Inspection on 18/09/07 for Sarum House

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 30 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sarum House 24/02/09

Sarum House 31/01/08

Sarum House 06/03/07

Sarum House 07/02/06

Sarum House 22/06/05

Sarum House 13/12/04

Sarum House 19/05/04

Sarum House 16/01/03

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Sarum House Beehive Corner Old Sarum Salisbury Wiltshire SP4 6BL Lead Inspector Alyson Fairweather Key Unannounced Inspection 18th and 19 September 2007 10:00 th DS0000032418.V341667.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 DS0000032418.V341667.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. DS0000032418.V341667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sarum House Address Beehive Corner Old Sarum Salisbury Wiltshire SP4 6BL 01722 335283 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) Wiltshire County Council Vacant Care Home 15 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (2), Physical disability (2) of places DS0000032418.V341667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: Sarum House provides personal care and accommodation for 15 people with a learning disability. The home is operated by Wiltshire County Council, and is on the outskirts of Salisbury. A nearby park and ride scheme offers regular bus journeys into the city, and Sarum House also has its own transport. The home is an older property, although good efforts have been made to maintain and enhance it. There are two floors for resident accommodation, and all residents have single bedrooms. Some of the residents on the top floor who have relatively small bedrooms also have their own sitting rooms. The home has no lift, making the upper floor unsuitable for anyone with a physical disability. Baths, showers and toilets for general use are on both floors. Communal areas include a ground floor games room. DS0000032418.V341667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in September. Several residents and staff members were spoken to, as well as the team leader and two senior managers of Wiltshire County Council. Eight residents and five relatives, four staff members and one GP responded in writing to our questionnaire. Various documents and files were examined, including care plans, risk assessments, health and safety procedures, staff files and medication records. The house is currently made up of two floors. The downstairs part of the home houses some older, frailer residents and some people who have lived there for a long time. The upstairs part of the house is used by the residents who have moved from Wiltshire County Council’s training and assessment unit, which has closed down, as well as some of Sarum House’s more able residents. All residents pay a top up fee in addition to the fee paid by the funding authority. In September 2007 this was: over 60 yrs - £98.60, 25-60 yrs £63.95 and under 25 yrs - £51.65 Since the date of the last inspection, the home has been visited by the Commission for Social Care Inspection (CSCI) pharmacy inspector, at their own request. The registered manager has recently been transferred to another area of Wiltshire County Council, and an interim manager had taken over two weeks before the inspection. At the last inspection, it was felt that the service was sufficiently underperforming enough to ask them for an improvement plan. This was so that they could show us how they planned to make things better. The manager showed us various improvements he planned to make which would mean that residents would have a better quality of life. Unfortunately, it was found at this inspection that he had failed to implement some of these improvements. There were a number of areas of concern noted, and it was felt necessary to return for a second day. As a result of these visits, an Immediate Requirements Letter was sent to Wiltshire County Council, outlining the most serious failings, and those which posed a threat to service users, and asking them to respond within seven days. At the previous inspection the manager was asked to seek feedback from the residents about the quality of the service provided, using an independent advocate where necessary. Four of the eight surveys returned to us were said to have been completed by an “independent advocate”. When questioned, staff and the acting manager said that this person had actually been the daughter of the registered manager. This person is not employed by, and does not act as a volunteer for, Sarum House. There is no evidence of her having any of the DS0000032418.V341667.R01.S.doc Version 5.2 Page 6 checks which Wiltshire County Council would make before employing staff to work with residents. When questioned about this, the acting manager said that the usual procedure would be to involve an independent, professional service, eg Swan Advocacy, all of whose workers are CRB checked. However, staff reported that this person may not have actually visited the home to speak to residents, but simply filled in the questionnaires at home and sent them in. The level of accuracy of the responses is therefore in doubt. There is also a suspicion that the manager has intentionally misled the CSCI by using a family member as an “independent advocate”. This deception is extremely concerning and CSCI will be contacting the providers, Wiltshire County Council in relation to this serious matter. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? All new staff now have evidence of induction training on file, using the new Learning Disabilities Quality framework. (LDQ). These showed that new staff are receiving training which will help them support the residents in they way they need. The Statement of Purpose has been amended and now contains accurate, upto-date information about the service. This information, which is given to DS0000032418.V341667.R01.S.doc Version 5.2 Page 7 prospective residents and their families has improved and this will help people to choose if they want to live in Sarum House with a fuller knowledge of its facilities and services. A fire risk assessment has been put in place for the building. This means that staff are aware of any hazards which might make the premises dangerous for residents and staff to be in. They can then take steps to make it safe. 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. The summary of this inspection report can be made available in other formats on request. DS0000032418.V341667.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 DS0000032418.V341667.