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Inspection on 14/10/08 for Mount Pleasant, St Agnes

Also see our care home review for Mount Pleasant, St Agnes for more information

This inspection was carried out on 14th October 2008.

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

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Many of the people using the service, who we were able to speak to, spoke positively about living in the home. People were positive about the food provided, and said care staff were supportive.

What has improved since the last inspection?

The registered providers have made some improvements to the service since the last inspection on 19th May 2008. The home was warm when we inspected. People we spoke to said they had hot water in bedrooms and this now did not run out.

What the care home could do better:

This visit has resulted in a significant number of requirements. In summary the registered providers are required to: *Ensure all people have a statement of terms and conditions of residency / contract. *Care plans are more detailed and are reviewed monthly. *The operation of the medication system is improved * There is improvement regarding procedures to carry out maintenance work which gives greater respect to people`s privacy and dignity. *Complaints and adult safeguarding policies and procedures are improved. *Window glass is replaced in some rooms. *Induction and training are improved. *Staff recruitment checks are improved. *Quality assurance procedures are improved. * There are better procedures regarding the management of the finances of people who use the service. *Health and Safety procedures are improved. The Commission for Social Care Inspection requires the registered providers to send us an improvement plan regarding how they will bring about change. The Commission will continue to monitor compliance. We may need to take further enforcement action. This could include cancellation of registration, if satisfactory action does not occur.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Mount Pleasant, St Agnes Rosemundy St Agnes Cornwall TR5 0UD     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ian Wright     Date: 1 4 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 42 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 42 Information about the care home Name of care home: Address: Mount Pleasant, St Agnes Rosemundy St Agnes Cornwall TR5 0UD 01872553165 01872553776 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Susan Ann Sear,Mr Godfrey William Sear Type of registration: Number of places registered: care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: To accommodate one named service user under the age of 65 years (62 years) Date of last inspection Brief description of the care home Mount Pleasant is located near the centre of St. Agnes. The registered providers are Mr G Sear and Mrs S Sear. Mount Pleasant provides accommodation and personal care for up to 22 older persons. The accommodation is on one level; there is full access around the home for people who use the service. There are 20 rooms of which 18 are for single occupation and two shared rooms. The majority of bedrooms have an en-suite toilet and washbasin facilities. Communal areas and rooms are decorated and furnished to a satisfactory standard. The kitchen area is clean and organised. The house is set in well laid out gardens, with pleasant views of the town and countryside. There is satisfactory parking for visitors. The home is close to local amenities with access to transport links into the main city of Truro. The range of fees at the time of Care Homes for Older People Page 4 of 42 Over 65 22 0 Brief description of the care home the inspection were £308-£410. A copy of this and previous inspection reports is available from either CSCI, for example at our website at www.csci.org.uk or from the registered provider. Care Homes for Older People Page 5 of 42 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Two inspectors completed this unannounced key inspection in one day. The methodology used for this inspection was: *To case track people who use the service. This included, where possible, meeting and discussing with the people who use the service their experiences, and inspecting their records. *Discussing with staff their experiences working in the home. *Discussion with other people who use the service and their representatives. *Observing care practices *Discussing care practices with management *Inspecting records and the care environment Other evidence gathered since the previous inspection such as notifications received Care Homes for Older People Page 6 of 42 from the home (e.g. regarding any incidents which occurred) were used to help form the judgments made in the report What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 42 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 42 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information provided to people who use the service (e.g. regarding services offered) needs improvement. For example all people who use the service must receive a statement of terms and conditions of residency or contract when they move to the home. This will ensure people are aware of their rights and responsibilities. Pre assessment procedures are generally satisfactory, although in some cases documentation needs to be more comprehensive, signed and dated. This will help to evidence that pre admission procedures are comprehensive. The registered provider must be clear, that they can meet the persons needs before admission is arranged. Evidence: We inspected files for two people who had moved to the home since the last inspection in May 2008. Service files inspected contained an assessment. One persons assessment was basic, was not dated or signed. However it was supported by assessments completed by the health department and the social services department. Care Homes for Older People Page 10 of 42 Evidence: The assessment completed for the second person was comprehensive, was signed and dated. It was supported by an external assessment completed by Cornwall Department of Adult Social Care. There was insufficient evidence that all people who use the service have a contract / statement of terms and conditions of residency at the time they move in to the home. Care Homes for Older People Page 11 of 42 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We are not confident the health and personal