Inspection on 15/04/08 for Russell Hill Lodge

This inspection was carried out on 15th April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell Hill Lodge 20/09/07

Russell Hill Lodge 18/04/06

Russell Hill Lodge 23/12/05

Russell Hill Lodge 15/08/05

Russell Hill Lodge 13/01/05

Russell Hill Lodge 12/08/04

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

CARE HOME ADULTS 18-65 Russell Hill Lodge 39 Russell Hill Road Purley Surrey CR8 2LD Lead Inspector David Halliwell Unannounced Inspection 8th April 2008 10:00 Russell Hill Lodge DS0000025833.V361432.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 Russell Hill Lodge DS0000025833.V361432.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. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell Hill Lodge Address 39 Russell Hill Road Purley Surrey CR8 2LD 020 8668 3212 F/P 020 8668 3212 ronchiwome@yahoo.co.uk 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) Laurel Residential Homes Limited Post Vacant Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 18 20th September 2007 Date of last inspection Brief Description of the Service: Russell Hill Lodge is registered to provide care to up to 18 adults who have past or present mental health problems. The home is situated close to Purley town centre and therefore well placed for access to the towns amenities and transport. The house is a large detached traditional brick built building. It has 18 single rooms, a lounge, dining area and conservatory. One of the single bedrooms has en - suite facilities, including bathing and catering facilities. There are also 2 self contained flats that are used for residents who are able to live more independently. Ownership of Laurel Residential Homes has recently been sold to a new Company that must now register with the Commission for Social Care Inspection. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection visit over 1 day undertaken by the Inspector responsible for Russell Hill Lodge. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with staff and service users. Informal interviews were conducted with other service users as a part of the inspection of the home. Since the last inspection carried out at Russell Hill Lodge some progress has been achieved by the Manager and his staff team in meeting the previously set requirements and recommendations from the inspection carried out in September 2007. As a result of this key standards inspection 10 requirements have been made and 2 recommendations. Feedback on all these new requirements and recommendations was given verbally to the Manager at the end of this inspection visit. The Inspector found the residents, the managers and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. What the service does well: What has improved since the last inspection? Specific areas where improvements have been achieved are as follows: 1. Needs assessments now include resident’s religious and cultural needs. Improved coverage has also been achieved in the needs assessment of the person’s rehabilitative and therapeutic needs and the residents own comments and views about their needs. 2. PRN medication guidance for staff has been included on the medication records for each resident who uses PRN medication. 3. A copy of the complaints process has been posted on the home’s notice board and in each resident’s service user guide. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 6 4. All staff except those newly recruited have received certificated training in POVA. 5. The Manager has mostly ensured that the areas of the home identified in the previous report that required repairs and maintenance were addressed. 6. A training matrix has been developed as a useful management tool. 7. Some progress has been achieved with implementing an appropriate quality assurance system in the home. What they could do better: Specific areas where improvements are required and recommended are as follows: 1. Diary sheet entries must be made that accurately reflect the work being done with residents and that care plan reviews monitor the success or otherwise of the specific care plan objectives and that they are revised in the light of the review findings. The latter part of this requirement is a repeat requirement. 2. Resident’s files should include all of the information required in Schedule 3 of the Regulations including photographs and contracts. 3. It is expected that there should be a comprehensive and daily skills building and activities programme for each resident supported by their keyworkers, that is focussed on achieving their agreed care plan objectives. 4. The Manager must ensure that the quality of the food ingredients being purchased is improved and that the new menu planning changes actually meet the hopes of the residents as described and provide healthy and nutritious meals. 5. Inspection of the kitchen equipment revealed that some pots and pans need replacement because they have broken handles. This could present a health and safety issue and so the Manager is asked to replace these pans. 6. The Manager must ensure that MAR sheet records are always accurately completed in order to protect both the residents and the staff. 7. A photograph of each resident must be placed on a new medication front sheet on their MAR sheet records so as to help Russell Hill staff ensure they are administering medication to the correct resident. 8. Medical records were inspected and stock levels of medications were seen not to correspond with the records. Stock that should have been returned to the Chemists in March 2008 had not been returned and there was no explanation as to why this was or as how an excess of medication tablets had arisen. 9. There is a need for a complete renewal and refurbishment of the front garden. 10. The floor in the communal areas needs to be replaced. 11. The Manager must complete the Registered Managers Award training within the next 3 months. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 7 12. The Manager must submit his application to become the registered manager at Russell Hill Lodge within the new timescale. Enforcement action may be taken if this timescale is not met. 13. A legionnaire’s water test needs to be carried out this year. 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. Russell Hill Lodge DS0000025833.V361432.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 Russell Hill Lodge DS0000025833.V361432.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): Standard 2 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and prospective residents may be assured that their needs and aspirations will be assessed and that this will include their religious and cultural needs as a part of the assessment process. EVIDENCE: Standard 2 – At the last inspection a requirement was made so as to ensure that the religious and cultural needs of a prospective resident are included in their needs assessments. In addition to this, improved coverage in the needs assessment of the person’s rehabilitative and therapeutic needs was also required. At this inspection we reviewed 4 of the 15 residents files and 3 of these files were for new admissions of residents to the home since the last inspection. Assessments of the resident’s needs had been undertaken by Russell Hill Lodge and these needs assessments now include the essential areas of a person’s life and their religious and cultural needs. On each of the files inspected residents had also signed their assessments indicating their agreement with the assessment of their needs. This should now mean that a resident or prospective resident can be assured that their individual aspirations and needs are fully assessed and that this information will be used to form their individual care plans or service user plans. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 10 In addition to this needs assessment information seen on the files inspected there was also assessment and care planning information supplied by the referring agencies. This was mostly seen in the form of care programme approach (CPA) documentation and CPA reviews. This information about the resident was seen to include the rehabilitative aims and objectives from the referring agencies at the time of their request to place the individual at Russell Hill Lodge. All of this helps to ensure that staff at Russell Hill have all the available information about a prospective resident at an early stage of the process and are fully informed to make the decision about whether and how best a residents needs could be met. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to make decisions about their lives with assistance as needed. Their care plans are based on their assessed needs, however the reviews of these plans need to focus more on the progress that has been made over the period under review as to the achievements or otherwise in meeting the care plan objectives. Residents are supported to take risks as part of moving towards a more independent lifestyle. EVIDENCE: Standard 6 - As indicated in the previous section we reviewed 4 residents’ files. We found evidence on each file of a new care plan format that had been drawn up and reviewed for each of these residents. The new “service user plans” refer to all the areas of the person’s assessed needs including mental and physical needs; daily living; cultural and faith needs; family and relationship; employment / activities / education; substance misuse; finance and accommodation. Following on from the care plans are a series of action plans each of which focuses on a single care plan objective. The action plans describe how the care plan objective could be met and sets out a schedule of Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 12 work for both the resident and the Russell Hill support staff helping them. It is intended that under each action plan a log is kept by support / keyworker staff that monitors and reviews the success or otherwise of implementing the action plans. Inspection of the 4 residents files indicated that this recording was inadequate both in the frequency of the recordings and in the details provided. On one resident’s file for instance, the action plan had been drawn up in January 2008 and there was no record of any work done to try and implement the care plan objective in January; only two entries were made for February and two for March. The detail in these entries was inadequate and did not show what had been achieved in trying to implement the care plan objective or what would be done where some success had not been achieved. Given that the prime focus for residents at Russell Hill Lodge is for their recovery and rehabilitation back into the community this is very unsatisfactory. The review of the residents’ files at this inspection showed that the needs assessment and care planning processes are now “fit for purpose” and the Manager and the staff are recognised for the positive progress that has been made towards achieving the previous requirement. However appropriate and effective implementation of the care plan objectives through monitoring and review by the support staff and the residents is crucial if the overall purpose of this unit is to be achieved. It is a requirement therefore that diary sheet entries are made that accurately reflect the work being done with residents in implementing the care plan objectives. Also that care plan reviews monitor the success or otherwise of the specific care plan objectives and that they are revised in the light of the review findings. The latter part of this requirement is a repeat requirement. Enforcement action may be taken is this requirement is not met within the timescale. Monthly reviews of care plan objectives should include sufficient detail relative to the progress or lack of it that had been made in