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): 1 and 2 Prospective residents do not have enough information to make a choice about whether they would like to stay in the home. Their needs, hopes and goals are not assessed and recorded before they move in to the home. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose has been updated since the last inspection, as requested. The Service User Guide had been updated as part of the improvement plan which the manager had to undertake following the last inspection. However, although a copy of this had been given to the CSCI, there was no evidence that this had been given to residents, and a copy of the old one was still on their files. The newest resident had not been given a copy at all. The acting manager and staff thought that it may have been stored on the computer. The registered provider has therefore been asked to make sure that all residents are given a written copy of the updated Service User Guide so that they have the most recent information about the services on offer. This is the second time this has been asked of the home. DS0000032418.V341667.R01.S.doc Version 5.2 Page 10 At the last inspection, there had been several new residents who had come to stay at Sarum House. They transferred from one of Wiltshire County Council’s independent living schemes which had closed down. When they moved in, no formal assessments had been done by the home to ensure that they would be able to meet the needs of the new residents, and the manager was asked to ensure that all potential residents had an assessment done before they move into the home in order to ensure that their needs can be met. Since then, another resident has been admitted from one of Wiltshire County Council’s services, a respite care unit. This resident had no assessment information on file in Sarum House, although the acting manager later found a community care assessment dated 2005, as well as a nursing needs assessment. She also said that a review had recently taken place. Although transferred from a nearby respite care unit, there was no recorded evidence of how staff at Sarum House planned to meet this resident’s specific health needs, and no details of how the move to a unit, where some of the residents are very frail, was to be managed. The registered provider has been asked to ensure that all potential residents have an assessment done before they move into the home in order to ensure that their needs can be met. This is the second time this has been asked of the home. DS0000032418.V341667.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): Residents’ support plans do not reflect their changing needs and personal goals. People are encouraged to make choices and decisions about their own lives as much as possible. Infrequently reviewed or no risk assessments means that residents are potentially at risk. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The format of resident’s support plans is still in the process of being changed. Some residents upstairs were being encouraged to complete their own support plans. Files which were completed by staff from the training and assessment unit contained good information and showed evidence of being reviewed on a regular basis. This was not the case for the residents downstairs. Residents upstairs have a daily diary which contains notes and entries about how their day has gone. This is not in use downstairs, and a system of loose diary sheets is used. It is recommended that all staff should the same system of recording daily events in residents’ lives. DS0000032418.V341667.R01.S.doc Version 5.2 Page 12 One resident had recently moved downstairs as a result of an incident involving another resident. The incident was recorded, but there was only one diary sheet entry, dated June 2007, on file. There had been no review of the care plan since the move downstairs. Another resident had a care plan relating to her mental health needs dated June 2007. The records said that it should be evaluated two weeks later, or sooner if necessary. There was no evidence of any review of the care plan, although the acting manager reported that the person’s mental health had deteriorated. We wrote immediately to the providers telling them that both of these people must have their care plans urgently reviewed. One resident was noted to have poor weight gain due to a nutritional problem, and a weight chart had been started in May 2007. This had not been completed regularly, and there were no records of any reason for this to stop. Another resident had a weight chart on file, but had been weighed only May and June. Again no reason was given for this being discontinued. Similarly, activity sheets and medication profiles were out of date or incomplete. The registered provider has been asked to make sure that all weight charts, activity sheets and medication profiles are kept up to date or removed from support plans if not necessary. The registered provider has also been asked to ensure that all residents’ support plans are reviewed on a regular basis and contain accurate, up-to-date information. This is the second time this has been asked of the home. Residents are supported to make decisions about their own lives with guidance from the staff. Some are able to manage their own finances, and some have family involvement. Some residents choose to go to day services, although local cut-backs have affected how often this takes place. Of the eight surveys returned to us by residents, four had been completed by an “independent advocate” and one was anonymous. All eight people were said to be able to choose what they wanted to do during the day. One resident has a somewhat restricted living arrangement as he was moved downstairs from the training and assessment unit as a result of an incident involving another resident. Residents’ risk assessments are now kept alongside their support plans, and these included such things as self medicating, travelling, cooking and gardening. Some of these were extremely detailed, but several were written on different formats. It is recommended that the same style of risk assessment is used as it would be easier for staff to be consistent in how they record risks and how to manage them. Several entries in the daily records had been made referring to one resident’s disturbed mental health. These indicated paranoia; repeatedly saying that no one wanted her to be there. The lady had, on several occasions, expressed a wish to die. It was extremely concerning to note that there was no risk DS0000032418.V341667.R01.S.doc Version 5.2 Page 13 assessment on file relating to the danger of self-harm or suicide. We wrote immediately to the providers telling them that a risk assessment must be put in place relating to any risk of self harm or harm to others for this resident. There was a risk assessment on file relating to inappropriate behaviour which had been done by staff in the training and assessment unit, and was dated 18th June 2007. This was due to be reviewed on 13th July 2007. The resident had been moved downstairs, but a risk assessment review had not been done by staff downstairs. This means that there was no risk assessment which related to any danger to some very frail and vulnerable residents downstairs. We wrote immediately to the providers telling them that a risk assessment must be put in place relating to the move by one resident from upstairs to live with some more frail residents downstairs. DS0000032418.V341667.