care needs of some people living in the home are satisfactorily promoted and met. Although people have care plans, some of these currently do not satisfactorily detail peoples care needs and review does not occur each month. The management of medication is only adequate; for example appropriate action has not been taken since the last inspection regarding the storage and recording of controlled drugs. There are other concerns about the general administration of medication. Although care staff are viewed positively, we are concerned about several incidents where people who use the service do not appear to have received appropriate care. This has resulted in safeguarding referrals in two cases and a multi agency review in regard to another person. Evidence: A care plan was contained on each service user file we inspected. There is evidence these are reviewed, although this should be done monthly in all cases. Care plans are accessible to staff. People who use the service, who we spoke to, were generally positive about the care they received. Care Homes for Older People Page 12 of 42 Evidence: The registered provider has introduced a new care planning system, which has been implemented, in regard to some people who use the service. However the information contained in some care plans needs to be more comprehensive. This is not the fault of the format used but how information is recorded. Sometimes information in care plans is contradictory. For example; *In regard to one person their mental health is seen as good for her age, but the person is also described as anxious and ha(ving) panic attacks. There is no plan of care how this issue should be addressed. *A person was also described in their care plan as very lucky not to have trouble with her skin, however we were informed by the district nurse that they visit the person periodically for pressure care. *We were told that one person could no longer use the bath, however the reasoning was not recorded in the care plan, what if any external advice or support had been obtained, and how the person would be assisted with their personal hygiene (although in regard to the latter issue there is a record in the persons daily notes they are having assistance with a strip wash). *One person has a colostomy. There is no information in the persons care plan regarding what support they receive regarding this issue of their personal care. Terminology used in some of the daily notes needs to be improved. For example one person was described as having a tantrum, and someone was described as hard work to put to bed. Negative and subjective comments in records need to be avoided. People who use the service said they were satisfied with the health care support they receive. This includes visits from GPs, district nurses, chiropodists, dentists and opticians. When they occur, medical interventions appear to be appropriately recorded in care files. We did raise a concern regarding the medical care of one person living at the home. We have advised the registered provider that the person will be visited by their GP regarding the condition. We spoke to a district nurse who was visiting the home. The district nurse was positive about care given to people using the service. The district nurse commended the home for looking after some challenging people, who are difficult to place elsewhere. We inspected the medication system. Storage of general prescribed medication is satisfactory. Medication records are appropriately maintained. However we do have several concerns about the operation of the system: * We raised concerns about the practice of staff dispensing medication into pots-six at a time- before administering the medication to the people concerned. This practice makes it easy for an error to occur and the practice must cease. The Care Officer said a new trolley was on order which Care Homes for Older People Page 13 of 42 Evidence: could be transported around the home. *No controlled drugs cabinet or controlled drugs register is maintained, and these systems need to be in place if controlled drugs are to be stored and administered. * People who self administer medication must have a lockable facility for the safe storage of their medicines. The registered providers improvement plan received by CSCI, on 21st August 2008 said matters regarding medication, raised in the last CSCI report had been addressed. However from our evidence at this inspection, this has not occurred, and the statutory requirement is renotified. We spoke to several people who use the service who were complimentary about the care they received. People said they felt their privacy and dignity was respected by care staff. People said they were always referred to by their preferred name. People said care staff were kind, very good, helpful. However, we received a complaint about the service just prior to this inspection. The person alleged that in the middle of the night the registered providers, and another member of staff, came into the bedroom of a person using the service and told the person they could not use their en suite toilet. Mr Sear then allegedly hammered a nail in the door en suite door to prevent the person using the facility. The justification for this action was that a toilet in a neighbouring room was blocked, and the registered providers wanted to ensure the problem was not exacerbated. The person using the service was very shocked and upset by the incident. They said if they had been told, they would not have used the toilet. The person was further distressed when they were subsequently told they could not use wet wipes, and these were confiscated from the person, and from other people using the service. The persons next of kin told us they approached Mr Sear regarding the incident, she said was unsympathetic and rude in his response to her concern. We discussed this incident with Mrs Sear on the day of the inspection. Mrs Sear said they had not awoken the lady concerned as they did not wish to disturb her. She said they had to take action at night as they feared the problem would be exacerbated if they did not take immediate action. Mrs Sear said people using the service were told not to use wet wipes as this appeared to be the cause of the blockage. Mrs Sear acknowledged that the person using the service was distressed by the incident, but said the incident was not a major issue. The Commission for Social Care Inspection does accept that this plumbing problem did require