meeting the objectives. Care plan objectives and action planning should be reformulated at the review in an appropriate way to better meet the resident’ needs. Sometimes care plan objectives will be completed changed where it becomes apparent they are unrealistic and unachievable. Care plans had been signed by residents and were dated. The care plans could also be seen to be linking in with the relevant care programme approach documentation of the mental health clinical teams. Not all of the information required in schedule 3 of the Regulations was seen on the files. On 3 of the 4 residents’ files there was not a photograph of the person. This is important for easy recognition of the resident by new staff. A copy of the contract between the home and the resident should also Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 13 be included on the resident’s file; none of the 4 files inspected had this included. It is a requirement that resident’s files do include all of the information required in Schedule 3 of the Regulations. 5 residents interviewed by the Inspector said that they had been involved in the drawing up of their individual care plans. All residents interviewed felt that they had been properly consulted as to their own views and wishes and that what they had said had been properly considered in their care plans. Regular residents meetings are held within the home and there is an opportunity for residents to make their views known about relevant topical issues. Standards 7 & 9 - Residents are enabled to make decisions about their lives with assistance as needed. Risk assessments were seen on each of the files reviewed as a part of the initial assessment and care planning undertaken by Russell Hill. This helps in making the appropriate decision about a suitable placement and then in taking risks as a part of developing an independent lifestyle Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents may not be being assisted sufficiently to take part in appropriate activities and in being involved in local activities. Residents have appropriate relationships and their rights and responsibilities in their daily lives are recognised and respected by the staff in the unit. Residents are offered a reasonnably healthy diet and they are assisted in learning cooking and food preparation skills. EVIDENCE: Standard 12 – The Inspector did find evidence that care support staff appropriately encourage the maintenance of resident’s relationships with family and friends if residents also wish to do so. The Manager told the Inspector that visitors to the home are encouraged and that they use the visitor’s book to sign in. The visitor’s book was seen in the hall and was evidently in regular use. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 15 The Manager said that residents are enabled to take part in appropriate activities by the care staff. A notice board in the main office does schedule some daily activities over the week for each resident however the Inspector was present at Russell Hill Lodge throughout the day of inspection and there seemed to be a lack of structured activities taking place on the day of this inspection and little evidence of 1:1 support work actually taking place between key-working staff and the residents. This may be a reflection of findings referred to under Standard 6 earlier in this report. However in a home that focuses on the recovery and rehabilitation of residents with mental health problems back into the community it is expected that there should be a comprehensive and daily programme for each resident carried out, that is focussed on achieving their agreed care plan objectives. This is a requirement therefore. Standard 13 - Interviews with residents demonstrated that they do attend some local community events although their wishes for an active community social life are somewhat limited. Information is made available and staff do encourage residents to be involved as much as possible in local activities. Some residents told the Inspector that they like to go to the shops. Residents make full use of local public transport facilities in order to get out and about and to see friends and family. Residents interviewed said that they thought local transport facilities were good. All residents living at Russell Hill Lodge are registered to vote in elections and are supported by staff to do so if they wish. The Inspector saw that some information is made available within the home about local activities for residents to take up if they wish. Standard 15 – Some of the residents interviewed by the Inspector said that they do keep in regular contact with their families and friends. Staff were seen to encourage the residents to keep and maintain contacts with family and friends so that they benefit from having appropriate relationships. There is a visitor’s room in the house that can be used by visitors who wish to see their relatives in the house. Standard 16 - Policies seen by the Inspector to be established within the unit ensure that resident’s rights to privacy, respect and dignity are respected. Residents who were interviewed confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 16 Interviews both with staff and residents confirmed that residents participate in household chores as a part of the community living experience and weekly “chores” are detailed in the weekly action sheets. Smokers are now required to go outside to smoke; however a tour of the premises together with one of the managers clearly revealed that people do smoke in their bedrooms and in the bathrooms. The Manager told the Inspector that this is strongly discouraged by staff. Standard 17 – The Inspector met with the home’s cook who said that residents had met recently with staff to make changes to the menu planning. This was later confirmed by a number of residents and the Manager who confirmed that residents had decided