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): 12, 13, 15, 16 and 17 Social and leisure activities are varied, although some people reported that if staffing levels were improved they would be able to do more. People have as much or as little contact with family and friends as they wish, and are encouraged and supported by staff. Residents’ rights are respected and responsibilities recognised in their daily lives. They are offered a healthy diet, and those who self-cater are encouraged to use healthy options. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are encouraged to develop and maintain their independence as much as possible and those who are able to can come and go as they wish. Some people have supported work and one resident works in the local Mencap shop. One resident goes to the Shaw Trust, and likes music and watching TV, and military bands. Another is a member of Salisbury Independent Self Advocacy DS0000032418.V341667.R01.S.doc Version 5.2 Page 15 Group. However, one support plan was seen to have on record that one particular resident had no weekend activities. Some residents use the local park and ride bus independently. Another resident has her own bicycle which she uses as transport. One resident is encouraged to keep a diary of her activities herself as she gets busy, and has learnt to text staff when she is out and about. One family who wrote to us said they were not aware of their relative’s programme of activities. “In previous years we have always been asked to attend a planning meeting but contact has been limited. A new key worker has recently taken over, and he is very good”. Staff said that until recently, when the acting manager started work, they were not able to support residents with activities. There had been only one staff member on duty on each floor of the house, which made it impossible for them to accompany residents out to any of their hobbies or interests. One staff member, when asked how the home could improve, said: “We should have adequate staffing levels to provide better day services. Most of the residents used to attend day care five days per week. This has been drastically reduced. Staffing levels have not increased to cater for the day service requirement. There has been a recruitment freeze on; this has now been lifted and may alleviate the situation”. Another said: “The location is too far out of town, meaning the people using the training and assessment service are spending £3.40 per day on the buses to get to and from their day service/work”. The survey completed by the “independent advocate” on behalf of one particular resident was inaccurate. The resident was said to be able to do what she wanted during the day, at night and at the weekend. This person has been very poorly lately, spending a lot of time in bed. She has shown deterioration in her mental health needs, and when she does walk, needs support from staff. It is noteworthy that all four of the surveys completed by the “independent advocate” and one anonymous one, said that residents were able to choose what to do in the evenings. This would seem in direct contrast to what the staff team have reported. Friendships both inside and outside the home are encouraged, and staff support links between residents and their family and friends, although the frequency of contact varies depending on the individual circumstances. Residents are free to visit friends outside the house at any time, and can entertain and choose to see who they like either in their own bedrooms or in the communal areas available. One family member who wrote to us said: “They are supportive in helping to contact by telephone and positive towards home visits to the family, encouraging the use of local transport where required”. However, another family said: “Quite often when we visit we are DS0000032418.V341667.R01.S.doc Version 5.2 Page 16 plagued by other clients and there doesn’t seem to be any effort made to give us privacy”. Staff encourage and support residents to develop the skills which will be needed by those who wish to move into less supported accommodation, and the people who live upstairs are somewhat more independent. They do their own cooking and cleaning and maintain their own rooms. Support is given to those people who are less able to do domestic chores such as shopping, cooking and laundry. The food provided in the home is of a good quality, with a good supply of fruit and vegetables available. Healthy eating options are encouraged, and records are kept of likes and dislikes. The upstairs and downstairs parts of the home have separate arrangements for cooking. Downstairs the food is prepared by staff for residents and a full menu is kept of what is on offer each day. Residents contribute to menu planning by telling staff what they would like to eat. The upstairs part of the house is where the people who moved from the training and assessment unit live. They make their own arrangements regarding food preparation, and each make a financial contribution to a food budget. The residents take it in turn to cook for each other. The menus showed that the main meal is usually in the evening, except at weekends. DS0000032418.V341667.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents do not always receive personal support in they way they prefer or require. Their physical and emotional health needs are not always met. Poor practice in medication recording, and staff lack of knowledge of their own procedures, means that residents are potentially at risk. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents have support plans for any personal care required. The information contained in them is gathered from the home’s own assessment and staff knowledge of the residents. People have guidelines in place which say how they like to be helped to get washed and dressed. There is a good gender mix of both male and female keyworkers. One staff member who wrote to us said: “Given the staffing levels, all elements of personal and social care are of a high standard”. One family who wrote to us said: “His personal care I have to say is poor. He suffers from something similar to cradle cap and we are always having to mention he needs help washing his hair. He also never has a hair cut unless we DS0000032418.V341667.R01.S.doc Version 5.2 Page 18 take him”. When questioned, staff reported that the resident is prescribed special shampoo, to be applied alternately with normal shampoo. Some records of this were kept, but these were not completed regularly, making it difficult to know how often it was being applied. The matter was discussed with care staff who agreed that he should have his hair washed on a daily basis and have records kept of the days when the special shampoo is used. The registered provider has been asked to make sure that detailed records are kept of when prescribed shampoos are used by residents. One resident has a change of a continence aid every 5-7 days, and the date of the next change is recorded whenever one has been completed. This is written on a large board in the medication room. However, the notice board said that this was due to be changed on 20th October, although this was only 18th September. Senior staff thought that this was a mistake, but didn’t know why this had been recorded like this. The registered provider has been asked to make sure that the date for changing any continence aid is clearly and accurately recorded. All residents are registered with a GP whilst living in the home, and all other medical professionals are seen as and when required. This varies according to the needs of individuals. There were records which showed people had visited a number of services, including the optician, dentist and orthodontist. The GP who wrote to us said that his patients are seen in private. However, one file examined showed a letter on file, dated June 2007, from a sexuality and relationships worker offering a resident two assessment periods in the next three months. There was no follow-up letter or any indication that care staff have pursued this option on behalf of the resident. We wrote immediately to the providers telling them that the planned assessment regarding sexuality and relationships for one particular resident must be urgently followed up. Another file examined showed that one resident was experiencing severe mental health problems. There were several entries indicating paranoia, repeatedly saying that no one wanted her to be there and several references to wanting to die. A behaviour assessment chart recommended by the mental health team had not been completed. Although this person has a “dual diagnosis” of learning disability, staff said that they believe that her mental health needs are greater than her learning disability. We wrote immediately to the providers telling them that the mental health needs of the identified resident must be urgently reviewed, with consideration given to the registration category of the home. The home has a policy in place for all medication, and all staff have medication training when they first start work. Medication is kept in a locked trolley in a locked room on the ground floor. All residents have a medication profile DS0000032418.V341667.R01.S.doc Version 5.2 Page 19 outlining what drugs they take, and these have information sheets from medication packs alongside. Medication risk assessments are now in place. We discussed various medication errors which had been reported to the Commission for Social Care Inspection with care staff and the acting manager. Since the acting manager has arrived, there are now two staff members administering medication, as per Wiltshire County Council policy. This had not been happening before. A new induction training pack for staff has been introduced regarding how to store, record and administer medication. This is a helpful addition to more formal training, but unfortunately did not contain reference to two staff doing medication administration together, as per the above Wiltshire County Council policy. The registered provider has been asked to ensure that any training pack developed for staff makes accurate reference to their policies. When we checked the medication in the cupboard, the stock did not tally with the Medication Administration Record (MAR) and what should have been in cupboard. The MAR had been signed daily. We discussed this with the team leader, who admitted that she had recorded that 20 tablets would be carried forward from one month to the next, but she did so two days in advance. Two tablets were then given out to the resident, making the total number of tablets wrong from the start. No stock check had been done to identify this. This was done because the team leader was not going to be on shift on the Monday morning so thought she would do it on Saturday. When asked why she had done this, she said that she thought there would only be relief staff on duty. When asked if they had medication training, the acting manager said that they did, and that the expectation is that anyone who has had medication training should be able to be in charge of recording and administering medication. The registered provider has been asked to ensure that a regular stock check is made of medication, which is administered on a daily basis. It is recommended that a matrix should be introduced to remind staff of when regular medication checks need done. The support plan for one resident had said that he was allergic to penicillin. There was no record of this on any of the medication documentation, although this had been done for another resident. Staff on duty said they were not aware of his allergy. The registered provider has been asked to make sure that medication records clearly highlight any allergies so that staff can be aware of any potential danger and pass this on to other health professionals if necessary. One resident has a supply of medication for occasional use (PRN) although the records show this has not been used since 2003. When asked, staff reported that she had recently had a medication review and this was still on the repeat prescription. On checking, staff also found that salbutamol was still being prescribed, although the resident has not had this for