some urgent attention if it was not to get worse. However, we are very concerned why (a) the registered providers did not wait until morning to go into the Care Homes for Older People Page 14 of 42 Evidence: persons bedroom (b) if the matter could not be delayed why somebody did not wake the person concerned and explain to the person not to use the toilet. This is particularly the case as the person has full mental capacity and there is no reason to suggest the person would not have cooperated with the registered providers (c) three people had to be involved in entering the persons room, without knocking. (d) the ensuite door was nailed shut particularly while the person was asleep (e) wet wipes have subsequently been confiscated. These are peoples private property and the registered provider should have provided a bin for individuals concerned. We are very concerned about this matter. It is essential that the registered providers promote and make proper provision for the health and welfare of people living at the home at all times.The privacy and dignity of people living in the home needs to be promoted and maintained at all times. Good personal and professional relationships need to be promoted and maintained at all times. We have referred the matter to our regional enforcement team. There have also been other matters which have resulted in us, and the Department of Adult Social Care having concerns about the care of some people living at the home. For example regarding: * The care needs of a person who was admitted to the home, who subsequently had a stroke and needed high levels of personal care. The person was transferred to a nursing home by the GP. The man developed pressure sores while in Mount Pleasant. Concerns were raised regarding lack of lack of hot water and the level of heating in the home while the person lived there.This is outlined in the previous report dated 19th May 2008. The matter was concluded during this inspection period up to the date of this site visit. *The care needs of a person whos needs changed significantly towards the end of their life. There appeared to be a multi agency failure regarding the persons care, however concerns were raised by health and social services regarding some aspects of the persons care in the home prior to their death. This is outlined in the previous report dated 19th May 2008. The matter was concluded during this inspection period up to the date of this site visit. It was subsequently agreed through Cornwall County Councils adult safeguarding process that all people funded by Cornwall County Council would be reassessed, and other people living in the home; for example people funded privately would be offered a reassessment by Cornwall County Council. Referrals from Cornwall County Council were also stopped for a period. Care Homes for Older People Page 15 of 42 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Routines, food and opportunities generally meet the needs of the people living in the home Evidence: People using the service, who the inspector spoke to, said they could get up and go to bed when they wished, and said routines in the home are relaxed.There are not many activities available in the home. The registered provider said it was difficult to motivate people to participate in activities. Staff members said they do try to get people to participate in doing things. One of the care assistants said they had tried to involve people to participate in board games and skittles the previous week. Books are available in the home if people want to read. There is a religious service once a fortnight. People who did not wish to have any organised activities appeared happy to organise their own time. Some people receive regular visitors, and some people go out with relatives. Staff do need to try and persevere with developing activities for people living in the home for example assistance to facilitate one to one activities with individuals / small groups etc. Care Homes for Older People Page 16 of 42 Evidence: People are very positive about the food provided. This appears to be to a high standard. There is always two options of main meal at lunch time, and people living in the home were very complementary about the standard of meals. There is also a choice of evening tea, and people appear to have hot and cold drinks / snacks available to them. One person complained to us that they were being prevented from having smoked fish due to the smell. The person does not eat very much meat. Mrs Sear said the person could have smoked fish when they wished, and there was a stock of this in the freezer. Care Homes for Older People Page 17 of 42 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The new complaints policy needs some amendment, and based on the evidence during this inspection period, we are not confident complaints are managed appropriately by the registered providers. Adult safeguarding processes and procedures need improvement to be more robust. Improvement in these areas should assist in giving people who use the service more confidence about how complaints and adult safeguarding processes are managed by the registered providers. Evidence: One complaint was investigated as part of this inspection. This was in regard to the incident how the registered provider reacted to a plumbing problem, which in our view inappropriately compromised the privacy and dignity of at least one person living in the home. The matter has also been referred to Cornwall County Council under their adult safeguarding procedures. The complainant also raised concerns regarding maintenance arrangements which are outlined in the environment section of this report. The registered provider has updated their policy regarding complaints. However this is still not correct: * It refers to the National Care Standards Commission which was superseded by the Commission for Social Care Inspection in 2004. The contact details Care Homes for Older People Page 18 of 42 Evidence: of the current regulatory authority is not provided * Although the procedure is generally satisfactory the section outlining who the complaints manager is has been left blank. There are also no details regarding how people, who are funded by local authorities, can access the local authority complaints procedure. * The policy was not available to people living in the home, or readily available to staff or for inspection. For example it took the registered provider several hours to access