Inspection on 26/06/06 for Peat Lane House

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peat Lane House 06/09/07

Peat Lane House 07/02/07

Peat Lane House 20/03/06

Peat Lane House 06/09/05

Peat Lane House 16/03/05

Peat Lane House 29/09/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Peat Lane House Sandylands Kendal Cumbria LA9 64A Lead Inspector Liz Kelley Unannounced Inspection 26th June 2006 09:30 Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 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 Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Peat Lane House Address Sandylands Kendal Cumbria LA9 64A 01539 773073 01539 773073 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.cumbriacare.org.uk Cumbria Care Care Home 19 Category(ies) of Learning disability (18), Learning disability over registration, with number 65 years of age (1), Physical disability (5) of places Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION 1. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. The statement of purpose should clearly set out the physical environmental standards met/not met by the home in relation to 24.2;24.9;25.3;27.2;27.4;28.2, and a summary of this information should appear in the service user’s The home is registered for a maximum of 19 service users to include: up to 18 service users in the category of LD (Learning disabilities) of whom 5 service users may have a physical disability (PD). 1 person in the category of LD(E) (Learning disability over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection to manage one home only. 20th March 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Peat Lane House is registered as a Care Home for 19 people with learning disabilities of whom five may also have a physical disability. The registered provider is Cumbria Care, who from the 1st April 2006 will come under the juristriction of Cumbria Social Services. The living accommodation is arranged into five separate flats accommodating between two and five people. Each flat had its own sitting room, fully fitted kitchen, bedrooms and bathroom facilities. The larger flats also have a separate dining room. A central laundry is available for some flats that do not have their own laundry facilities. The flats are linked by communal corridors and accessed via a shared entrance door and entrance hall, off which are staff offices. The Home also had a large separate communal lounge and a sensory room. One flat is a respite facility, which accommodates up to three people. The home has its own large car park. Each flat has its own dedicated staff team who offer support, supervision and personal care. The current scale for charging is £501.81. A Handbook is available for prospective residents, which includes a summary of the homes customer survey findings. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection where all the key standards were examined and included three visits to the home. On the first visit, 26/06/06, two other inspectors were present, Cath Wilson and Paula Malaney. The second visit, 28/06/06, was to speak to as many residents as possible and the third, 03/07/06, was to gain access to staff files and to speak to the manager. Additionally a visit was made by the Pharmacy Inspector, Angela Branch on the 27.06.06. A tour of the building was carried out, and the home completed a questionnaire and questionnaires where received from residents and relatives. What the service does well: What has improved since the last inspection? What they could do better: The Pharmacy Inspector carried out a separate inspection earlier in the year and made a number of requirements and recommendations. Another visit was made on 27.6.06. The findings were that no progress had been made and additional shortfalls were found. She judged that “The systems for recording Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 6 administration of medicines were poorly managed and put resident’s health and wellbeing at risk”. There was some progress on building repairs and refurbishment but overwhelmingly the building continues to offer a poor environment. The areas of repairs and refurbishments are too long to list in this section of the report, and the manager was instructed to carry out an audit of each flat. There are some repairs that are urgent and deadlines will be set to ensure these are carried out as quickly as possible, these mostly relate to unsafe and unhygienic areas of the toilets and bathrooms. The layout and design of the building continues to present problems in meeting the needs of those with more complex needs. As mentioned in previous reports one flat in particular is over crowded, too small for its purpose and is of a poor design for anyone with mobility or behavioural issues. A series of reviews with social workers has commenced to try to find a solution to this issue. Even for those with good social skills the institutional nature of the building creates a barrier to integration into the community and labels individuals. Even staff refer to the home as a Hostel. Peat Lane House is an out-dated model of accommodation and while it still exists inappropriate placements will continue to be made. The formal supervision sessions of staff is haphazard and does not always focus on practice and development issues for each staff member. The manager needs to ensure these take place regularly, focus on quality and care issues and records are stored in a more orderly fashion. The same applies to annual appraisals. While the majority of recruitment practices were satisfactory the manager needs to put in place additional measures while awaiting a persons full CRB to be returned. Cumbria Care need to develop a policy on the use of POVA 1st, and the home