some time, and it is not DS0000032418.V341667.R01.S.doc Version 5.2 Page 20 recorded on the MAR. The team leader was concerned that the GP had not amended this, but the acting manager reminded her that it was the home’s responsibility to ensure that the medication held by them is an accurate reflection of the medication needed. The registered provider has been asked to make sure that a medication review is held for the use of PRN medication for residents who have not recently needed it. This is the second time this has been asked of the home. Staff have introduced a system where they count the medication, which is prescribed for occasional use. They do this on a weekly basis. They also now record why the drug is given, as well as the date, the dose and the time when the medication is given. Unfortunately, the individual “PRN” profile does not have an allocated space for the date, making it difficult to know when this was drawn up. It is recommended that the date should be recorded when a new “PRN” medication sheet is written for a resident. DS0000032418.V341667.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): 22 and 23 There was little evidence that residents or families feel their views are listened to and acted on. The particular instance relating to one resident means that others are at risk from potential abuse, and that person’s needs are being neglected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection, all residents said they knew how to make a complaint. These people had been helped to complete the survey by the manager and staff, and it was recommended that the help of an independent advocate should be sought when asking for residents’ views of the quality of the home. This time, all eight people said they knew who to speak to if they weren’t happy and six said they knew how to complain. Four of these were said to be helped by “an independent advocate” and one was anonymous. The level of accuracy of the responses is in doubt because of the way they were gathered and recorded. (See Summary and Standard 39 below). The home’s complaints policy has been updated and a copy of the new one was seen to be on residents’ files. Of the five families who wrote to us, four said they were aware of the home’s complaints procedure, and one said they were not. One family said they had made a complaint to the previous manager about a staff member. They said he was really rude to them and simply said he would “have a quiet word”. The family were not convinced that this would happen. On examination of the complaints file held in the home, there was no DS0000032418.V341667.R01.S.doc Version 5.2 Page 22 evidence of any complaint being made, either by this family or by anyone else. The registered provider has been asked to make sure that a log is kept of any complaint made to the home, and kept ready for inspection. This is the second time this has been asked of the home. The home has a copy of the organisational policy and procedure on responding to allegations of abuse, and staff said that they would be comfortable reporting any incidences of poor practice if they saw them. There was evidence that staff have had training in Protection of Vulnerable Adults, and all four staff who wrote to us said they were aware of the procedures, which should be followed. A recent incident in the home had led to an appropriate referral to the local vulnerable adults’ team. As a result of this meeting, the resident concerned was moved from an upstairs room to a downstairs room. There had been no risk assessment put in place following this move, and the registered provider was written to immediately and asked to do so. It was concerning to note that the community care assessment done following this meeting showed that the conclusion of the meeting had been that the resident needs to move from Sarum House into another placement. There had been no action taken by the home to follow up this recommendation. This means that the resident is in danger of having his needs ignored and the other residents are potentially at risk. We wrote immediately to the providers telling them that the POVA/APC conclusions relating to one resident and the need for a new placement must be urgently followed up. DS0000032418.V341667.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): 24 and 30 The home is clean and hygienic throughout, and residents live in a homely, comfortable and safe environment. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been many recent changes in the building. There are now eight single bedrooms downstairs, including one large one, and seven more upstairs. Four of these were registered over a year ago, and because of the small size of the bedrooms, each of the four residents was given another adjacent room, which could act as their sitting room. This is still currently called by staff the “Training and Assessment Unit”. The furnishings throughout the house are of good quality and have a homely feel. Residents’ bedrooms were comfortable and each contained individual personal items, such as stereos and TVs. One resident said: “I feel that we are too close to each others’ rooms, and sometimes we are on top of each other”. One relative who wrote to us said: DS0000032418.V341667.R01.S.doc Version 5.2 Page 24 “Whilst Sarum House is in desperate need of repair, the facilities are adequate”. Future plans for Sarum House mean that some people will be moving from residential accommodation to more independent, supported living. When the home closes, some of the residents may still require to be living in registered accommodation. One family said to us that their relative would be “better served living with people more in his age range”. The home was clean and tidy. There was a kitchen and a separate laundry area, which reduced the risk of cross-infection. New infection control guidelines were in place. Of the eight residents who wrote to us, all said that the home was always fresh and clean. DS0000032418.V341667.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): 32, 34, 35 and 36 It was impossible to verify that residents are supported by competent and qualified staff. Not all relevant information was available to verify that residents are protected by Wiltshire County Council’s recruitment policies and practice. Residents do not have their needs met by appropriately trained staff, and they do not benefit from well supported and supervised staff. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many of the staff working in Sarum House have had a number of years experience of working with people with learning disabilities, although some have recently been employed. They have knowledge of the specific conditions of residents and seek advice from the appropriate professionals when they need more support. The recognised qualification for care staff is the NVQ, and they can study for NVQ Level 2 or 3. It was not possible to discover how many staff had achieved an NVQ or how many were currently studying for one, because there was no record of who had done so in place. The acting manager was sure that there were several people, although only one staff file showed this to be the case. The registered DS0000032418.V341667.R01.S.doc Version 5.2 Page 26 provider must keep an up-to-date record of the number of staff with NVQ and the number of staff still studying for NVQ. This is the second time this has been asked of the home. Of the eight residents who responded to our questionnaire, seven people said that staff “always” treated them well, and one said “sometimes”. Because of the fact that the “independent advocate” who completed the surveys was a relative of the manager, it is difficult to know if this is how people really feel. There are two members of staff in the house at any given time, with two sleep in staff, one upstairs and one downstairs. Relatives who responded to our questionnaire were happy with the care which staff provided. One person who wrote to us said: “In my opinion they do a fantastic job and all appear to have the skills required”, and another said: “She seems happy and reasonably well dressed when I go to see her”. One other family member named an individual staff member and said he was “very good. He is thorough in doing what he says he will do. He also makes an effort to stimulate my relative”. Staff reported that there were times when the home had been short staffed, and relief staff were often used. Comments from staff included: “A bank of relief workers is being built up instead of employing full time staff. This is a cheaper option if the work is there, which it definitely is. Surely permanent, full time staff should be employed”? There were comments from various staff members about not being able to go out with residents, and about how staffing levels have not increased to cater for the residents who do not have the same day care arrangements as they used to have. Many of the people living at Sarum House have high needs, and it is recommended that staffing levels should be reviewed in light of current residents’ level of need. Sarum House is supported in its recruitment by Wiltshire County Council’s human resources department. Employment checks include Criminal Records Bureau (CRB) and checks against the Protection of Vulnerable Adults (POVA) register, two written references and a medical declaration. All potential staff complete an application form, and this should be kept on the individual staff member’s file. On examination of four staff files, it was noted that three people had no references on file. The registered provider has been asked to make sure that all staff files contain two written references. This is the second time this has been asked of the home. Two files had no photographic identification and two had no contract of employment. One file had no evidence from Wiltshire County Council of medical fitness, although the acting manager had asked the person to sign a fitness statement. One person had no GP details, and had not completed the section on the form asking about immunisation for Hepatitis B. Another person had answered that they had “never” had vaccination in reply to the question about the Hepatitis B vaccination. The form said “Will see her GP”, although it DS0000032418.V341667.R01.S.doc Version 5.2 Page 27 was not stipulated who would check this. The registered person has been asked to ensure that these issues are dealt with. All four staff members had a letter on file from Wiltshire County Council stating that they have had a CRB check. Unfortunately, there was no reference on this letter to say that the check was done at an enhanced level and that a POVA check had also been done. Following the last inspection, when some files were missing evidence of CRB checks, advice and information was given to the registered manager and to two service managers who work/worked for Wiltshire County Council, (WCC) about the content which CSCI have agreed will be sufficient evidence of CRB checks. The guidance was reproduced in the last report, and is once again laid out for information. “Guidance issued by CSCI says that the minimum expectation with regard to evidence of CRB checks is that on receipt of the Disclosure, the umbrella organisation or corporate body should issue a letter to providers stating the name of the person; date of Disclosure; Level of disclosure; Including POVA Check (if requested); Disclosure reference number; date POVAFirst check was received (if this was sought); and POVAFirst Reference number. Inspectors will accept the letter as evidence of the providers meeting the requirement for staff to be CRB checked. Letters (rather than Disclosures) should be kept on file in the home. This will assist CSCI inspectors when they sample Disclosures to confirm that employers have followed robust recruitment practices”. The registered person has been asked to ensure that all staff files have evidence of an enhaced level CRB and POVA check. This is the second time this has been asked of the home. Staff files now contain evidence of training, and this included manual handling, fire training, stoma care, medication handling, infection control, food hygiene and protection of vulnerable adults. New staff have induction training using the new Learning Disability Quality (LDQ) framework. However, several staff had no evidence of any manual handling training and the registered provider has been asked to ensure that all staff receive training in manual handling. There was no evidence of any training in writing risk assessments, and the registered provider has been asked to ensure that all staff responsible for writing risk assessments have training in how to do so. One resident is currently experiencing a period of mental ill health and has refused to see her psychiatrist. A behaviour assessment chart was given to care staff by the mental health team, and this had not been added to. There was no evidence that staff have had training in the particular aspects of the resident’s mental disorder. This was confirmed by the acting manager and other staff. At the last inspection, another resident’s mental health was causing concern, and