the policy via a computer hard disk. *Based on how the registered providers responded to the complaint outlined above (for example as outlined in the health and personal care section of the report) we are not confident this policy has been implemented, or the registered providers would respond appropriately to complaints made by people using this service, their representatives or other parties. In regard to Adult Safeguarding, at the last inspection in May 2008, we made a statutory requirement for the registered provider to develop the the policy to be more robust e.g. in regard to reporting procedures (e.g. outlining Cornwall County Council as the coordinating agency for investigations, including contact addresses and phone numbers for appropriate agencies), and ensuring the policy is accessible to staff, people who use the service etc. (See CSCI report dated 19th May 2008). The improvement plan the registered provider sent to us on 21st August 2008 stated the registered provider would ensure that all policies and procedures complied with CSCI regulations. We however were not presented with an updated policy at todays inspection and therefore the statutory requirement is renotified. Care Homes for Older People Page 19 of 42 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Mount Pleasant provides a generally satisfactory environment for the people living there. However we remain concerned that the previous requirement to address a problem with the glazing (making it hard for some people to see through the windows) has not been addressed. We are also concerned regarding whether remedial action to address concerns regarding a satisfactory supply of hot water, and to ensure satisfactory levels of heating, appropriately address the concerns raised. We will continue to monitor this situation. Evidence: The building was inspected. There is suitable shared space, for example, a large lounge and dining room. There is also a small quiet area with seating, and this area also includes the pet parrot, and tea/ coffee making facilities which people living in the home can use. Communal lounges are generally pleasant and homely. Toilet and bathroom facilities are suitable in size and facilities provided. We received concerns that the bath hoist was not operational. We checked this and there does not appear to be a problem although, according to Mrs Sear, it was not operational for a short period. Bedrooms are generally decorated and furnished according to individual tastes. However some areas do require upgrading for example as outlined below. People who Care Homes for Older People Page 20 of 42 Evidence: use the service said they were able to bring their own furnishings and belongings with them when they moved in. One visitor complained that their relatives toilet seat was broken, and there was inappropriate delay in this being repaired. Mrs Sear said the person would fall on to the seat due to their decreased mobility. She said the seat had broken a number of times but was repaired at least within a week of any damage occurring. We discussed with the provider that the person may need more specialist equipment to assist with the manoeuvre such as a frame or handle on the wall. We suggested the provider contact Cornwall County Council for assistance if such a problem cannot be resolved by the staff team. We also received comments regarding the slowness in the registered providers responding to other maintenance issues for example dealing with black mold in one persons bedroom / ensuite; and also attending to a broken window catch. The catch has now been repaired but we did note black mold in the persons en suite and also in some areas of the persons bedroom. This needs to be attended to as it is not acceptable. In the last report dated 19th May 2008 we noted that some of the double glazed windows have become clouded with patches of condensation. The registered providers improvement plans sent to CSCI on 9th May 2008 and on 21st August 2008, both said the affected windows would be replaced. This has still not occurred, and the previous requirement is renotified. We previously received concerns there was an inadequate supply of hot water (for example as outlined in the previous report dated 19th May 2008). The registered provider states in their improvement plan, received by the commission on 21st August 2008, that the system is being checked four times a day and the booster on the system is used to reheat the water as necessary. While such a system appears antiquated, we have not received any further complaints about lack of hot water. It seems more appropriate the system is upgraded to prevent staff having to constantly check the system. During this inspection we checked hot water in a number of rooms in the home. This was a satisfactory temperature. People using the service made no complaints to us about the availability of hot water. Should we receive any further complaints about this issue we will consider taking enforcement action. Similarly we previously have received concerns regarding the home being warm enough due to insufficient heating. The registered provider states in the improvement plan received by the commission on 21st August 2008 that they were checking and testing the system and would fit additional heaters if required. When we met with Care Homes for Older People Page 21 of 42 Evidence: Mrs Sear at this inspection she stated the convector feature on the existing storage heaters in the lounge had been fixed, and these can be put on if it is cold. During this inspection we checked the home was warm enough in a number of rooms. The temperature of the home appeared satisfactory. People using the service made no complaints to us about the temperature. We will monitor this situation over the winter. Should we receive any further complaints about this issue we will consider taking enforcement action. The building was generally clean and hygienic on the day of the inspection. A cleaner is now employed in the home, and a number of people who use the service were very complimentary about how this person carried out their duties. Laundry facilities appear adequate, although floor covering needs replacing. The registered providers have stated in the Annual Quality Assurance Assessment (AQAA), dated 08/09/08, that the laundry flooring would be replaced in the next 12 months with a washable surface. The AQAA also states that over the last 12 months a considerable amount of painting and decorating