should not be routinely employing staff people using this measure. This practice should only be used in emergency situations, with additional safeguards in place and with agreement with CSCI. The home should follow Cumbria Care disciplinary procedures for dealing with staff not suited to the caring role. The home should improve its referrals under Adult Protection guidelines, and record any response from social services, even if no action is felt necessary by social services. The home should look at ways to improve communication between staff and to have improved consistency of systems, practices and quality monitoring across the home. Care plans and residents files would benefit from a review, and clearer instruction for staff on daily routines and personal care for each person. Health care plans are unclear on a person’s current medical condition. A tool is available - HealthCare Booklet - but use of this was inconsistent across the Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 7 home. Both care plans and health care plans require up-dating and need to be stored in a more secure and orderly manner. Four matters were identified at the unannounced visit which required urgent action. These were storing chemicals safely: not propping open fire doors; ensuring that foods were not out-of-date; and repair of an light fitment over a wash basin. 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. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 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 Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The placement of new residents has not been well managed over the past year and existing residents have suffered. There is inadequate consultation with existing residents to allow them to make real choices about whom they live with. EVIDENCE: Records show that the home is addressing the issue of inappropriate placements. Discussions have taken place with referring social workers regarding the need to ensure new admissions do not negatively impact on existing residents. The admissions procedure includes an initial review period during which the appropriateness of a placement is assessed. A recent complaint made to social services about placements was partially upheld, in that a new placement had extremely negative consequences for one existing resident. The outcome also raised questions about the need to review current placing procedures and indeed provision in the area. Individuals’ plans also included information about the negative impact of previous inappropriate placements. Staff report that their views are not taken into account about the suitability of a new placement. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 10 The manager needs to continue to work to ensure no inappropriate placements are accepted and that communications and consultations regarding potential new residents are strengthened with the staff team, residents and relatives. This will continue to be a problematic area to manage while Peat Lane offers long-term accommodation and also responses to crisis and emergencies. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care planning system used in the home is unwieldy and difficult to follow. The care needs of residents are being met by acquired knowledge of a relatively stable staff team, rather than clear plans. EVIDENCE: Each person has a file, and a care plan. However these files are large and unwieldy, containing personal information that is old and in most cases out-ofdate. These files need to be better organised and old material archived so that important information, including risk assessments are readily available. The evidence would indicate whilst there is much information recorded about service users it is not clear how up-to-date or how the home monitors need and outcome in a proactive manner. No one system seems to be in operation, and it was difficult to tell which was the latest care plan. Information on basic care was lacking while some areas developed on a person centred model were in good detail. These tended to focus on lifestyle and future aspirations whilst personal care needs were missing. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 12 The standard of recording and care plans varies between the different flats. One flat with a new supervisor had identified issues with care planning and each keyworker and the supervisor were reviewing care plans and files at each supervision. However, in this flat care plans and records were still being held in exactly the same way as at the last inspection when the home were advised to store them in a safer, more orderly and confidential manner. Care plans are still being stored, one on top of the other in a large plastic box, and other important information can be found on window sills, by bread bins and on top of the fridges. Staff and the manager need to continue to develop and strengthen the care planning system. It would also be beneficial if risk assessments became an active practice in all elements of the care planning system. There was no evidence to suggest that the supervisor or manager were carrying out any type of quality audit check to measure quality or frequency of review or adapting to changing needs of residents. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All the above standards Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Wherever possible residents are supported by staff to have varied activities and choices in their lives. However, in those flats that have problems with compatibility or with the lay-out of the building, the choice and life-style of these people is compromised. The home has developed good relationships with relatives that are supportive and enhance resident’s quality of life. Mealtimes and menus are flexible around resident’s choice and dietary needs. Residents are offered varied and good quality foods ensuring a well-balanced and healthy diet. EVIDENCE: Relatives have always said they are made to feel very welcome at the Home and are made to feel a key part of the team caring for their relative. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 14 Details of family and friends were very much in evidence in residents care plans including key information and also developmental issues, and frequency of contact. The Home had space to allow residents to see family and friends in private. The weekly menu is planned with residents and purchases for the menu carried out with residents, who take turns to help. Mealtimes are flexible and organised according to the homes activity. During the week packed lunches were taken to daytime activities, and a cooked evening meal is provided in the evening. Again residents help if this is part of an assessed care planning need. Service user also enjoyed a variety of take away meals and meals out. Specialist diets are catered for and from time to time dieticians were consulted. Details of residents being encouraged to have healthy diets was noted in care plans, and flats contain fresh fruit and vegetables. A resident spoken to was aware of foods that were good and others that she should try to avoid, and she said staff helped her to make these choices. The home is able to offer some flexibility in staffing to offer extra support. Evidence was available to show that this has recently occurred in two flats. In one flat that requires extra support due to complex needs, staff hours have recently been rearranged in order to allow more opportunities for residents to go out. And another flat experiencing compatibility issues has also received extra staff support. There are increasingly older people living at Peat Lane, and due to the unsuitability of the building this has resulted in them becoming isolated, unable to go out independently or otherwise. This will be a more frequent problem without adaptation or long-term plans for those living at Peat Lane House. The most recent example was of a resident of more than 30 years being reluctantly moved to a large home for older people, after being used to a 3-bedded flat. Three young people are living in a flat with minimal staff support as they are assessed as independent and able to manage with this level of support. However, it would be much more preferable for their lifestyle opportunities if these independent young people were living in their own home in the community, and not for example having to report to the staff office to say their going out to visit a friend. While these are short-term strategies the home needs to look at the future long-term plan for the home and individuals. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The systems for recording administration of medicines were poorly managed and put residents at risk to health and wellbeing. The monitoring and recording of healthcare needs was poor and requires coordination to ensure that residents are getting the support they need to maximise their health and well-being. EVIDENCE: The Pharmacy Inspector, Angela Branch, carried out two separate inspections recently, one the 20th October, 2005 and the other 27th June 2006. Nine more requirements were added at this inspection. One requirement had previous dead lines of 01/12/05 and 30/04/06 and now 01/08/06. A separate letter was sent out, but the requirements have been added to this report in the section on requirements and recommendations later in this report. These were the main shortfalls: A prescription only cream had been received for a resident but was not being applied and was not listed on the medicines administration record. Records showed that another cream had been requested. There was no evidence that treatment had been changed or that staff had queried why a different cream Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 16 had been received. There must be a system to ensure that staff query with the doctor and pharmacist if medicines are received that are unexpected or are different to previous supplies. Records were poorly maintained. There were missed signatures for administration. This puts residents at risk from duplicate administration if staff administer a medicine that has already been given but not signed for. Staff must use codes for non-administration appropriately. Hand-written medicines administration records were not consistently complete for strength of medication. All hand-written administration records must be signed, checked and dated. Rectal diazepam for seizures was prescribed. A care plan for this was found for one resident but was not seen for another. Guidance was available on information to be included in a care plan for rectal diazepam but current practice did not comply with this. This must be in place to ensure residents receive appropriate treatment within a written plan that is delivered consistently. In general, records of medication changes were poorly documented. 25 staff were listed of which three were documented as having medicines training. 