to make some changes to their meals following some expressed concerns by them. This included a request for more fresh vegetables and better bread. Once implemented the changes should help to ensure a planned and varied new menu that residents told the Inspector they wanted. A number of residents referred to the quality of the food being purchased, one resident said, “they buy Tesco basics and you know that it is not that good quality”; another resident also told the Inspector, “the food could be better”; and another said, “we don’t get enough fresh vegetables or fruit”. The Manager must therefore ensure that the quality of the food ingredients being purchased is improved and that the new menu changes provide a varied, healthy and nutritional diet for the residents. The Inspector saw planned menus for the week ahead. Specific needs are catered for and alternative choices are provided. The Inspector was shown some new equipment that has just been installed in the kitchen including a new cooker and one of the Managers told the Inspector that a new dishwasher is to be installed next week. Inspection of the kitchen equipment revealed that some pots and pans need replacement because they have broken handles. This could present a health and safety issue and so the Manager is asked to replace these pans. The Inspector asked the Manager whether a dietician is ever asked for assistance, given the fact that weight-monitoring records are maintained for each resident. The Manager said that where necessary a dietician’s advice will be sought, as will the advice of the clinical team in CPA reviews where weight or diet is an issue. The Manager told the Inspector that residents do sometimes prepare their own food, and evidence of this was seen by the Inspector in the evening when a number of residents had prepared their own meals and who had been supported where necessary by the cook. Residents who had prepared their own food evidently enjoyed being able to do so and told the Inspector so. One Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 17 resident who had prepared a tuna / pasta dish said, “I know how to cook this dish, its easy and it’s tasty”. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 18 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): Standards 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users may be assured that they will receive personal support in the way that they prefer and require and that their physical and emotional needs will be met. Service users cannot rely on the home providing a well-managed service with regards to medication. EVIDENCE: Standard 18 – The Manager explained to the Inspector that residents are expected to be up and about each morning by 9.30am so that they are able to participate in their rehabilitative care packages and this includes their need to take their medications each morning. The residents interviewed at this inspection said that they do choose when to go to bed, when to have a bath, what they wish to wear and what activities they do during the day. Some said that they have allocated housework chores on specific days of the week. Residents do not have a choice of their allocated key worker however the Manager said that they have a chance to discuss any issues they may have or Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 19 which arise subsequent to the allocation of their key workers. Residents did not raise any concerns with the Inspector about their key workers. Residents at Russell Hill Lodge continue to receive regular input from their Community Psychiatric Nurses and from other professionals in their clinical teams. Standard 19 – With regards to the health care of the residents the Manager informed the Inspector that all residents are supported to keep well through accessing appropriate healthcare and associated mental health care support. All residents are signed up with local GP surgeries and some are registered with local dentists. At the time of this inspection one resident popped into the office to let the staff know they were off to see their dentist. On their return the Inspector asked the resident how they had got on, they said, “I have got to have one filling next week!” The Manager told the Inspector that annual health checks take place at the GP surgeries and residents attend there. The Manager said that whether or not a resident uses the dentist is left up to the resident’s own decision but staff will encourage residents to use this service if required. Residents who spoke with the Inspector said that they go to see their GPs as and when necessary but they said they prefer not to go to the dentist. The Manager told the Inspector that an optician visits Russell Hill Lodge once annually. Standard 20 - The unit’s policies and procedures manual contains a policy for medication that includes the procedures that staff need to take in order to ensure the safe administration of medication to residents. The Manager told the Inspector that only senior staff administers medication to the residents and only once they have completed training to do with the safe handling of medicines. The Manager informed the Inspector that some residents do administer their own medication unsupervised and others self medicate but with supervision. Following a recommendation previously made by the Inspector, the Manager said that risk assessments have now been completed in conjunction with residents who are unsupervised. This is welcomed as it should help to minimise any potential hazards for the resident or others. Inspection of the medication records / MAR sheets found some unexplained gaps in these records. The Manager was unable to explain why the records had not been completed as required. It is essential that MAR sheet records are always accurately completed in order to protect both the residents and the staff. This is a requirement. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 20 At a previous inspection a recommendation had been made that a photograph of each resident be placed on a new medication front sheet on the MAR sheet records so as to help Russell Hill staff ensure they are administering medication to the correct resident. On inspection this time it was seen that not all the records had a photograph as described. This is necessary as it should assist in the protection of residents by ensuring that staff give medication to the right person every time it is administered. This is a requirement. At the last inspection a requirement was made for each resident who uses PRN medication to see if there is staff guidance relating to the PR medication. The Manager showed the Inspector at this inspection that this has since been implemented and is in place for each resident, held in the medication files and readily accessible for staff and residents alike when needed. The guidance sets out clear information for each person using PRN medication covering possible side effects, when to give the medication and when not to give it. This should help protect the residents, ensure that PRN medication is given appropriately and when required. The Inspector undertook a stock take of medications held in the home, together with the Manager. Records kept were inspected and stock levels of medications held did not match the records. 2 residents’ medications were checked and excess stocks were being held. Stock that should have been returned to the Chemists in March 2008 had not been returned and there was no explanation as to why this was or as how an excess of medication tablets had arisen. There may be a link with the gaps seen in the MAR sheets although this could not be confirmed. The Manager said that usually all excess stock of medication is returned monthly. Appropriate medication cabinets were seen in the office. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 21 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): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views can be fully confident that their complaints will be acted upon at Russell Hill. Residents are protected from abuse, neglect and self-harm by the policies and procedures of the home. EVIDENCE: Standard 22 – The Manager showed the Inspector the complaints record book as a part of the inspection process. The Manager said that no complaints had been made by residents since the last inspection on 20.9.07. At the last inspection a requirement was made that any complaint be followed up by the Manager and staff at Russell Hill Lodge and that the policy and procedures are strictly followed in terms of process and timescales. A copy of the complaints process should be posted on the home’s notice board and in each resident’s service user guide. The Manager told the Inspector that this has since been carried out as required and showed the Inspector evidence of the complaints process being on the notice board. Standard 23 – The Manager advised the Inspector that there is in place a policy for the Protection of Vulnerable Adults and that staff have been provided with training and guidance about what actions they need to take if the need arises. The Inspector saw the policy in the Unit’s policies and procedures file, the procedures are robust for responding to suspicion or evidence of abuse or neglect and they include a whistle blowing procedure for staff. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 22 The Inspector inspected 3 staff files and looked at the training records. 2 of the 3 staff had received POVA training from an authorised trainer in June 2006 and the third member of staff was newly appointed and so had not yet received this training although the Manager assured the Inspector that this training will be provided to all new staff. This is important as it helps to ensure that all staff are up to date with the policies and procedures and other issues to do with the protection of vulnerable adults at Russell Hill Lodge. An inventory for each resident is now being kept on the residents’ files of their valuable belongings. The Inspector saw evidence of this Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 23 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): Standards 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a comfortable and safe environment. The home is clean and hygienic. EVIDENCE: Standard 24 – Russell Hill Lodge provides accommodation both in the main house and also in 2 additional flats attached to the main house. One of the Managers told the Inspector that both flats were now in use at the time of this inspection. The accommodation in the house provides a large lounge and dining room, a number of single bedrooms, a kitchen with good catering facilities, and several bathrooms and toilets on both floors. As a part of this inspection the Inspector made a tour of the home together with one of the managers and Peter, the maintenance repairs man. These were the findings on the day of the inspection: Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 24 The floor covering in the communal areas laid in April 2006 has still not been finished in that it remains unsealed at its edges and where it joins with other rooms the floor levels are different providing trip hazards that provide a real danger to unwary residents. The lack of a sealed edge around the landing floors must make it extremely difficult to clean and could also provide a health hazard. This has been a recurring problem. Some of the floor is now lifting in addition to the above problems as a result of water ingress. In summary this floor covering should be completely removed and replaced with a new appropriate covering that can be cleaned properly, that is safe and serviceable. Six of the residents’ bedrooms were inspected and those bedrooms that had been previously identified as being in a poor state have since been refurbished to a