has been completed, a new industrial carpet cleaner has been purchased and improvements to the grounds have been completed. Care Homes for Older People Page 22 of 42 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels appear satisfactory to meet the needs of people currently accommodated at the home. We are concerned that there is continuing noncompliance with recruitment checks for new staff and training provided to all staff. This could put people who use the service at risk from people not fit, skilled and/ or knowledgeable to work who may be vulnerable. Evidence: On the day of the inspection there were three care staff on duty from 07:00 to 14:00 and two care staff on duty from 14:00 to 21:00. A cleaner is employed and was on duty during the morning of the inspection. A cook was on duty in the morning until after the evening tea. An administrator has been employed and works during the day. One waking night member of staff is on duty from 21:00 to 07:00. The registered providers live in the neighbouring bungalow. The record of staff hours (recorded in the house diary) appears to show there is satisfactory staffing levels provided for the people the home is registered for. Personnel records were inspected for thirteen staff (i.e. staff on duty during the 24 hour period on the day of the inspection, new staff employed since the last inspection, plus a sample of some of the other staff employed). Care Homes for Older People Page 23 of 42 Evidence: The following was found at the inspection: *Nine staff had an application form. In addition two people had a CV. Two staff did not have an application form or CV (both of these people commenced employment since the last inspection in May 2008). *Three people had two references, five people only had one reference (all of which started since November 2007; three of whom commenced employment since the last inspection), one person only had a verbal reference, and four people had no references at all (including one person who commenced employment since the last inspection). *All people had a Criminal Records Bureau check (CRB). Most staff had a Protection of Vulnerable Adults First check (POVA First). However this was not available for two staff who commenced employment since the last inspection. *Some staff (including two staff who commenced employment since the last inspection), did not have evidence of their identity or a self declaration of medical fitness as required by the regulations. The Commission for Social Care Inspection served the registered providers a Statutory Requirement Notice on 9th July 2008 regarding repeated breaches of regulations regarding ascertaining fitness of staff. We are concerned that although there has been minor improvement regarding this matter, the registered providers have failed to comply with the notice served. We looked at whether staff had a National Vocational Qualification in care. According to the thirteen records assessed four people had a copy of an NVQ certificate in care. The AQAA supplied by the home states 44 of care staff employed have an NVQ 2 or above in care (4 people) and a further 5 people are working towards this qualification. We checked records of training staff have received. By law staff require the following training: * Regular fire training in accordance with the requirements of the fire authority. * There must always be at least one first aider on duty (at appointed person level) *All staff must have manual handling training and regular updates of this (e.g. annually) *All staff must have basic training in infection control. * Staff who handle food receive food hygiene training. * All staff must have an induction and there needs to be a record of this. In regard to the thirteen records assessed: * Six people had a record of fire traininglast received in 2007. * Four people had a valid first aid certificate. On the day of the inspection there was satisfactory first aider cover during the day, and at night. However one of the night staff, did not have a valid first aid certificate despite this person regularly completing waking night duties on their own. * Four people had received manual handling training since the beginning of 2007. Only five people appeared to have ever received manual handling training. * Three people had any Care Homes for Older People Page 24 of 42 Evidence: record of receiving infection control training. * Five people had any food hygiene training * Three people had some records of staff induction when they commenced employment. Of the staff who commenced employment since the last inspection (6) only one person had a record of induction. The previous inspection report dated 19th May 2008 stated the registered provider needed to: * Develop a training policy * Develop individual training profiles for staff which should include what training they needed to obtain. * Ensure staff received the training required according to regulation. * Staff must not be placed on duty, untrained and in situations where they and people using the service are put at risk. We have also assessed what the registered provider said they would do in its Annual Quality Assurance Assessment (AQAA) and Improvement Plan (following the last inspection). From this analysis, and this inspection, we conclude: * A training policy has been developed. However this does not specifically state what training will be delivered to individual staff i.e. according to the National Minimum Standards; Care Home Regulations and related health and safety law. It does however state staff will have a training needs analysis, receive induction training, supervision and knowledge / job specific training. There is limited evidence of actual compliance with the registered providers own policy. * There is no evidence of individual training profiles being completed. * As outlined above there is very limited evidence of compliance with training required by regulation. There is no evidence of development of this since the last inspection. The registered provider however did state they would arrange some training shortly. *According to the records presented, we are concerned that staff do appear to be placed on duty, untrained, and in situations where they and people using the service are at risk. For example there is limited evidence of staff induction, no development of manual handling training and staff completing night duty may not have received first aid training which could result in people not receiving first aid in