12 staff had received training on the use of rectal diazepam and 11 had epilepsy awareness training. All staff that administer medicines must have appropriate training. The room was not secure for storing medication. . Some medicine packs had mixtures of tablets indicating that staff were mixing supplies. This is dangerous practice as incorrect medicines may be mixed up. The contents of the fridge were checked and three tubes of a cream were found that were labelled “do not keep in a refrigerator”. All medicines must be must stored according to manufacturers requirements. The home have introduced a Health Care Record, which are in pictorial format, in an attractive coloured binder, which are easy to use and follow. These have the potential to be useful documents. However, these are not always completed and did not contain a section on medical history of resident, only on family history. For example one persons epilepsy was not noted in health record. And another persons epilepsy plan was held in the main office. Often details of resident’s health care were discussed and noted in individual staff supervision files, and therefore not accessible to the whole team. Recording and follow-up advice of healthcare appointment were not noted and these should be more clearly recorded and any changes should be noted on care plans. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The home has an adequate complaints system, with evidence that residents feel that their views are listened to and acted upon. The handling of Adult Protection issues is poor and needs to improve to safe guard residents protection and well being. EVIDENCE: The Home has a complaints procedure, with a response time of 28 days. A system was in place to record all complaints. However on the day of the visit the complaints file could not be found. All service users have a copy of the complaints procedure, and details of how to complain were posted in the home and were available in different formats. Up-to-date information about the Commission for Social Care Inspection was included. Evidence indicates that referrals are not being made to social services of alleged incidents involving residents. The home was not following recommendations made at a previous adult protection meeting about arrangements for one staff member. The homes disciplinary procedures should have been invoked and were not. This results in residents being placed at risk and to them not being protected by the systems of the home. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26,29 and 30 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. This home is of an unsuitable design and lay-out, is run down both externally and internally and is not kept to clean and hygienic standards. In all Peat Lane House provides a poor standard of accommodation for the people living there. EVIDENCE: There have been some progress on building repairs and refurbishment but overwhelmingly the building continues to offer a poor environment. These improvements have been namely a newly installed shower room and two bedrooms refurbished in the respite flat. All of the other issues raised on the 20.03.06 remain the same and are repeated in the end section of this report on Requirements. Additionally the following were added as requiring attention: Respite flat: There is no storage for dry foods and tins. The lounge carpet is stained. Dining room chairs are badly worn. There are no paper towel dispensers. Derwent Flat: All carpets are in need of replacement being stained and worn. One armchair in particular is very badly worn. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 19 Coniston flat: a number of carpets need replacing, including the lounge. Hand rails in the toilet are damaged and expose rusty metal which is not hygienic. Ullswater: Shaver lights in Ullswater flat need urgent attention to make them safe. This was carried out by the 28.6.06. Toilet in Ullswater flat is leaking and has soaked into the surrounding woodwork. Kitchen unit drawer fronts in Ullswater flat need to be repaired to make them safe and useable. The handle on the kitchen door in Ullswater flat must be repaired. Generally around the building: On initial entry to the reception area of the building a mal odour was present, and this was also present in some flats. Furniture in communal lounge, and office chairs are torn and will no longer be fire retardant, these need to be re moved and replaced. On a positive note examples of staff putting considerable time and effort into making the flats more homely by decorating was a positive feature of the home. There was a lack of understanding about who should fund items in the home. Some residents were purchasing, dishwashers, and vacuum cleaners. Staff were not sure why this was happening. The manager needs to ensure that this does not happen, as a routine practice. A recent development has been the purchase of the building by Impact Housing Association, and discussions have been underway about up-grading. A three year programme of improvements has been agreed of £123,5000 from Impact. A plan of improvements required for each flat was requested at the last inspection but this has not been produced. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The service has a recruitment procedure that is adequate and generally meets the regulations and the national minimum standards although at a basic level. Development and supervision of staff is inconsistent and staff lack leadership. The number of qualified staff is below the expected standards. EVIDENCE: The Home has less than 25 of staff qualified in NVQ level 2 in Care. This was required to be a minimum of 50 by 2005. Five more have been identified for the next group to be enrolled. The home has a large number of relief staff and these training figures are brought down by this fact. Staff are trained to work with people with learning difficulties through the Learning and Disability Award framework for induction. All staff require a Safe Handling of Medication training, as identified by the pharmacy Inspector. A newly appointed supervisor has been given training as a key area of their work. Good progress has been made on drawing-up a training matrix for the home which should help in identifying shortfalls. Staff files were examined and were stored confidentially and safely, in a storage room off the communal lounge. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 21 The majority of staff recruitment files were well organised and up-to-date. Three new staff files examined, demonstrated evidence of a staged induction programme which was good practice to familiarise new members of staff. “Fitness for Life” files are kept by the home, which monitors records of sickness and return-to-work paperwork. A number of staff reported high sickness levels. Examining the paperwork it was difficult to ascertain these levels as they were only individually held in each persons section of the file and even then a running tally was not held. A recommendation was made that this would be a useful QA tool across the home. Formal staff supervision sessions are not consistent or regular, and do not always focus on practice and development issues for each staff member. The manager needs to ensure these take place regularly, focus on quality and care issues and are stored in a more orderly fashion. The same applies to annual appraisals. While the majority of recruitment practices were satisfactory the manager needs to put in place additional measures while awaiting a persons full CRB to be returned. Cumbria Care need to look at developing a policy on the use of POVA 1st, and the home should not be routinely taking people using this measure. This practice should only be used in emergency situations and with agreement with CSCI. The home should follow Cumbria Care disciplinary procedures for dealing with staff issues, especially were this concerns an allegation of abuse. A recent allegation was not reported to social services. Staff reported lack of communication regarding important issues in the home and developments. The home should look at ways to improve communication between staff and to have improved consistency of systems across the home. For example frequency and quality of supervision differs between flats. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 39, and 42 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. The management structure has suffered from lack of consistency over the last five years. The home lacks direction and leadership. EVIDENCE: After a long period of uncertainty a new manager has been appointed to the Home. This person will need to have a clear focus and strong leadership skills to address the shortfalls identified in this report. The co-ordination of five separate flats and staff teams, with a total of over fifty staff, with the added complication of building issues, is a huge task even for the most experienced manager to undertake. The current manager works for 4 days per week, and the organisation currently requires her to manage a small care home in the local vicinity. A condition of the manager’s registration was to manage one home only. Other arrangements must be put in place as soon as possible. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 23 Staff have reported that communication in the home has been poor, with some information heard on the grape-vine. There are no full staff meetings and this, coupled with some flats not having supervisors, has contributed to staff reporting that they feel unsupported and communication channels being poor. This has also not been helped by erratic supervisions, low staff morale and high sickness levels. All of this is not surprising in a period of change and uncertainty but measures now need to be taken to re-establish effective management and co-ordination. This should be helped in future months by the appointment of two experience supervisors. Quality assurance monitoring is not effectively implemented as a core management tool. Resident’s interests are not safeguarded as evidenced by poor recording and not fully following set procedures. This has lead in some circumstances to putting service users at risk, for example by poor recording of medication and recruitment practices. There is no evidence that spot checks and quality monitoring systems are in place. A number of health and safety issues were identified at this visit, and the following four immediate requirements were made: ensure the safe storage of hazardous materials (COSHH), in particular in Ullswater flat; light fittings in Ullswater flat need to be repaired by 30 June 2006; foods must be used by the stated “use by date”; and fire doors must not be propped open. The home responded very quickly to these requirements with a letter to say the doors propped open had been in agreement with the Fire Officer. The home needs to produce written notice of this. Lights were fitted within 2 days, and other matters attended to straight away. Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 2 1 2 2 X X 2 X Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Medicine administration records All administration of medicines must be signed for Reasons for nonadministration must be documented MARs must be accurate for the prescribed medicine MARs must list all prescribed medicines (Previous dead lines 01/12/05 and 30/04/06) Compatibility issues for service users in Grasmere flat must be addressed and future actions sent into the Commission for Social Care Inspection (Previous dead line 30.11.04 and 31.10.05) Compatibility issues for service users in Derwent flat must be addressed and future actions sent into the Commission for Social Care Inspection (Previous dead line 30.11.04 and 31.10.05) The manager must develop a DS0000036525.V291307.R01.S.doc Timescale for action 01/08/06 2. YA6 12 30/06/06 3. YA6 12 30/06/06 4. YA24 23 31/08/06 Page 26 Peat Lane House Version 5.1 plan of improvements to the building (Previous dead line 30.11.05 and 11/04/06) 5. YA24 23 Flats must be kept clean and hygienic (Previous dead line 30.09.05 and 31/03/06) The fitness for purpose of Grasmere and Derwent flats must be assessed (previous deadline 30/05/06) Derwent flat kitchen must be replaced Adequate storage must be provided for Derwent Flat, for food, paperwork and items such as a vacuum cleaner. Bath seals and cracked tiles must be replaced The hand rail in Derwent toilet must be replaced. (previous deadline 30/04/06) 31/07/06 6. YA24 23 31/10/06 7. 