higher standard. The tour of the premises identified a need for the renewal and refurbishment of the front garden. This is a requirement. The existing state of the driveway is poor and has been badly damaged by rain. The flowerbeds are overgrown and a line of dead tree stumps look very unsightly. There is an inappropriately institutional and huge sign marking the house number that should be removed as soon as possible to assist in normalising and integrating the house within the local community. The overall effect of all this does nothing to lift the spirits and is depressing. Given the purpose of the unit this cannot be helpful for achieving the stated aim and purpose of this home with the residents. The Inspector asked the managers if there may be a possibility of starting a gardening project with residents as appropriate that could help to achieve this need as well as helping residents gain some helpful skills and knowledge. Standard 30 – Within the home’s policies and procedures manual information is provided relevant to the control of infection. The home also has an infection control procedure which staff who were interviewed said they were aware of. Some training is provided by the agency and staff told the Inspector that they had received training in this area of work. Systems are in place to ensure that the spread of infection is controlled and minimised. Laundry facilities are sited so that soiled articles are not being carried through the kitchen and hand washing facilities are appropriately provided to ensure staff can use them where appropriate. This helps to ensure the protection of the residents’ health and to ensure that the home is clean and hygienic. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 25 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): Standards 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent staff and by the home’s recruitment policy and procedures. Service users needs are benefiting from well-supervised staff. EVIDENCE: Standard 32 – The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. At a previous inspection the Manager could not confirm that all staff had been asked to sign to say that they had read, had a chance to discuss the policies and procedures with their supervisor in their supervision sessions and would be willing to work within them. This has since been done as was recommended at the last inspection. Evidence was seen by the Inspector on the 3 staff files inspected. The Manager told the Inspector that there is a new training programme underway that has been drawn up using training needs identified in staff supervision sessions and from information identified by the quality assurance audit recently carried out. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 26 The Manager told the Inspector that most staff have now completed or are completing their NVQ training at level 2 or above but evidence will need to be seen of NVQ certificates (for those staff still receiving training) on the staff training files, that confirms that all staff have obtained their NVQ qualifications. Staff were able to confirm with the Inspector that they had received their NVQ training and they said that they had found it useful in assisting them with their jobs. The Manager told the Inspector that the new staff recently appointed will be enrolled to do their NVQ level 2 this year. Residents interviewed told the Inspector that staff are approachable and the Inspector saw staff taking time to deal with resident’s questions. Standard 34 - There is in place an appropriate recruitment policy. 4 of the staff files were inspected. Generally the files were in much better order than at the last inspection and most of the information required under the Standard 34 was in evidence. Staff interviewed did confirm that have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home, however a copy should be available for reference in the unit. The Manager is reminded that all the staff at Russell Hill Lodge must have appropriate and valid criminal record bureau checks for their work at Russell Hill and not elsewhere and that these checks should be renewed every 3 years. The Inspector saw evidence that 3 of the 4 staff files inspected had valid CRB certificates and another had one that needed renewing as it was provided in 2003. Standard 35 - The Manager informed the Inspector that a structured induction programme is offered to all new staff. At this inspection 2 new staff confirmed they had attended the induction training and evidence of this training having been provided was seen by the Inspector on the staff member’s files. The Manager informed the Inspector that there is an overall training and development plan and budget for the 3 units that make up the Laurel Group of Homes. Disaggregating the information specifically for Russell Hill was not possible. There is a person responsible for the training and development of staff. At the last inspection it was suggested that the Manager draw up training files for each member of staff that identifies what training that individual has achieved and when; what their training needs are that need to be met and evidence of the training courses attended. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 27 The Manager explained to the Inspector that he has drawn up a newly developed training file that contains some information about what training staff have completed and that certificated evidence of training is now being held in individual staff members files. The Manager also showed the Inspector a training matrix that contains all the information about his staff group identifying what training they have received and when. The Inspector recommends that this is part of the training file and that the future staff training needs are included so as to give a complete picture “at a glance”. This should prove to be a useful management tool as the Manager will then know what new training needs are to be planned and when as well as knowing what training staff have received. Standard 36 – 4 staff files were inspected in relation to staff supervision and good records were seen to show that this takes place on a regular basis. 