emergency situations. The registered provider stated in the Improvement Plan received by CSCI on 21st August 2008 that a training officer would be appointed, training records would be kept up to date, and staff would receive all relevant training. The AQAA completed by the registered provider dated 08/09/08 also stated that over the previous 12 months every member of staff has completed all required training. We conclude there is limited evidence of this from the information gained on this inspection. We will meet with the registered providers shortly to discuss this, and other matters of non-compliance. We are discussing with our regional enforcement team options Care Homes for Older People Page 25 of 42 Evidence: available due to this and other matters of non compliance. We are considering further enforcement action which may include cancellation of registration. Care Homes for Older People Page 26 of 42 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Commission for Social Care Inspection remains concerned about the registered providers competence to manage the service according to the regulations and National Minimum Standards. The registered providers lack of progress in bringing about required improvement to the service, for example since the last inspection, brings into question whether the registered providers should continue to be deemed fit to carry on running the home. The failure to meet basic standards, in some areas, has a considerable impact upon the lives of people using the service. Examples of this include failure to carry out care planning appropriately, failure to recruit and train staff appropriately, and to take appropriate action to comply with previous requirements. Evidence: The registered providers have owned and managed the home for a number of years. Mrs Sear said she has attended a City and Guilds Advanced Management course, and an accountancy training course. Mr Sear is from an electrical engineering background. Since the last inspection there have been some developments regarding the day to day Care Homes for Older People Page 27 of 42 Evidence: management of the home. For example one of the Care Officers has been promoted to Assistant Manager of the home. Another person has been employed as an administrator. However it must be noted that both of these appointments do not dilute, from the Commission for Social Care Inspections perspective, the day to day responsibility of the management of the home for which Mr and Mrs Sear both have joint legal responsibility. We remain concerned about the day to day operation of the home. Again this inspection has resulted in a significant number of statutory requirements. The lack of compliance with the regulations does have a significant impact on the lives of people living in the home. For example concerns about assessment and care planning / care planning review, has significant impact on particularly the more vulnerable people accommodated in the home. Since the last inspection we have been involved in an adult safeguarding case, one multi agency review, and a complaint (which has been referred to social services under their adult safeguarding procedure) which all evidence poor care. We are very concerned about the lack of compliance with the Statutory Requirement Notice, issued in regard to the registered providers carrying out their responsibilities to ensure the fitness of new staff. We are also concerned there has been no development of staff training which puts staff as well as people using the service at significant risk. We are currently consulting with our Regional Enforcement Team regarding further options for enforcement action. These include the issuing of further statutory requirement notices, prosecution, imposing conditions (e.g. stopping or limiting further admissions) and ultimately the cancellation of registration. We will meet with the registered provider to discuss what actions we will take. We will also share our concerns regarding care standards in the home with other organizations such as social services departments and the Primary Care Trust. We inspected the registered providers Quality Management Policy. The policy states there will be regular monthly meetings with people living in the home, an annual survey of people using the service and a quality management system based on a Total Quality Management approach. It states Mr and Mrs Sear would complete a quality audit on an annual basis. It states staff will receive appropriate training and have a personal development plan. The AQAA supplied by the home states the owners purposely eat the same food as the people living in the home to ensure it is the best, and regularly talk to the residents to make sure they are happy with the way in which they are being looked after. The AQAA states the registered provider has begun to reorganize and upgrade the administration system, and allocated more dedicated office hours to develop a more Care Homes for Older People Page 28 of 42 Evidence: competent and efficient way of working. The Improvement Plan submitted to the Commission for Social Care Inspection states new quality assurance forms for the residents, families and visitors have been developed, and will be used as a monitoring arrangement to bring improvement. During the inspection we were told no audit has been completed. There has however been a questionnaire completed by individual people who use the service to measure satisfaction with meals provided. We conclude the changes in management arrangements have not as yet made any significant impact regarding improving the service. We are concerned regarding the number of requirements issued at this inspection, and particularly the number of re-notifications of previous statutory requirements. We assessed arrangements regarding the management of the finances of people who use the service. Records kept for the management of individual monies need improvement. For example it is essential that receipts are provided for any expenditure completed on behalf of people using the service. Any monies kept on behalf of people using the service need to be kept individually, and not pooled together. We were told no valuables are kept on behalf of people who use the service. We were concerned regarding a letter written by Mrs Sear, on behalf of one person using the service. This was to transfer money from a savings account to their current account so the person could pay bills and their fees. The person themselves