Inspection on 29/03/07 for Newlands Cottages (10)

This inspection was carried out on 29th March 2007.

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

Other inspections for this house

Newlands Cottages (10) 27/10/05

Newlands Cottages (10) 05/10/04

Newlands Cottages (10) 13/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Newlands Cottages (10) 10 Newlands Cottages Fox Lane Coulsdon Common Coulsdon Surrey CR3 5QS Lead Inspector Lee Willis Key Unannounced Inspection 29th March 2007 10:40 Newlands Cottages (10) DS0000025818.V331802.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 Newlands Cottages (10) DS0000025818.V331802.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. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newlands Cottages (10) Address 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) 10 Newlands Cottages Fox Lane Coulsdon Common Coulsdon Surrey CR3 5QS 01883 349 507 01883 349 507 thfcare@newlandscottages.fsnet.co.uk THF Care Estates Limited Dana Thompson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: 10 Newlands Cottage is no longer owned by THF Care Estates Limited as the organisation was recently taken over by Consensus Care in 2006. The home is still registered with the CSCI to provide personal support and accommodation for up to three younger adults with moderate learning disabilities. Dana Thompson continues to be the registered manager of the home where she has been in operational day-to-day control for well over three years. This older style semi-detached cottage is situated on a small rural housing estate in between Coulsdon and Caterham. The home is within easy walking distance of a local parade of shops and a popular country pub. The home is also on a main line bus route, which has good links to Caterham and Croydon. Built over twostories the cottage comprises of three single occupancy bedrooms, two relatively small but cosy lounges, a much larger open plan kitchen and dinning area, a ground floor office, two WC’s and a bathroom. The laundry is located in the garage and the facilities are shared with the neighbouring cottage. Both the front and rear gardens are relatively well maintained. Service users and their representatives have access to copies of the homes most up to date Statement of Purpose, Residents Guide, CSCI inspection reports, and terms and conditions of occupancy. These documents contain all the information service users and their representatives need to know about the fees charged for facilities and services provided, which currently ranges from £1,200 to £1,400 per week. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process, which included a site visit to the care home, the Commission for Social Care Inspection (CSCI) has judged the service as having a number of strengths as well as areas of particular weaknesses that require urgent action to improve it. Most of the key National Minimum Standards are being met, although a potential risk to service users safety was identified during the inspection. Nonetheless the Commission has received written confirmation that this matter is being responded to by the providers. This unannounced site visit was carried out on a Thursday between 10.40am and 3.10pm. During the course of this four and a half hour inspection two service users, a senior support worker, and the homes registered manager were all spoken with at length. The remainder of the site visit was spent examining the homes records and touring the premises. As part of the inspection process the home was also sent a pre-inspection questionnaire and a number of comment cards for service users and their representatives to complete. The Commission received six cards back from all three of the service users currently residing at the home as well as their relatives. What the service does well: The written and verbal feedback received was in the main very complimentary about the quality of care provided at the home. One service user spoken with at length said they liked living at Newlands Cottage because they “got on well with the other two residents and all the staff”. Another service users relative wrote on a comment card “they had built up an excellent working relationship with the staff, who were all excellent”. The home is good at encouraging and supporting service users to take responsible risks to enable people to maintain and develop their independent living skills. The people who live at the home said staff always helped them to get involved in the day-to-day running of their home and participate in domestic chores around the house. E.g. During the visit one service user was observed preparing a dessert for their evening meal, while another person said staff always encouraged them to do their own laundry. All the service users spoken with told us that they really liked the food at the home. The home is also good at helping service users to make ‘informed’ choices about their lives. Records revealed that residents meetings are held on a regular basis and people who live at the home said staff always took account of their point of view. All the service users met said they really liked the staff team. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All the positive comments made above notwithstanding there are still a significant number of weaknesses the home needs to urgently improve: The homes policy for charging residents for so called ‘extra’ services that are not included in the basic price of their placement, such as admission charges to certain community based activities or petrol money for use of the homes vehicle, is not very clear. The providers must ensure information about what service users and their representatives can expect to be charged ‘extra’ for is made more accessible and therefore transparent. The homes arrangements for handling medication need to be improved, specifically staff record keeping and protocols for the use of ‘as required’ medication, to ensure the service users welfare is safeguarded. Arrangements for recording the action taken by the providers in response to any complaints made about the homes operation need to be improved. A number of issues relating to the homes environment were identified during this site: Firstly, the home is overdue an inspection by an Environmental Health Officer and the providers should make every effort to consult their local authority about this matter. The homes policy of not allowing residents to use the only ground floor toilet unless they seek staffs permission to do so, is clearly a rather draconian measure that limits the freedom of service users to choose which WC they use in their own home. There is only one other toilet on the first floor and consequently this unnecessarily restrictive practise must Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 7 cease immediately. Furthermore, the dead lock fitted to the aforementioned toilet will need to be replaced with a more suitable device that can be overridden by staff in an emergency to prevent people who do use it getting stuck. Finally, the poor state of repair of the front driveway and lack of nighttime lighting in this area represents a tripping hazard for anyone living or visiting the home. Arrangements for a second member of staff to be on call at night who is able to reach the home within 20 minutes to help the only sleep-in member of staff deal with an emergency appears to be very dependent on the availability of the registered manager, who lives relatively close to the home. The system needs to be reviewed as a matter of urgency. The home will need to improve its training programme for staff to ensure that sufficient numbers are suitably qualified to administer basic first aid, recognise, prevent and report abuse, and control infection. The homes quality assurance system is still not sufficiently robust to ensure service users and their representatives views about the standard of care provided underpins the services development. The providers have persistently failed to address this matter and have been formally warned that the Commission will consider taking enforcement action if it remains outstanding. Maintenance arrangements for repairing any electrical problems experienced by the home also remain woefully inadequate and will need to be reviewed as a matter of urgency. An Immediate Requirement Notice was served at the time of this inspection to ensure this outstanding issue, which representatives as serious breach of the Care Homes Regulations (2001), was rectified within three days. 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. Newlands Cottages (10) DS0000025818.V331802.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 Newlands Cottages (10) DS0000025818.V331802.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): 2&5 Quality in this outcome area is good. This judgement has been made using all the available evidence. People’s needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. Each service user is supplied with a written and costed contract so service users and their representatives know what their terms and conditions of occupancy are and how much they can expect to be charged for facilities and services provided. EVIDENCE: The manager confirmed that the service continues to be fully occupied and consequently the home was not receiving any new referrals. Written and costed contracts that set out service users terms and conditions of occupancy were made available on request for two individuals selected for case tracking. Both the service users and the homes manager had signed these documents, and each contained all the information the service user and their representatives needed to know about the services and facilities being provided by the home. Newlands Cottages (10) DS0000025818.V331802.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using all the available evidence. The homes approach to developing care plans is sufficiently robust to ensure service users unique assessed needs and personal goals are reflected in each of their individual plans. Service users participate in all aspects of life in the home, but records should be kept of all the meetings they attend about the home to demonstrate this. Staff ensure service users are supported to take ‘responsible’ risks as part of a structured programme to promote their independent living skills and lifestyles. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 11 EVIDENCE: The care plans for the two individuals being case tracked were examined in some depth. It was noted that these documents had been drawn up by the individual’s keyworkers and contained detailed information about each service users unique personal, social, and health care needs. The inspector is aware that the homes new owners intend to introduce a far more person centred approach to developing care plans that places a greater emphasis on service users unique strengths and personal aspirations, as opposed to just their individual needs. Progress on the matter will be assessed at the homes next inspection. It was positively noted that documentary evidence was made available on request to show that both the care plans being case tracked had been reviewed on a monthly basis by the individual’s keyworkers and up dated accordingly to reflect any changes in need. Service users have their own meetings, which records revealed