3 staff interviewed said that their supervision happens every 4 - 6 weeks. Staff are asked to sign their supervision records as was evidenced by the inspection of these records and staff confirmed that they find this support very helpful and that they are given a copy of the minutes for their information. Staff spoken to said that the following issues are discussed at their supervision sessions as a standard format: • Keywork with residents • Training needs • Personal issues. They told the Inspector that they felt well supported in the home and felt that the management team were helpful when they had concerns or problems arising in their work. Residents should therefore benefit from wellsupported and supervised staff. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 28 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): Standards 37 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users may be assured that they will benefit from a well run home. They should also be assured that their health, safety and welfare will be promoted. EVIDENCE: Standard 37 – At this inspection the Manager told the Inspector that he is now due to complete the NVQ training for the Registered Manager’s Award [at Level 4], he is previously a qualified Registered Nurse and he maintains his professional registration. However at the last inspection the Manager told the Inspector that was expecting to complete it by October 2007. This timescale has been exceeded Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 29 and it is a requirement that he does complete the training within the next 3 months. It is also a requirement that the Manager submits his application to become the registered manager at Russell Hill Lodge within this timescale. Enforcement action may be taken if this timescale is not met. The Inspector was shown by the Manager his job description that covers all the requirements set out under the Standard 37.3. Standard 39 – This standard was not inspected at this inspection. Standard 42 – The Inspector was shown information to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. Up to date and satisfactory pass certificates were seen by the Inspector for: Boiler & Gas – 3rd September 2007 Fire alarms – 29th February 2008 Fire equipment – 29th February 2008 The electrical installation test – 28th January 2005 A legionnaires / water test – July 2004 – needs to be carried out this year. Records were seen by the Inspector that confirmed regular tests had been carried out for the: Fire alarm - weekly Fire drill – last 14th December 2007 for day staff and 24th January 2008 for the night staff and residents. Fire extinguishers - weekly Emergency lighting – 6 monthly – last 29th February 2008 Fridge and freezer temperatures records were checked and records indicate that they came within the acceptable ranges. Accident records were checked – none had been noted. Hot water temperatures were also checked and records indicated that they also came within the acceptable range – a previous requirement has now been met. The Manager told the Inspector that all COSSH legislation has been reviewed and new practices established. This was borne out in the inspection process so residents should now be better protected. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 30 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X X X X 3 X Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 Requirement That the reviews of care plans and diary sheets monitor the success or otherwise of the care plan objectives and that they are revised in the light of the review findings. This is a repeat requirement. All the information required under Schedule 3 of the regulations must be held on resident’s files. It is expected that there should be a comprehensive and daily programme for each resident carried out, that is focussed on achieving their agreed care plan objectives. The Manager must ensure that MAR sheet records are always accurately completed in order to protect both the residents and the staff. A photograph of each resident must be placed on a new medication front sheet on their MAR sheet records so as to help Russell Hill staff ensure they are administering medication to the correct resident. The Manager must ensure that DS0000025833.V361432.R01.S.doc Timescale for action 01/06/08 2. YA6 14 01/06/08 3. YA12 15 01/06/08 4. YA20 13 01/05/08 6. YA20 13 01/05/08 7. YA20 13 01/05/08 Page 32 Russell Hill Lodge Version 5.2 8. YA24 20 stock levels of medications held on site match the levels that are recorded in the MAR sheets. All excess stock of medications must be returned to the Chemists. That the Manager ensures that 01/08/08 the areas of the home identified in this report that require repair and maintenance are addressed within the timescale set out here: • Renewal and refurbishment of the front garden. • The floor in the communal areas needs replacement. That the Manager completes the Registered Managers Award training within the next 3 months. That the Manager submits his application to become the registered manager at Russell Hill Lodge within the new timescale. Enforcement action may be taken if this timescale is not met 01/08/08 9. YA37 9 10. YA37 9 01/08/08 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 YA17 YA17 Good Practice Recommendations Improvements are recommended in the quality of the food provisions. Replacement of some kitchen pots and pans. Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Russell Hill Lodge DS0000025833.V361432.R01.S.doc Version 5.2 Page 34 - 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. 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