said they were happy about this, and did not think there had been any wrong doing. Mrs Sear said this task was completed as the person using the service could not write, and did not have any body to assist them. We stated to Mrs Sear that she should have got the persons social worker to carry out this task as the registered provider could be accused of acting inappropriately, particularly as no other records were kept regarding the transaction. We have informed the social services department of our concerns, and although we have stated that Mrs Sear appeared only trying to help the person concerned, that if necessary an adult safeguarding referral should be made if there is any concerns. The registered provider has a health and safety policy. There is also a fire risk assessment. Testing of fire extinguishers and the fire system appears to have been completed appropriately by external contractors. In regard to fire precautions emergency call points are tested weekly. Suitable checks have been completed on fire doors and fire drills have been completed appropriately. However the testing of emergency fire lighting has not been completed since June 2008, and testing must be completed in line with guidance issued by the fire authority. We have outlined concerns regarding lack of fire training in the staffing section. Care Homes for Older People Page 29 of 42 Evidence: An external health and safety audit was completed in February 2008. This highlighted a number of areas for improvement is required, in line with health and safety legislation. For example in regard to health and safety monitoring and risk assessment, and the testing of the electrical hardwire circuit. It is not clear from discussion with the registered provider, or from records, what actions have been taken as a result of the audit. Portable electrical appliances were last tested in August 2007. These need to be tested at least every two years in line with Health and Safety Executive guidelines, and preferably annually. The registered provider said the electrical hardwire circuit was tested, but documentation deems the circuit unsatisfactory. The registered provider stated that she has arranged for the circuit to be retested. We have however repeated the previous requirement regarding this matter. There appears to be suitable precautions regarding the prevention of legionella. Care Homes for Older People Page 30 of 42 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 9 13 The management and 01/09/2008 storage of controlled drugs needs to be improved, with reference Royal Pharmaceutical Society Guidelines and Care Homes Regulations 2001. Issues outlined in the report need to be addressed. People who use the service can then be more assured their drugs are appropriately stored and managed in a secure manner. 2 18 10, 12, 13, 19 The registered provider must 01/09/2008 have a suitable adult safeguarding policy. Matters outlined in the report must be addressed. Having an appropriate policy will help to give people who use the service, and other stakeholders, more assurance that agreed multi disciplinary procedures will be followed when necessary. 3 19 23 Where the glass in some of the windows is clouded, the registered provider must replace the glass. This will ensure people who use the service can see out of the window. 01/09/2008 Care Homes for Older People Page 31 of 42 (Timescale of 01/06/08 amended to 01/09/08) 4 29 18(c)(i)(ii) The registered person shall 21/05/2008 ensure there are appropriate induction arrangements in place for all new staff, there is a comprehensive induction checklist, and induction is appropriately documented. This will help to ensure people who use the service are supported by suitably trained and skilled staff. (Previous deadline of 21/01/08 not met. Seventh Notification.) The registered person must: 01/09/2008 Develop a training policy. This must outline what training differing grades of staff will receive, and when, during the duration of their employment. Develop a training profile for individual members of staff which includes training received, and further training required. Ensure all staff receive the training they require according to regulation, and the policy. Ensure staff are not placed on duty, untrained and in situations where they and people using the service are put at risk. This will help to ensure people who use the service are supported by suitably trained and skilled staff. 5 29 18, 19 6 31 19 You are required to carry out 01/08/2008 appropriate checks prior to staff commencing work at the home. There must be evidence that Care Homes for Older People Page 32 of 42 POVA First checks are in place for all staff working at the home, and evidence that CRB checks are in process for all staff working at the home, and evidence of this must be available for inspection in the home. All staff that are employed on the basis of a POVA First check, prior to receipt of a CRB check, must be monitored by a clear system that ensures these persons are constantly supervised. Evidence of the operation of such supervision must be available for inspection in the home. The home must obtain two references for all staff prior to the commencement of their employment and documentary evidence of these references must be available for inspection in the home. (Previous requirement and timescale of 21/01/08 not met. Fifth Notification) 7 33 7, 9, 12, 13, 24 Further develop the quality 01/09/2008 assurance system to monitor standards in the home for example regarding care planning, medication, staff recruitment, staff training, health and safety etc. Measures taken should be included in the quality assurance policy. This will help improve service quality and help minimise risks to staff and people who use the service. A copy of a satisfactory 01/09/2008 electrical hardwire certificate must be forwarded to the 8 38 13, 23 Care Homes for Older People Page 33 of 42 commission. This will give the commission assurance that the electrical circuit in the home is safe, and there is less health and safety risk to staff and people who use the service. Care Homes for Older People Page 34 of 42 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 5 All people who use the service must receive a statement of terms and conditions of residency or contract when they move to the home. This will ensure they are aware of their rights and responsibilities. 