8. YA24 YA24 23 23 30/08/06 30/08/06 9. 10. YA24 YA24 23 23 30/08/06 31/07/06 11. YA24 23 The communal areas, corridors of Derwent and Grasmere must be redecorated (previous deadline 30/05/06) Additional tiles must be put around the shower area in Grasmere Flat (previous deadline 30/04/06) Old dining room chairs must be thrown away or replaced (previous deadline 30/04/06) DS0000036525.V291307.R01.S.doc 30/08/06 12. YA24 23 30/08/06 13. YA24 23 31/07/06 Peat Lane House Version 5.1 Page 27 14. YA3 12 Residents must be consulted and their wishes and feelings taken into account on the placement of new residents to their Home. (previous deadline 31/03/06) The registered person must ensure that there is clear documentation of changes to medication in residents’ records. 30/06/06 15. YA20 13(2) 01/08/06 16. YA20 15(1) The registered person must ensure that care plans are in place for all residents who are prescribed rectal diazepam 01/08/06 17. YA20 13(2) All photographs of residents used for the purpose of safe administration must be labelled with their name. 01/08/06 18. YA20 13(2) The registered person must ensure that hand-written medicines administration records are signed, checked and dated. 01/08/06 19. YA20 23(2)(l), 13(2) 01/08/06 The registered person must review the storage of medicines to ensure that it is clean and tidy and that there is no risk of medicines being mixed up through damaged packages. Medicines that are out-of-date or are no longer required must be disposed of. The room where medicines are stored must be secure. 01/08/06 The registered person must ensure that medicines are stored 20. YA20 13(2) Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 28 in their original containers and that staff do not mix up multiple supplies. 21 YA20 13(2) The registered person must ensure that there is a system to ensure that staff query with the doctor and pharmacist if medicines are received that are unexpected or are different to previous supplies. 22 YA20 13(2) The registered person must ensure that medicines are stored according to manufacturers requirements. 23 YA20 19(5)(b) The registered person must ensure that all staff that administer medicines have appropriate training. 24 YA6 17 Care plans and health care plans must be kept up-to-date, and stored in an orderly and confidential manner. Risk assessments must be regularly up-dated and readily available to instruct staff. The premises must be suitable for the purpose of achieving the aims and objectives set out in the statement of purpose. The location is appropriate, the physical design and lay-out must meet the needs of service users. All allegations of abuse must be reported to social services in accordance with local guidelines. Respite flat: There is no storage for dry foods and tins and this must be provided. Derwent Flat: All carpets are in Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 29 01/08/06 01/08/06 01/09/06 31/08/06 25 26 YA9 YA24 17 23 (1)(a,b) (2) (a) 31/08/06 31/10/06 27 28 YA23 YA24 12 23 31/07/06 30/09/06 need of replacement One chair in particular is very badly worn. Coniston flat: a number of carpets need replacing. Hand rails in the toilet are damaged and expose rusty metal which is not hygienic. Ullswater: Shaver lights in Ullswater flat need urgent attention to make them safe. This was carried out by the 28.6.06. Toilet in Ullswater flat is leaking and must be repaired along with the surrounding woodwork Kitchen unit drawer fronts in Ullswater flat need to be repaired to make them safe and useable. The handle on the kitchen door in Ullswater flat must be repaired. There must be no odours in the building, including the entrance hall. Furniture in communal lounge, and office chairs are torn and will no longer be fire retardant, these need to be removed and replaced. 29 YA34 19 The manager needs to put in place additional measures while awaiting a persons full CRB to be returned. DS0000036525.V291307.R01.S.doc 30/08/06 Peat Lane House Version 5.1 Page 30 30 YA36 18 31 YA39 24 32 YA37 9 Cumbria Care need to look at developing a policy on the use of POVA 1st, and the home should not be routinely taking people using this measure. Formal supervision and appraisal sessions that focus on quality and care issues and are stored in a more orderly fashion must be given to all staff An effective quality assurance and management monitoring system needs to be put in place to improve quality and consistency of practices and care. The manager must manage one registered home only, as set out in the homes conditions of registration. 31/08/06 31/08/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA20 YA39 YA38 Good Practice Recommendations Medicines that are no longer required should be disposed of appropriately A record of overall staff sickness is recommended as a tool for quality measuring. Communication across the home should be improved and consideration given to full staff meetings to address staff reporting that they are not informed of important issues, or have channels to express views The home should review the need for a deputy manager 4 YA37 Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Peat Lane House DS0000036525.V291307.R01.S.doc Version 5.1 Page 32 - 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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