Inspection on 25/10/05 for Robinsfield

This inspection was carried out on 25th October 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Robinsfield 11/11/08

Robinsfield 19/11/07

Robinsfield 15/08/06

Robinsfield 23/01/06

Robinsfield 31/08/04

Robinsfield 15/04/04

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Robinsfield Robinsfield 35 Whyteleafe Road Caterham Surrey CR3 5EJ Lead Inspector Vera Bulbeck Announced Inspection 25th October 2005 10:15 Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Robinsfield Address Robinsfield 35 Whyteleafe Road Caterham Surrey CR3 5EJ 01883 330070 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) Welmede Housing Association Ltd Ms Jacky Barker Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: Up to 5 persons 21-55 YEARS WITH ONE NAMED PERSON BEING IN THE AGE RANGE 17-21 YEARS Persons with learning disabilities accommodated at the home may also have an additional physical disability 31st August 2004 Date of last inspection Brief Description of the Service: The home is set in a residential area of Caterham and is in keeping with the surrounding premises. It is near a bus route and is within walking distance of a few local shops. All the bedrooms are of single occupancy and located on the ground floor. Other facilities include a lounge, a kitchen/dining room, staff sleep in room, office laundry, two bathrooms and a walk in shower room. The six residents living in the home are of high dependency; there are a number of hoists and wheelchairs to facilitate resident’s needs. All staff have been trained appropriately to meet the needs of residents. There is a well-kept garden to the rear of the building, which is shared with the tenants who live up stairs in five supported living flats. The front door of the home is shared with the supported living tenants. Robinsfield has its sleep in room and laundry off the hallway in the main entrance of the home. A dividing door into residents living accommodation is kept locked from the entrance main door, to stop people entering the home. The car parking area facilities are ample to accommodate a number of cars. The home does not have its own transport. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first announced inspection to be undertaken by the Commission for Social Care Inspection year April 2005 to March 2006. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. Mrs J Barker the registered manager for the home was present. The inspection was undertaken over 3 hours and 45 minutes. There are currently six residents living in the home and the majority have lived in the home for some considerable time. The residents were not at home on the day of inspection; therefore the inspector was not able to speak with the residents. One member of staff was spoken to and commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. The inspector received three relatives comment cards, which were all very positive and spoke highly of the care provided in the home. Two comment cards were also received from the G.P who visits the home when necessary; and other times residents are taken to the surgery. The comments were of satisfaction by the doctor. It was disappointing to note that two requirements from the previous inspection were not met. The home needs to update the statement of purpose, and the service users guide, and a number of policies and procedures need to be updated and should be specific for Robinsfield. The inspector would like to thank the manager and staff member for their time, assistance and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report What the service does well: The manager and staff team are committed to providing a safe and homely environment for residents. Resident’s are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by the use of sign and body language. The registered manager informed the inspector that questionnaires have been implemented and sent out to families and an advocate for feedback on the Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 6 services provided in the home. Only two have been returned so far. The home will send these out on a yearly basis. What has improved since the last inspection? What they could do better: 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. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 7 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 Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 8 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): 1 and 5. The home has a detailed and informative statement of purpose and service users’ guide. These documents, together with the home’s procedure of carrying out detailed assessments and offering a well-structured series of visits prior to admission, enable residents and prospective residents and family to make an informed choice about admission to the home. The individual written contracts need to be revised to ensure that all relevant information is available. EVIDENCE: The homes statement of purpose needs to be updated and should include relevant information as detailed in The Care Homes Regulations 2001, Schedule 1 including the change of National Care Standards Commission to Commission for Social Care Inspection The service users guide has been written in a format for residents to be able to read. Three care plans were sampled and it was noted that care plans are well documented and contain detailed information. The registered manager informed the inspector that care plans are regularly reviewed. It was noted that at times residents are requested to pay for staff that are accompanying residents when having meals out. This practice also applies for transport and holidays. The inspector advised the registered manager that residents should have a discount on their meals when not eating in the home for example Sunday lunch at the local pub. All extra payments should be included in their contract. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 9 Contracts were in place but need to be updated to include room numbers and should include extra expenses for example as stated above. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. The resident’s individual plans are well documented. including details of needs and goals. They also incorporate known or indicated preferences and risk assessments. EVIDENCE: Plans reflect areas of need; they are up to date and have been regularly reviewed. Entries made could be more explicit and indicate the actual care given. A number of risk assessments had been completed. A key worker system is in place and staff have the responsibility of helping residents achieve everyday goals, such as holidays or going shopping. Staff in a key worker role help residents to arrange social events of their choice or preference also hospital and GP appointments. The inspector was not able to speak with residents, as they were all out at various day centres and were not expected home until after 3pm. The inspector was informed staff have a good understanding of the needs of residents and are able to communicate by means of sign and body language with residents. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 11 The home has a confidentiality policy in place and staff records and resident’s records were held in a locked facility. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 17. Activity programmes are varied and on the whole are designed to meet individual need. Links with the families, friends and the local community are good EVIDENCE: The six residents attend day centres none of the residents are able to attend adult education activities. Residents had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Residents have a number of leisure activities which they enjoy these include the cinema, bowling and going to another care home for tea. On occasions residents like to go to the disco, a taxicab takes the residents there and back, and costs £30.00; this expense is divided between two residents. All transport arrangements are paid for by the residents even when going on holiday the residents pay for the hire of a car. It is unfortunate that the home does not have its own transport or able to share transport with another Welmede home. Staff attempt to maintain links with resident’s families, one resident goes home to her parents for the weekend on a regular basis. Another resident has an Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 13 advocate who visits two or three times a week. The registered manager stated she is currently trying to organise an advocate for another resident. However, there is a short supply of advocates. There are no restrictions in terms of visiting times. There was evidence in the care plans that residents are supported to be as independent as possible, and are free to make decisions where possible. Mealtimes were not observed however, it was noted that the dining area is located within the kitchen. There are eight places at the table and all residents require assistance with meals taken. The menu is varied and drawn up with the residents their likes and dislikes are taken into consideration. The nutritional content is followed and encouraged by staff. Staff undertake the cooking in the home. The management of the home to ensure all staff undertaking cooking duties must have basic food hygiene training. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medications. However, there were some discrepancies with regards to the administration of medication. EVIDENCE: From the tour of the premises, it was clear that residents are provided with a variety of aids and equipment to assist with their independence, including tracking hoists, electrically operated beds and wheelchairs specifically designed for individuals. The inspector was informed residents are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. The manager stated that the administration of medication is carried out by nominated, “key holder”, members of staff. These members of staff are detailed on a daily handover sheet, which specifies the staffing arrangements for each shift. Shortfalls in the required standard of administering medication were noted: • Gaps were present on the medication administration record (MAR) sheet. DS0000013766.V254276.R01.S.doc Version 5.0 Page 15 Robinsfield • • • • The prescribed dosage of a medication had been altered on a MAR sheet and the medication box. The registered manager stated medication from the Pharmacist is often dispensed wrongly. Medications that had been dropped and disposed of were not recorded accurately on the MAR sheet. There are no divisions or photographs of residents between each MAR sheet, which help to prevent the administration of medication to the wrong resident Medication was noted to have been missing and found on the floor. All staff must ensure residents take their prescribed medication as and when required by the doctor. The Commission for Social Care Inspection must be notified of any medication errors under Regulation 37. The Inspector has provided management of the home with a copy of the Royal Pharmaceutical Society of Great Britain document “The administration and Control of Medicines in Care Homes and Children’s Services” this document must be followed The Pharmacist inspector has been requested to undertake an inspection in the home. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. All required policies and procedures are in place however, these need to be updated to ensure that residents feel their views will be listened to. Policies are in place to protect residents from abuse and neglect. EVIDENCE: The manager informed the inspector there had been no formal complaints received by the home, and there was no record of the home ever receiving a complaint. However, it is not possible for residents to be able to make a complaint but family, friends and advocate have been provided with a copy of the complaints procedure. The organisation Welmede Housing Association Ltd have its own adult protection policy and procedure and a copy of Surrey’s multi agency vulnerable adult procedure was available in the home. Some staff has received training in this area and all new staff cover the training as part of their induction. All staff must have regular updates to the protection of vulnerable adults procedure training. Staff are aware of the policies and procedures and are aware of the whistle blowing policy and all staff have signed indicating they have read and understood the policies and procedures. The complaints policy and procedure needs to be updated. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30. The location and layout of the home is suitable for it’s stated purpose. It is accessible and well maintained. However, the shower room needs to be reviewed. The home was found to meet resident’s individual and collective needs in a comfortable and homely way. EVIDENCE: The home is homely and welcoming all the bedrooms are personalised and residents have TV’s music centres, and a number of personal items. New furniture is on order for one resident. The bedrooms were without a lockable facility. Staff support residents to maintain their bedroom to a good standard. The shower room needs to be reviewed, on the day of inspection it was noted that the radiator was rusty, the shower hose needs replacing, the extractor fan needs to be reviewed to be able to eliminate the amount of condensation which was seen to be causing the tiles to go mouldy. The towel holders on the door need to be secured and the door was not closing appropriately. It was also noted that the sliding door from the lounge into the kitchen was off its runner and propped up in the kitchen waiting to be repaired. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 18 The premises were found to be clean and hygienic all staff to be congratulated on the cleanliness of the home. It was of some concern to receive a regulation 37 notification regarding one of the upstairs tenants opening the front door to a stranger and hence her DVD player went missing. The incident was reported to the police. The main front door is shared and Robinsfield has a sleep in room in the entrance hall and the laundry, which is left unattended. However when staff are undertaking laundry duties the door into the home is left open. The present arrangements need to be reviewed, to ensure the home is safe at all times. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36. Staffing levels need to be kept under review and provided to meet the needs of the residents at all times. Action must be taken to improve recruitment procedures. EVIDENCE: The management of the home has implemented a training programme, which details staff training. A number of staff have received training courses. These include nine members of staff who have completed medication training all new staff receive induction training. Eight care assistants have completed NVQ Level 2 and three have completed NVQ Level 3. The registered manager is to commence the Registered Managers Award, a starting date has yet to be finalised. Records of staff supervision were seen and found to be well documented and undertaken on a regular basis. Recruitment procedures were checked and it was found that, for one member of staff who has been working in the home since 06/12/04, a (CRB) criminal record bureau check had not been undertaken. There was no evidence of a first POVA check being undertaken, also there was no application form or references available. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 20 Recruitment procedures need to be followed. All staff should have a contract and training qualifications should be held on file as well as relevant documentation detailed in The Care Homes Regulations 2001, Schedule 2. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 21 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, 39, 40, 41 and 42. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known. Action must be taken to ensure that all records as specified in Schedule 2 and 4 of the Care Homes Regulations 2001 are in place to promote and protect the health, safety and welfare of residents. EVIDENCE: The registered manager has enrolled to undertake the Registered Managers Award but has not started the course. The manager has only been registered by the CSCI since June 2005 and has two years in which to complete the course. Monthly, quality audit inspections are undertaken by a representative of Welmede, and a number of areas are covered during this period. Records seen were well documented. A number of records were observed, these include the accident book, fire records, training as well as health and safety records and the majority were found to be well documented. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 22 There is a need to ensure all fire records are maintained in one folder the fire alarm system was recorded on a regular weekly basis and fire drills are undertaken three monthly. It was pleasing to note that a recent fire drill undertaken on 29/09/05 and the building was cleared within minutes. There is a need to produce a fire risk assessment on the whole building room by room, and management needs to produce an emergency plan for use in the event of any emergency and details must be kept in the fire record folder. There were a number of policies and procedures that are in need of updating, these documents should be more specific to Robinsfield. The current policies and procedures are written for all Welmede services, this area needs to be reviewed. Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Robinsfield Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 3 2 X DS0000013766.V254276.R01.S.doc Version 5.0 Page 24 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 1 Regulation 6 Requirement The statement of purpose must be updated to reflect any changes in the home and the changing from NCSC to CSCI. (Timescale not met 30/09/05). All policies and procedures need to be updated. (Timescale 31/09/05 not met). Medication procedures must be followed and the CSCI must be notified under Regulation 37 of all incidents. The shower room needs attention and must be reviewed. Recruitment procedures must be followed and all staff working in the home must have a CRB. Detailed records must be maintained at all times. Timescale for action 02/12/05 2 3 40 20 17 13 & 37 02/12/05 11/11/05 4 5 6 27 34 42 23 19 17 09/01/06 11/11/05 11/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 25 Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Robinsfield DS0000013766.V254276.R01.S.doc Version 5.0 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!