. I don’t want to go anywhere. I’ve got all the things I need here. They help you budget here. DS0000017874.V325667.R01.S.doc Version 5.2 Page 6 Lychgate House • I am well treated and staff are patient with me. These are some of the comments the inspector received from relatives and friends of residents: • • • • I have always found the staff friendly and welcoming. I consider my relative gets excellent care. My relative appears to be much happier at this home and this shows in their personal appearance. I am entirely satisfied with the standard of care. What the inspector found: • • • • Anyone thinking of living at Lychgate House could visit several times before making a decision to move in. Residents were helped to understand and manage the risks of smoking and to adopt healthier lifestyles. Staff spent time with residents, sometimes with a specific purpose or just being available to provide companionship. The manager ensured that all staff attended periodic training. What has improved since the last inspection? What they could do better: • The home needs to make sure care plans cover all important aspects of residents’ lives and are kept up to date and show what progress the residents have made. Residents need to be as involved as possible in their care plans. More careful planning is needed to ensure that residents are getting the most out of life and how they spend their time. Residents should have the chance to develop independence in planning, preparing and serving meals and drinks. Menus should include the cultural foods they enjoy. • Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 7 • The home needed to work on its policies for keeping residents safe and supporting them with their medication. Not all the information they contained was accurate and helpful. The people in charge must also make sure that staff do not work long hours without proper breaks. This is not good for them or residents. There are some things that the people in charge need to know about staff to make sure they are the right person for the job they are doing. Not all of this important information was on staff files. The people in charge need to make sure that new staff have had enough training and have shown they know how to support residents before they are expected to do so. They also need to make sure that all staff have regular supervision as this affects how well they care for residents. Records need to be signed and dated so that people know who made them and whether they are about ‘now’ or some time in the past. At least once a year, the people in charge must review everything about the home to make sure it is as good as it needs to be for the people living and working there. • • • • • Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • Residents’ admission to the home was based on individual assessments of need. Residents had the opportunity to visit before making a decision to move in. EVIDENCE: A pre-admission assessment and care plan had been completed for a person, admitted since the last inspection. These records covered the main presenting needs and risks but, as before, could have been more detailed in relation to lifestyle issues and aspirations. The resident confirmed that they had been involved in the assessment; their signature was also on the document. The new resident said they had visited about four times, including an overnight stay, before making a decision to move in. They did not recall being given any written information about the home, such as a Service User Guide. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • Residents’ assessed and changing needs were not fully reflected in their individual plans. Residents were supported to make decisions about their lives although this was not always documented. Service users were supported to take appropriate risks. EVIDENCE: The care plan sampled for a new resident was linked to their Care Programme Approach Review but limited in the areas it covered. For example, the assessment identified religious affiliation and independence with hot drinks and snacks but nothing in the care plan said how these areas would be supported. New care plans had been drawn up for each resident and signed by them. One person said this had followed discussion with them about their care plans but others said they had not read or discussed the plans before signing them. One person said they thought everyone had been asked to sign their care plans. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 11 The structure of the new plans showed that objectives and support plans had been considered for each of the identified needs. Although these plans were relevant and helpful as they stood, they did not cover individual needs and strengths fully or reflect all the support that residents were receiving. For example, one care plan only covered the person’s physical needs; it listed things the person enjoyed doing but lacked a plan for ensuring the person received the support they needed to do them. The same care plan made no reference to the person’s mental health needs. Another person’s significant communication needs were not identified in their care plan. Monthly evaluations were linked to care plans but did not cover them fully. For example, one person’s need for support to have the kind of food they liked had not been followed through. The evaluations were also very brief and did not show whether progress had been made or any modification to the plan was indicated. Evaluations for one person had discontinued in May 2006 and the last review on their file was dated 2004. This person’s daily records did not reflect the range or complexities of the person’s needs with entries such as ‘pleasant day, ate well’. On the initial day of inspection, in the manager’s absence, residents only had access to the amount of money that had been set aside for them, according to their usual daily budget. The member of staff in charge said that, if they requested or needed more money, it could be borrowed from petty cash, as staff were not given full access to residents’ personal money. The manager explained subsequently that if she were off duty, the providers were usually available to deal with service users’ finances but the inspector had encountered an exceptional circumstance, where all three registered persons had been absent together. On 9/1/09, a sample of records, receipts and balances for two residents were examined and found to be in order. Residents had signed each entry in the transaction record. One resident showed they knew how their money was spent. Another said ‘They help you budget here’ and confirmed they were satisfied with their agreed budget. Staff said that, when they went shopping with or for residents, they always brought back receipts. Care plans included individual risk assessments and it was evident from records and discussion, that residents had been made aware of the risks they faced and given appropriate advice and support to minimise them, whilst retaining the right to choose their own lifestyle. Records were kept of service users’ movements outside the home. One example of good risk management was smoking. It was clear from one resident that they had talked with management/staff about the risks to their health and decided to try to stop smoking. Lychgate House were providing the necessary support with this and the resident felt pleased with the results. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • • • The lifestyle service users experienced at Lychgate House suited them but their opportunities might improve with better planning. Service users were supported to have contact with the significant people in their lives. Care practices promoted the rights of service users. Service users were offered a balanced diet and enjoyed their meals and mealtimes. Residents’ cultural needs were not fully catered for and they had limited involvement in the planning, preparation and serving of meals. EVIDENCE: Residents had varying lifestyles, with some going out regularly to college, a drop in centre or church activity, a number taking themselves into town or to the local shop and pub. Those, who needed an escort for outings, were occasionally taken to a restaurant, cinema or shops. One person said that the cinema outings were decided and arranged for them; it was evident that they Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 13 did not know when these outings would happen. No plans were in place to support residents to have holidays. Two residents spoken with said they were content just to be at home and it was evident from observation and discussion that they were able to pursue their own interests, such as listening to music, reading and knitting, and that staff also provided support with crafts and board games on a daily basis. However, although the home made some general provision for activities, residents did not have person-centred activity plans, which reflected their interests and aspirations and identified how they would be supported to pursue them, either at home or in the community. One respondent to the Commission’s survey of relatives’ views said, ‘I have always found the staff friendly and welcoming.’ Other respondents indicated that they could visit their relatives at any time and in private and they felt they were appropriately consulted and kept informed. It was evident from discussion that residents were supported to maintain links with the people who mattered to them. Staff said that all service users had family or friends, who took an active interest in them. The manager described how they had tried to promote family involvement. Staff were observed supporting residents to send Christmas cards. One service user said they would be able to bring their local friend to Lychgate House, although they had not done so. Observation on the initial day of inspection showed that daily routines were relaxed and flexible. People could get up and dressed at leisure, shower as often as they liked, be alone, go out independently or join in the main activity of the home. One resident said, ‘They like you to go to bed at 10 pm. They don’t mind if you have a lie in. You can have a fag or filter in the night and they let you have a drink if you want.’ Smoking rules were clear and care plans covered individual needs in this area. Staff were observed interacting with residents throughout the inspection, sometimes with a specific purpose or just being available to provide companionship, while they were watching television or reading. However, it was evident during the inspection that there was no provision or encouragement for residents to make drinks or snacks for themselves or to participate in the planning, preparation and serving of meals. Although residents did not question this and the manager said they lacked the necessary motivation, all the routines and rules of the home should promote independence and accommodate the diverse needs, strengths and interests of residents. The meal served on the first day of inspection was nutritious, balanced and well presented. Residents appeared to enjoy it. The person preparing the meal said they consulted residents beforehand to ensure they were happy with the menu. Residents said that they had plenty of food, liked the meals, Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 14 sometimes got their favourite dish and that alternatives were available, if they chose not to have the menu for the day. At lunchtime some had chosen to have pasta rather than potato. It was evident from one resident’s till receipts that they had bought ready meals with their own money. The manager said that she would cook these for the resident but that residents were expected to pay for anything not on the menu. The registered person should ensure that residents do not have to cover the cost of meeting their cultural needs in respect of food and that suitable options are included on the menu. Records of service users’ actual food intake were kept for lunch and tea and, following advice on the first day of inspection, records for breakfast and supper were introduced. This is to ensure that all the food that service users consume can be tracked. The menus inspected appeared balanced and nutritious. A dietician had been consulted about the menu in respect of one person, with particular needs. It was suggested that the dietician be invited to comment on the menus and nutrition generally as part of the home’s quality assurance. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • Residents were receiving personal support, appropriate to their needs. Residents’ physical and emotional health needs were being met although documentary evidence was sometimes lacking. Residents were not fully protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Individual care plans covered personal care needs but could have been more specific in relation to the preferred routines, likes and dislikes of service users, who could not easily communicate their needs and preferences. However, staff showed understanding of their role as key workers and the particular needs and lifestyles of the residents for whom they had this responsibility. Residents also confirmed that they were happy with the way they were supported by staff and key workers. It was evident from observation and discussion that residents were free to shower and dress as it suited them and that appropriate support was given to ensure that their clothes, hairstyles and general appearance promoted individuality and dignity. One resident stated that they were able to be themselves and pointed to the fact that they were Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 16 still in their dressing gown in the afternoon. One relative commented, ‘My (resident) appears to be much happier at this home and this shows in (their) personal appearance, which has very much improved of late’. Another said, ‘I consider my (relative) gets excellent care.’ Residents’ health continued to be monitored through the Care Programme Approach, with input from the local surgery and mental health teams. Specific concerns identified through this process had been referred on to the appropriate specialist. It was evident from discussion that the home was successfully supporting one person to follow the dietician’s recommendations, although their care plan had not been updated to reflect this. It was also noted that the dates of medical appointments had not always been recorded in full, specifying only the month in which they took place. Most care plans sampled evidenced regular weight monitoring and covered known risks to health such as smoking and frequent consumption of unhealthy drinks and snacks. It was evident that residents had been informed of the risks to their health and safety and that support to residents, who wished adopt healthier lifestyles had been appropriate and effective. At least three care plans made no reference to the resident’s mental health needs and how these were being addressed by the home. Another care plan gave no indication as to how the person’s communication difficulties were being addressed. One resident said they knew what medication to expect and were confident that staff could handle it. Staff reported that, since the last inspection, their local pharmacy had provided training in medication administration for all staff. The home’s medication policy was last reviewed in 2003. It was not all relevant to arrangements at Lychgate House, making reference for example to a fridge for medication and a medication trolley, which the home did not have. This policy needed to be reviewed in line with guidance from the Royal Pharmaceutical Society and made specific to the situation at Lychgate House. Staff had checked with a resident’s GP that it was safe to administer a particular homely remedy. It is recommended that a list of non-prescription remedies held by the home be presented at individual medical reviews to ensure they would not be contra-indicated for the person concerned. The registered manager had introduced a card system as a handy reference for residents’ medication. Although these had been updated, the date of the original entries had not been recorded. No gaps were identified on the current administration records and a list was available of the people authorised to administer medication and their signatures. During the initial site visit it was found that arrangements for the storage and administration of a controlled drug did not meet requirements. At the second visit, the manager stated that the GP had prescribed a substitute for the controlled drug and, therefore the home no longer needed to make special provision for it. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • Service users’ wishes and views were listened to and acted on but not always documented. Service users were not fully protected from the risk of abuse. EVIDENCE: Although the home’s complaints logs remained empty, one respondent to the Commission’s postal survey said they had made a complaint. The manager said that she was not aware of a complaint but would check with staff that there had been no oversight. In discussion about what should be recorded as a complaint, the manager acknowledged that it had not been their practice to treat negative comment or requests for change as a complaint. It was suggested that, whenever they received negative feedback from residents, relatives or other stakeholders that required action from staff, or the person in charge, this needed to generate a record, so that any trends of dissatisfaction could be identified. Comments about the care of residents were positive. One resident said they were well treated and that staff were patient with them. Relatives said things like, ‘My relative gets excellent care’, and ‘My relative appears to be much happier at this home’. All respondents to the Commission’s survey said they were satisfied with the care provided. Records and discussion evidenced that nine staff had attended protection of vulnerable adults training (23/10/06) which had covered the key learning Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 18 areas. However, the home’s protection of vulnerable adults policy and procedures were not dated and still contained some instructions that were not fully in line with locally agreed guidance. In the light of recent experience of handling an allegation of abuse at Lychgate House, the manager acknowledged that the home’s procedures needed revision. In the main, action taken by the manager in the wake of the allegation had been appropriate, but she should have contacted Social Services, which takes the lead in investigations, before obtaining statements from members of the staff team. She should also have ensured that action agreed in the wake of the allegation for the safety of residents was adhered to in full. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • Service users were living in a safe environment, suited to their needs. The home was clean and hygienic. EVIDENCE: Records sent to the Commission evidenced completion of an extensive programme of improvements to the premises, including upgrading bathrooms and toilets and redecorating a number of areas. This was confirmed by a partial tour of the premises. Fire seals had been fitted to all fire doors and the local fire safety officer’s visit on 11/06/06 led to a satisfactory report. The home had still to implement a new food safety programme, introduced at an inspection by the environmental health officer on 15/11/07. They had missed their intended implementation date of 01/01/07 but the manager gave assurances that it would be up and running in the immediate future. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 20 Residents said that they had been consulted about the decoration of their rooms. One bedroom inspected very much reflected the culture and personality of the occupant and was very comfortable and homely. Although the person with main responsibility for keeping the home clean was off duty for a period, the home was clean and fresh in all areas inspected. Nine staff had attended infection control training in June 2006. Staff described appropriate use of protective gloves and aprons. The infection control policy included the handling of clinical waste and detailed hand-washing procedures. Instructions for hand washing had been displayed in staff areas although, in the laundry they were not specific to avoiding cross infection, when using the same sink and taps for laundry, as for washing hands. The domestic washing machine had the capacity for a 95-degree wash, and staff confirmed the use of this programme, where possible, for soiled items of clothing. The registered persons should ensure that the supply of paper towels and liquid soap for staff is maintained. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. • • Residents were supported by sufficient numbers of staff but the number of hours sometimes worked by individual staff could place them and residents at risk. Residents were not fully protected by the home’s recruitment, training or supervision practices. EVIDENCE: During the period of inspection the home had two or three vacancies but had continued to maintain staffing levels as for 12 residents. However, the roster inspected for the week beginning 11/12/07 showed that several staff were working many hours overtime to cover the shifts. For example, one person was covering 64 hours over a period of 3 days and two staff were scheduled to work 110 and 100 hours respectively over the week, in one case working one period of 40 hours, with only 4 hours off duty. Staff cannot be working at their best if they do not have proper breaks. The situation was particularly concerning because, at the time, the home was supporting a resident with complex and challenging needs. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 22 The roster for the week beginning 14/1/07, inspected during the second site visit, showed that one member of staff was continuing to work excessive hours. This person was due to cover 84 hours, including a continuous period of 36 hours involving two 12-hour day shifts with a sleep in duty in between. The manager explained that they had experienced exceptional circumstances; with 2 staff having to come off the roster at short notice, she decided she had no alternative but to let remaining staff help out by covering additional shifts. She had recruited two new staff but was still waiting for clearance from the Criminal Records Bureau. Whilst CSCI commend the willingness of staff to provide emergency cover and acknowledge the difficulties presented by a sudden loss of staff, excessive working hours pose a real risk to the health and safety of residents and the staff involved. Four out of nine staff had attained National Vocational Qualification in care, Level 2. The home should strive to ensure that at least 50 of staff are qualified. Staff spoken with demonstrated understanding of the needs of residents and feedback from residents and their relatives was positive in respect of the care provided. One resident said that, apart from the GP, it was only the staff, who could understand what they were saying. Residents appeared relaxed with the staff on duty and showed that they found staff approachable. For different reasons recruitment records were not accessible during the first two inspection visits. On the second visit a new member of staff described a thorough recruitment process, including presentation of a CV, an initial and follow up interview, completion of an application form and the take up of references and POVA First before starting work. They described how they had had to work under supervision until the Criminal Records Bureau had completed their checks. However, inspection of staff records on the subsequent visit to Lychgate House (19/01/07) showed that recruitment had, in fact not been robust: Two new members of staff were working at Lychgate House without written references. For a period of 2 weeks they had worked without full CRB clearance (with POVA First only) and without references. One of the above also had an incomplete application form. A member of staff, meant to be working under supervision following disciplinary proceedings, had been placed on awake night duty, with nobody supervising their work. These omissions placed residents at risk. One relatively new member of staff said they felt their induction (an initial day of instruction following by a period of working alongside a senior member of staff) had prepared them well for working independently with residents. However, records provided no evidence of induction training for 3 new staff and there was insufficient evidence that a fourth person, who had started work at Lychgate House in September 2006, had completed a satisfactory programme of induction. The manager was arranging for new staff to attend Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 23 an external one-day course covering health and safety topics and the protection of vulnerable adults. She should ensure that this training covers these topics to the standard specified by Skills for Care (organisation that sets standards for social care training) and that she carries out her plan to introduce the Common Induction Standards, developed by Skills for Care. Certificates confirmed that, since the last inspection, all staff had attended infection control training with the Essex Health Protection Unit (June 2006), emergency first aid (15/9/06) moving and handling (28/9/06), and protection of vulnerable adults training (23/10/06). In each case the manager had reasons for confidence in the trainers and the certificates showed suitable course contents. The registered manager said she thought that the inspector was not authorised to inspect staff supervision records. However, Section 31 of the Care Standards Act 2000 empowers persons authorised by CSCI to inspect any documents or records relating to the care service. In the event, files of two staff who started working at Lychgate House in July and September 2006, respectively, contained no evidence of supervision and the last supervision record for a longstanding member of staff was dated February 2005. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • • In the main, residents were benefiting from a well run home but, in some respects, management were not meeting regulatory requirements and compromising the safety and welfare of residents. Residents could not always be confident that their views underpinned all developments in the home. The home’s record keeping procedures did not always serve residents’ best interests. The health, safety and welfare of residents was promoted and protected. EVIDENCE: Staff indicated that the providers phoned and visited the home daily and were good caring bosses. They also said they were well supported by management in the course of their work. The registered manager said she was awaiting the certificate on completion of National Vocational Qualification in Management Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 25 and Care Level 4 and she had continued to undertake periodic training with the rest of the staff group. In discussion, she showed a good knowledge of the needs of the service users for whom the home is responsible. However, a number of the shortfalls identified in this report involved key management tasks, such as recruitment and training. Also, on three successive occasions the inspector did not have full access to staff records and, in only one of these instances, was this because the manager was not on the premises. It is a requirement of the Care Homes Regulations 2001 that specified records, including those relating to staff, are available for inspection at all times. Whilst it is acknowledged that the home was trying to encourage greater participation from residents in their care plans, they should not sign records unless they have read and agreed their content. Not all records were signed and dated, which significantly reduced their value and meaning. The quality assurance process remained as at the inspection a year ago, when recommendations were made for its development. The quality assurance audit included a brief analysis of service users’ feedback questionnaires and a report on how the premises were being improved. There were also a number of tick boxes for self-assessment but no evidence of how the registered persons had determined the outcomes. Discussion about one area showed that, in fact, the home were not logging negative comments or requests for change and that a more proactive approach to complaints was needed for the purpose of quality assurance. Records showed that installations and equipment were routinely checked and serviced and that staff had covered the required health and safety training. No risks to health and safety were observed in the course of this inspection. Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X 1 3 X Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 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 YA6 YA19 Regulation 15 Requirement The registered persons must ensure that residents’ individual plans of care are kept under review and that records of these reviews are held on their files. This requirement exceeded the timescale of 31/03/06, agreed following the last inspection. They must also ensure that care plans show how individual needs in respect of health and welfare are to be met. The registered persons must ensure that procedures for supporting residents with medication fully promote their safety. The registered persons must ensure that all complaints are logged, together with the action that was taken in response. The registered person must amend the home’s adult protection policy to clarify the limits of their responsibilities with regard to investigation. This requirement exceeded the timescale of 31/03/06, DS0000017874.V325667.R01.S.doc Timescale for action 31/03/07 2. YA20 13 31/03/07 3. YA22 22 28/02/07 4. YA23 13 31/03/07 Lychgate House Version 5.2 Page 28 agreed following the last inspection. They must also ensure that their actions in the wake of an allegation fully protect residents. 5. YA33 18 The registered persons must ensure that they have sufficient staff to cover the roster and that they protect residents and staff by having regard to working time regulations. The registered persons must ensure that recruitment procedures protect residents and that satisfactory information and documentation, as required by these regulations, are obtained before staff begin working at the home. The registered persons must ensure that staff have the induction training necessary for the work they are to do. The registered persons must ensure that persons working at the home are appropriately supervised. The registered persons must maintain a system for reviewing and improving the quality of care provided by the home and supply to the Commission a report in respect of any review conducted by them. The registered persons must ensure that records specified by Schedule 4 are at all times available for inspection in the home. They must also ensure that all records are signed and dated. 28/02/07 6. YA34 17 Shed 4 19 Shed 2 19/02/07 7. YA35 13, 18 19/02/07 8. YA36 13, 18 28/02/07 9. YA39 24 31/05/07 10. YA41 17(3)(b) 19/02/07 Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2 YA6 YA13 Good Practice Recommendations The registered person should ensure that care plans address the individual’s strengths and personal goals. They should also continue, where possible, to work towards residents and staff taking a more active part in the ongoing evaluation of care plans. The registered persons should ensure that residents are actively encouraged to participate in the planning, preparation and serving of drinks and snacks and that the menu caters for their cultural needs and preferences. The registered persons should develop procedures for washing hands that are specific to the facilities available in the laundry room. The registered persons should ensure that the home’s quality monitoring report covers all aspects of care and provision, and is linked to a costed business plan. If residents need assistance completing satisfaction questionnaires, this should be from someone independent of the home. 2. YA17 3. 4. YA30 YA39 Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 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 © 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 Lychgate House DS0000017874.V325667.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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