01/12/2008 2 7 15 Care plans must contain suitable detail to inform and direct staff to provide care to people using the service. Care plans need to be reviewed at least monthly. (Previous timescale of 01/08/08 not met Second Notification) Detailed care plans, which are regularly reviewed, assist care staff to provide appropriate levels of care for people who use the service. 01/02/2009 3 9 13 The management and storage of controlled drugs needs to be improved, with 01/02/2009 Care Homes for Older People Page 35 of 42 reference to the Royal Pharmaceutical Society Guidelines and Care Homes Regulations 2001. For example controlled drugs must be stored in a controlled drugs cabinet, and a controlled drugs register must be maintained. People who use the service can then be more assured their medication is appropriately stored and managed in a secure manner. 4 9 13 The operation of the medication system must be improved, with reference to the Royal Pharmaceutical Society Guidelines and Care Homes Regulations 2001. For example medication for people who use the service must be administered for one person at a time, and people who self administer their medication must have a lockable drawer / cabinet for its storage. People who use the service can then be more assured their medication is appropriately stored and managed in a secure manner. 5 10 12 1. You are required to 18/12/2008 ensure that a system is put in place so that emergency maintenance work can be carried out without effecting peoples privacy and dignity. 01/11/2009 Care Homes for Older People Page 36 of 42 2. You are required to compile a plan that describes how you will achieve this. 3. You are required to make this plan available fro inspection. This will help to ensure people living in the home receive a service where they are treated with respect, privacy and dignity at all times. 6 16 22 The registered provider must have a suitable complaints procedure (for example containing the information outlined in the national minimum standard and the body text of the report). This will help to ensure if people have a complaint there is an appropriate procedure for concerns to be addressed. 7 18 13 The registered provider must have a suitable adult safeguarding policy. Matters outlined in the report must be addressed. Previous timescale of 01/09/08 not met. Second Notification Having an appropriate policy will help to give people who use the service, and other stakeholders, more assurance that agreed multi 01/02/2009 01/02/2009 Care Homes for Older People Page 37 of 42 agency procedures will be followed when necessary 8 19 23 Where the glass in some of the windows is clouded, the registered provider must replace the glass. (Timescale of 01/09/08 not met 2nd Notification) This will ensure people who use the service can see out of the windows. 9 29 18 The registered provider shall 01/12/2008 ensure there are appropriate induction arrangements in place for all new staff, there is a comprehensive induction checklist, and induction is appropriately docuented. (previous deadline of 21/9/08 not met. Eighth Notification) This will help to ensure people who use the service are supported by sutably trained and skilled staff 10 29 19 The registered provider 01/12/2008 must ensure suitable checks are performed on all new staff working in the home as outlined in the regulations (for example POVA First check, CRB/POVA check, two written references). Guidance issued by CSCI, and other statutory authorities must be followed. (Previous timescale of Statutory Requirement Notice 1/8/08 not complied with Sixth Notification). 01/02/2009 Care Homes for Older People Page 38 of 42 This will help ensure people who use the service are protected from people who are unsuitable to work with the vulnerable 11 30 18 The registered provider 01/02/2009 must: 1. Develop a training policy. This must outline what training differing grades of staff will receive, and when, during their employment. 2. Develop a training profile for individual members of staff which includes training received, and further training required. 3. Ensure all staff receive the training they require according to regulation and the policy. 4. Ensure staff are not placed on duty, untrained and in situations where they and people using the service are put at risk. (Previous deadline of 01/09/08 not met. Second Notification) This will help to ensure people who use the service are supported by suitably trained and skilled staff 12 33 24 Further develop the quality 01/02/2009 assurance system to monitor standards in the home for example regarding care planning, medication, staff recruitment, staff training, health and safety etc. Measures taken should be Care Homes for Older People Page 39 of 42 included in the quality assurance policy. Previous timescale of 01/09/08 not met 2nd Notification This will help improve service quality and help minimise risks to staff and people who use the service 13 35 13 Appropriate records must be 01/12/2008 maintained regarding any monies and valuables kept on behalf of people using the service. This should include receipts and records of all transactions. Peoples monies should not be pooled together. This will help to ensure there is suitable evidence that any expenditure on behalf of people who use the service is legitimate, and any risk of financial abuse of peoples monies is minimized. A copy of a satisfactory 01/02/2009 electrical hardwire certificate must be obtained. (Timescale of 01/09/08 not met Second Notification) This will ensure the electrical circuit in the home is safe, and there is less health and safety risk to staff and people who use the service. 15 38 13 The registered providers 01/12/2008 must ensure all fire equipment is tested in line with requirements of the fire authority. 14 38 13 Care Homes for Older People Page 40 of 42 (Immediate Requirement dated 19/05/08 not complied with Second Notification) This will help minimise health and safety risks to staff and people who use the service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 19 The registered provider should upgrade the hot water heating system to ensure there is a more appropriate system to ensure there is hot water at all times. The heating and hot water systems should be upgraded to ensure people living in the home can have more control over hot water and room temperature in communal spaces and their bedrooms. 2 25 Care Homes for Older People Page 41 of 42 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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