the manager was asked to provide training in mental health issues. The previous resident has now moved out, but the other resident’s needs have escalated. We wrote immediately to the providers telling them of our concerns for this resident, and telling them that all staff DS0000032418.V341667.R01.S.doc Version 5.2 Page 28 must have training in mental disorder specific to the needs of the resident in question, in order to support her fully. Four staff members said that they received formal one-to-one supervision with their supervisor. Most thought that this was planned and recorded, although one person said they did not know if this was the case. All four confirmed that staff meetings are held, and felt that they have enough support to do their job well. Some staff supervision records were available, and were seen to be up to date, although the quality of the records varied. However, one team leader who should have been supervised by the registered manager had no supervision records on file at all. The registered person has been asked to ensure that all staff receive formal, recorded supervision at least six times in every year. This is the second time this has been asked of the home. One staff member was receiving appraisal from a Wiltshire County Council service manager during the inspection. She couldn’t find any of the paperwork he had asked her to provide, and it was then found that she had no appraisal done since 2003. It is recommended that all staff have an appraisal of their work done every year. There was no evidence of any training given to senior staff in how to support staff during supervision. The expectation in Sarum House is that the team leaders will supervise the care staff and the manager will supervise the team leaders. Neither of the two team leaders whose files were examined showed evidence of any training in supervision skills. The registered person has been asked to ensure that all staff responsible for supervising staff have training in supervision skills. DS0000032418.V341667.R01.S.doc Version 5.2 Page 29 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents do not benefit from a well run home. They cannot be confident that their views underpin the monitoring and review of care practice. Their health, safety and welfare is not always promoted or protected. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager, Mr Len Clarke, had left his post for another one with Wiltshire County Council by the time of the inspection. The acting manager, on an interim, temporary basis, is Ms Lynda Heath, who was previously registered as manager of a respite care home in another part of Wiltshire. Recruitment for the permanent position was said to be ongoing. The service management arrangements have also changed, in that the manager’s direct line manager has been re-deployed with Wiltshire County Council, and replaced by another DS0000032418.V341667.R01.S.doc Version 5.2 Page 30 person. There are now two new service managers covering all the residential care and respite care homes in Wiltshire. Both these managers are employed on a short term contract. Ms Heath is to be congratulated on conducting the inspection despite having been in post for only two weeks. The surveys sent to residents and families were sent out whilst the registered manager was still in post. One of the families told us that they felt the manager “should be more approachable. He can be rude and abrupt. The previous manager always made us feel he was working with us, not against us”. Another family had told us that they had made a complaint to the previous manager about a staff member. They said he was really rude to them and simply said he would “have a quiet word”. The family were not convinced that this would happen. On examination of the complaints file held in the home, there was no record of any complaint being made. The GP who wrote to us said that he was satisfied with the overall care provided to service users. He went on to say: “At one time orders given from higher levels of management (those outside the home) were often impractical and hampered staff ability to look after the users. This appears to have diminished recently which has improved the clients’ access to necessary care”. The annual quality assurance assessment which each home has to provide to the CSCI had not arrived, in spite of several reminders sent to Mr Clarke, both by letter and telephone calls. Mr Clarke was insistent that he had sent it by email, although it later transpired that he did not know how to send an attachment. Thanks must go to the acting manager, Ms Lynda Heath for ensuring that it was safely sent. The home now has its own questionnaire which is given to residents to find out their opinions of how the home is run. This is available in picture format. When asked: “Is there anything we can do to make your home better”? one resident replied: “Can we have our own front door key”? This was dated April 2007, but there was no evidence that this, or any other comment, had been responded to. It is recommended that a record is kept of the responses made by the home to their residents’ survey. Part of the responsibility of the senior managers of registered care homes is to visit the home on a monthly basis and to write a report about what they looked at and to whom they spoke. This is to ensure that they are monitoring both the health and safety of the residents as well as the quality of the service offered. The manager was asked to make sure that these visits were conducted on a regular monthly basis and that a copy of the report was sent to the Commission for Social Care Inspection (CSCI). Although some of these reports have been received, they have not been sent monthly. The registered person has therefore been asked to make sure that this is done. DS0000032418.V341667.R01.S.doc Version 5.2 Page 31 At the previous inspection the manager was asked to seek feedback from the residents about the quality of the service provided, using an independent advocate where necessary. Four of the eight surveys returned to us were said to have been completed by an “independent advocate”, and one was anonymous. When questioned, staff and the acting manager said that this person had actually been the daughter of the registered manager. This person is not employed by, and does not act as a volunteer for, Sarum House. There is no evidence of her having any of the checks which Wiltshire County Council would make before employing staff to work with residents. When questioned about this, the acting manager said that the usual procedure