are held approximately six times a year. The shift leader said she believed these meetings were held more frequently than this, but was unable to locate any more minutes at the time of this inspection. Minutes that were found revealed that these meetings were well attended by the service users. Topics covered included fire safety, respecting privacy and dignity, and ideas for keeping fit. A comprehensive list of assessments that set out the action to be taken by staff to minimise identified risks contained in the two care plans being case tracked. The assessments included detailed guidance to help staff deal with behaviours that could potentially challenge the service. The manager and the senior member of staff in charge of the early shift both demonstrated a good understanding of how to carry out a thorough risk assessment and develop effective risk management strategies. Newlands Cottages (10) DS0000025818.V331802.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): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Opportunities for service users to participate in social activities remain excellent and offer people full and flexible choice in how they spend their day. However, the provider’s arrangements for charging for so called ‘additional’ services not covered by the basic cost of each service users placement remains unclear. This system needs to be made far more transport to ensure service users and their representatives have a ‘better’ understanding of what they can expect to be charged for. Dietary needs and preferences are extremely well catered for and meals nutritionally well balanced, providing daily variety and interest for the service users. EVIDENCE: Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 13 It was evident from individual daily diary notes sampled at random and from comments made by staff on duty at the time of this site visit that service users live very active social life’s. On arrival two service users were out at college. The one individual who remained at home was observed being helped by a member of staff to prepare a dessert for the evening meal. This individual told us that he liked living at Newlands Cottage because he was able “to play computer games when he liked and make his own drinks”. This service user also confirmed that everyone who resided at the cottage was expected to help out around the house, prepare some of their meals, and do their own laundry. The manager said all the service users had been on holiday in the past twelve months to destinations as far a field as Bulgaria and Poland. The manager confirmed that service users are still expected to contribute a proportionate amount related to the use of the homes transport for so called ‘social’ outings and must also pay the full cost of expenses incurred by staff who accompany them on residents holidays or community based social, leisure or recreational activities. For example, admission fees, meals out, and travel cards are all considered ‘additional costs’ that are not covered by the basic price of each of the service users placement. The manager explained that some of the service users receive an annual lump sum from their funding authorities to pay for holidays and social activities, whilst others do not. The provider’s arrangements for charging service users and their representatives for these so called ‘extras’ is not reflected in the service users guide or their individualised terms and conditions of occupancy. There is also no policy in place regarding the providers scale of charges that people can expect to pay for any services additional to those mentioned in descriptions of the standard services offered by the care home. The home continues to have an open visitors policy and the one service user spoken with at length said they were not aware of any restrictions on visiting times. Two service users asked about the quality of the main meals provided said they were excellent. The manager said staff actively encourage the service users to plan the weekly menus every Sunday afternoon. In addition to the planned menus staff also maintain a daily record of all the food consumed by service users at main mealtimes. As previously mentioned in this report it was positively noted that on arrival a service user was observed helping a member of staff prepare a dessert for there evening meal. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 14 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has sufficiently robust arrangements in place to ensure the health care needs of the service users are continually recognised and met. Recording procedures for handling medication in the home, including dealing with ‘as required’ medicines, will all need to be improved to ensure the service users are protected from unnecessary harm. EVIDENCE: Both service users met during the course of this site visit said they had the freedom to choose what time they got up, went to bed; what activities they engaged in; and what they wore each day. The two care plans being case tracked all contained detailed information about each of the service users specific health care needs, as well as all the medical appointments that they had each attended in the past few months. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 15 The homes accident book revealed that none of the service users had sustained any ‘major’ injuries or been admitted to casualty in the past twelve months. The manager assured the inspector that only one ‘significant’ incident involving a service user had occurred in 2006. It is the homes policy to record such incidents, a copy of which is kept on the relevant service users care plan. The incident sheet was eventually located in the individuals care plan. The inspector recommends the home considers keeping incidents sheets in a separate single bound source for ease of referencing purposes. All the Medication Administration Record (MAR) sheets in current use were examined during this inspection and a number of recording errors (i.e. gaps) were noted where staff had failed to indicate when a service user had been away on social leave. The manager has agreed to remind her staff team about not leaving gaps on MAR sheets. Nonetheless all the MAR sheets accurately reflected medication stocks currently held by the home on service users behalves. The manager confirmed that some of the service users are prescribed ‘as required’ (PRN) medication. Staff spoken with were very clear about when and how to administer PRN medication and are authorised to use it. However, no written protocols for the use of PRN medication could be located during this inspection. The manager has agreed to draw up more specific guidelines for its use. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 16 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): 22 & 23 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to enable service users and their representatives to raise any concerns they may have about the homes operation. However, staff must ensure they record any action taken in response to complaints made as a means of demonstrating their commitment to taking stakeholders views seriously. The homes vulnerable adult protection protocols minimise the risk of service users being abused, harmed, or neglected. EVIDENCE: All the service users met said staff were good listeners and always took their viewpoint into account. The homes complaints book revealed that two formal complaints about the homes operation have been made in the past year. The manager explained that both these complaints were dealt at the time to the complainant’s satisfaction. No written evidence of the action taken by the home in response to last of these complaints could be located at the time of this inspection. The manager confirmed that there have been no allegations of abuse made within the home. Furthermore, the senior in charge of the early shift demonstrated a good understanding of the local authority’s vulnerable adult protection protocols and the providers own whistle blowing procedures. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 17 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): 24, 27 & 30 Quality in this outcome area is poor. This judgement has been made using all the available evidence including a site visit to this service. The physical layout of the home, which is furnished and decorated to a reasonable standard, ensures service users live in a relatively comfortable environment. However, the lack of a routine maintenance to ensure the front driveway is kept in a good state of repair is placing service users, their guests, and staff at risk of harm. The homes policy of not allowing residents to use the only ground floor toilet without staffs permission restricts service users freedom of choice and power to make decisions in their own home. EVIDENCE: Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 18 During a tour of the premises the home felt pleasantly warm throughout and was free of any offensive odours. The manager conceded that she was unable to recall when an Environmental Health Officer (EHO) representing the local authority last visited the home and was therefore unable to produce the homes most recent EHO report. During a tour of the garden it was positively noted that staff had been supporting service users to grow their own vegetables and herbs. However, it was disappointing to note that despite the registered managers repeated warnings to her superiors about the poor state of the homes front driveway no action has been taken by the providers to repair the large number of potholes that have formed on it. These potholes are not only unsightly, but represent a ‘serious’ tripping hazard for service users, their guests, and staff. The manager, several members of staff, and two service users met during this site visit, all confirmed that this problem is exasperated at night because of the lack if lighting in this area. Furthermore, a lack of adequate drainage also means the potholes quickly form large pools of muddy water when it rains, which service users and staff find difficult to avoid, especially at night. The ground floor toilet is fitted with a dead lock that staff cannot override to gain access in the event of an emergency. The manager explained that the ground floor toilet had been designated for staff use only, although service users could seek staff’s permission to use this facility if they wished. This practice seems unnecessary restrictive for a care home of this size and nature whose underpinning ethos is to promote freedom of choice and movement. A service user spoken with at length told us they often used the ground floor toilet without seeking staff’s permission to do so because it was more convenient to do so when you were sitting in the kitchen or the lounges. If the care home wishes to persist with this unnecessarily restrictive practice then the Commission must be supplied with a full written explanation of the manager’s rationale behind its continued implementation. The homes laundry facilities are located in the garage and its washing machine is capable of washing clothes at appropriate temperatures. No laundry has to be taken through areas where food is stored, prepared, or eaten. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. Sufficient numbers of suitably competent staff are employed on a daily basis to ensure the individual needs of the service users are generally met. However, not enough staff have received training in first aid, vulnerable adult protection protocols, or infection control to be able to fully meet the needs of the service users or safeguard their welfare. Furthermore, although service users are supported by an effective staff team during the day, the homes on call arrangements will need to be reviewed as a matter of urgency, to ensure they are adequate to safeguard the service users welfare at night. The homes recruitment procedures are sufficiently robust to protect the service users from avoidable harm. EVIDENCE: Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 20 Several service users spoken with at length about the homes staff team said that in the main they were generally very approachable and always treated them with the utmost respect. One service user said they got on extremely well with their allocated keyworker who was frequently on hand to offer them support and advice as and when they required it. The manager and all the other staff on duty at the time of this inspection were observed interacting with the service users in a very professional manner. Documentary evidence was made available on request to show that the vast majority of the homes current staff team had either already achieved an National Vocational Qualification Level 2 or above in care, or were enrolled on a suitable NVQ course. On arrival a senior member of staff was the only person on duty. The shift leader explained that at least two staff would normally be on duty during the morning, but because one service user was out it was perfectly acceptable to have just the one member of staff on. The senior went onto explain that the homes manager was taking an exam that morning. It was noted that as identified on the homes duty roster for that day three members of staff arrived after lunch for their late shifts, which included the manager. The manager confirmed that only one member of staff, who sleeps-in, is on duty throughout the night, although a second member of staff is always designated as on call. Having inspected a random sample of the homes duty rosters flaws were identified with these on call arrangements. The manager conceded that some of the people designated, as on call system would be unable to reach the home within 20 minutes to help the sleep-in member of staff deal with an emergency. The homes nighttime staffing levels need to be reviewed as a matter of urgency. The home has experienced a relatively high rate of staff turnover in the past year with three new members of staff recruited during this period to replace those that had left. The personal files for all three of the homes most recently employed staff were examined in depth and found to contain all the relevant recruitment checks, including completed job applications, two written references in respect of each of them, up to date Criminal Records Bureau and Protection of Vulnerable Adult checks, and proof of their identities. The manager demonstrated a good understanding of the law regarding employing foreign nationals and Home Office approved working Visas/Permits were produced on request in respect of the relevant members of staff. The duty roster revealed that a member of staff working on a foreign student visa worked less than 20 hours a week in term time in accordance with Home Office rules. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 21 Documentary evidence was made available on request to show that all the new workers had completed structured inductions that covered safe working practices, worker roles, and the needs of service users. The manager has carried out a thorough assessment of her current staff teams skills and training needs. This assessment along with certificates of attendance of various training courses revealed that sufficient numbers of the homes current staff team had received training in fire safety, basic food hygiene, and handling medication in a residential care setting. The homes manager is aware that more of her staff team need to attend a first aid courses to ensure at least one suitably qualified member of staff is always on shift, as well as training in recognising, preventing and reporting vulnerable adult abuse and infection control. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 22 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 & 42 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. The service users benefit from living in a home that is run by an experienced and competent manager. The homes quality assurance system is not sufficiently robust to ensure service users and their representatives views about the standard of care provided underpins the services development. The homes maintenance arrangements for the repair of its electrical installations are inadequate to safeguard the service users, their guests and staff’s health and welfare and must be reviewed as a matter of urgency. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 23 EVIDENCE: The homes manager is still studying for her Registered Managers Award, which she hopes to have completed by August 2007. The homes manager said she receives a lot of support from her line manager to carry out the duties of running a residential care home. Documentary evidence was made available on request to show that senior representatives of Consensus Care continue to carry out monthly-unannounced inspections of the home as part of the providers self-monitoring systems. However, it was disappointing to note that despite repeated requirements being made by the Commission the home had still not introduced an effective quality assurance system for ascertaining service users and their representatives views about the standard of care being provided at Newlands cottage. A letter as being issued by the Commission ‘warning’ the providers that continued failure to address this outstanding matter will result in enforcement action being considered to ensure compliance. The homes fire records revealed that its fire alarm system continues to be tested on a weekly basis, and fire evacuation drills are still being carried out at regular intervals. Up to date certificates of worthiness were made available on request to show that the homes fire alarm system, fire extinguishers, emergency lighting had all been tested in the past year by suitably qualified engineers in accordance with good health and safety guidelines. However, it was extremely concerning to note that despite it being identified as a serious health and safety breach at the homes previous two inspections very limited action had been taken to resolve problems with the homes lighting and electrical wiring. During a tour of the premises it was noted that a number of battery powered emergency lamps were strategically placed throughout the home. The homes manager and two other senior members of staff met during the site visit confirmed that these lamps were a necessity, as the homes electrics would regularly fail if to many electrical appliances were turned on at once. This represents a serious breach of the Care Homes Regulations (2001) and following a management review meeting an Immediate Requirement Notice was issued by the Commission for this outstanding health and safety matter to be resolved by the end of March 2007. Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 24 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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 1 X Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 25 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 YA14 Regulation 5(1)(bc) (c) Requirement Each service user must be supplied with a Guide and contract that includes more detailed information about the providers arrangements for charging and paying for so called ‘extra’ services (specifically holidays and community based activities), which are not covered by the basic price of their placement. Staff must appropriately maintain medication administration records at all times. Protocols for the safe handling of ‘as required’ (PRN) medication must be developed and be made available for inspection on request. A record of any action taken by the providers in respect of a complaint made about the homes operation must Timescale for action 01/07/07 2. YA20 13(2) 01/04/07 3. YA20 13(2) 15/04/07 4. YA22 17(2), Sch 4.11 15/04/07 Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 26 always be made available for inspection on request. 5. YA24 23(5) The providers must 01/05/07 undertake appropriate consultation with the authority responsible for environmental health for the area in which the care home is situated. The providers must assess the risk posed by the damaged driveway and establish a time specific action plan setting out when they propose to repair it. Furthermore, this whole area must also be adequately light at night. The dead lock fitted to the ground floor toilet must be replaced with a more suitable locking device that can be overridden in an emergency. The providers must ensure service users have access to all the homes WC’s. The homes night time on call arrangements must be reviewed as a matter of urgency and the Commission notified about the outcome. Sufficient numbers of the homes current staff team must receive training in first aid, vulnerable adult protection, and infection control. Documentary evidence of attendance of this training must be made available on request. DS0000025818.V331802.R01.S.doc 6. YA24 12(1)(a), 13(4)(a) & 23(2)(b), (o) (p) 01/06/07 7. YA27 12(1)(a) & 13(4) 01/05/07 8. YA27 12(1)(a), (3) (4)(a) & 23(2)(j) 13(4) & 18(1)(a) 15/04/07 9. YA33 01/06/07 10. YA35 13(3), (4)(c) (6) & 18(1)(c) 01/08/07 Newlands Cottages (10) Version 5.2 Page 27 11. YA39 24(2) The home must introduce an effective quality assurance system for ascertaining service users and their representative’s views about the standard of care provided and publish the results of their findings on an annual basis. Previous timescales for action of October 2004 and 31st December 2005 not met. Warning letter issued regarding this persistent breach of the Regulations. The registered provider must arrange another electrical safety inspection for the home to demonstrate that the system complies with current legislation. Previous timescales for action of 31st July and 31st December 2005 not met. Immediate Requirement Notice issued on 30th March 2007 regarding this serious breach of health and safety Regulations. 01/08/07 12. YA42 13(4) 02/04/07 Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 28 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. 2. Refer to Standard YA7 YA19 Good Practice Recommendations Service users meetings should always be minuted and made available for inspection on request. The manager should consider introducing a separate single source document for recording all the significant incidents that occur in the home for ease of referencing/auditing purposes. The homes manager should have completed her Registered Managers Award by August 2007. 3. YA37 Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Newlands Cottages (10) DS0000025818.V331802.R01.S.doc Version 5.2 Page 30 - 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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