would be to involve an independent, professional service, eg Swan Advocacy, all of whose workers are CRB checked. However, staff reported that this person may not have actually visited the home to speak to residents, but simply filled in the questionnaires at home and sent them in. The level of accuracy of the responses is therefore in doubt. There is also a suspicion that the manager has intentionally misled the CSCI by using a family member as an “independent advocate”. This deception is extremely concerning and CSCI will be contacting the providers, Wiltshire County Council in relation to this serious matter. The home now has a fire risk assessment in place. This was dated April 2007 and is valid for one year. One staff member has been responsible for improving the fire records, and those examined showed that all routine inspections and servicing of fire equipment had been done. Fire extinguishers had been serviced on November 2006, and other routine checks had been carried out regularly. Fire instructions are meant to be given quarterly, and had been done for July to September. However, they had not been done for January to March or April to June. The registered provider has been asked to ensure that fire drills are carried out quarterly, according to the homes procedures. This is the second time this has been asked of the home. The fire risk assessment dated April 2007 identified that the caretaker is storing lots of boxes and equipment in the electrical cupboard, and that this clearly constituted a fire hazard. Further investigation showed that these are still there, although it was planned in the future to have them moved. The registered provider has been asked to ensure that the electrical cupboard is kept free of hazardous materials. DS0000032418.V341667.R01.S.doc Version 5.2 Page 32 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 2 2 1 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 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 1 X 1 X X 2 X DS0000032418.V341667.R01.S.doc Version 5.2 Page 33 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 YA1 Regulation 5 (2) Requirement All residents must be given a copy of the updated service user guide. Comment: this is the second time this requirement has been made. All potential residents must have an assessment done before they move into the home in order to ensure that their needs can be met. Comment: this is the second time this requirement has been made. There must be an urgent support plan review for the resident with mental health needs. Comment: We wrote immediately to the providers telling them that they must do this. There must be an urgent support plan review for the resident who has transferred from upstairs to downstairs. Comment: We wrote immediately to the providers telling them that they must do this. Timescale for action 20/10/07 2 20/10/07 YA2 14 (1) (2) 3 YA6 15 (2) (b) 21/09/07 4 21/09/07 YA6 15 (2) (b) DS0000032418.V341667.R01.S.doc Version 5.2 Page 34 5 YA6 15 (2) (b) 6 YA6 7 15 (2) (b) YA9 13 (4) (c) 8 YA9 13 (4) (c) 9 YA18 10 YA18 11 12 (1) (a) 13 (2) All residents’ support plans must be reviewed on a regular basis and must contain accurate, upto-date information Comment: this is the second time this requirement has been made. Weight charts, activity sheets and medication profiles must be kept up to date or removed from support plans if not necessary. An immediate risk assessment must be put in place relating to any risk of self harm or harm to others for the resident who has recurrent mental health problems. Comment: We wrote immediately to the providers telling them that they must do this. An immediate risk assessment must be put in place regarding the move by one resident from upstairs to live with more frail residents downstairs. Comment: We wrote immediately to the providers telling them that they must do this. Detailed records must be kept of when prescribed shampoos are used by residents. The date for changing any continence aid must be clearly and accurately recorded. The planned assessment regarding sexuality and relationships for one particular resident must be urgently followed up. Comment: We wrote immediately to the providers telling them that they must do this. 20/10/07 20/10/07 21/09/07 21/09/07 20/10/07 20/10/07 24/09/07 YA19 13 (1) (b) DS0000032418.V341667.R01.S.doc Version 5.2 Page 35 12 YA19 12 (1) (a) The mental health needs of the identified resident must be urgently reviewed, with consideration given to the registration category of the home. Comment: We wrote immediately to the providers telling them that they must do this. A medication review must be held for the use of PRN medication for residents who have not recently needed it. Comment: this is the second time this requirement has been made. A regular stock check must be made of medication which is administered on a daily basis. Any medication training pack developed for staff must make accurate reference to Wiltshire County Council’s policies. Medication records must clearly highlight any allergies so that staff can be aware of any potential danger and pass this information on to other health professionals if necessary. A log must be kept of any complaint made to the home, and kept ready for inspection. Comment: this is the second time this requirement has been made. The POVA/APC conclusions relating to one resident and the need for a new placement must be urgently followed up. Comment: we wrote immediately to the providers telling them that they must do this. 28/09/07 13 YA20 13 (2) 20/10/07 14 YA20 13 (2) 20/10/07 15 YA20 13 (2) 20/10/07 16 YA20 13 (2) 20/10/07 17 YA22 17 Schedule 4 (11 20/10/07 18 YA23 12 (1) (a) 24/09/07 DS0000032418.V341667.R01.S.doc Version 5.2 Page 36 19 YA32 18 (1) (a) 20 YA34 17 Schedule 2 (3) 17 Schedule 2 (7) 21 YA34 22 23 YA34 YA35 17 Schedule 2 (1) 18 (1) (c) (i) The registered provider must keep an up-to-date record of the number of staff with NVQ and the number of staff still studying for NVQ. Comment: this is the second time this requirement has been made. All staff must have two written references on file. Comment: this is the second time this requirement has been made. All staff must have evidence of an enhaced level CRB and POVA check Comment: this is the second time this requirement has been made. All staff must have photographic identification on file. All staff must have training in mental disorder specific to the needs of the resident in question, in order to support her fully. Comment: we wrote immediately to the providers telling them that they must do this. All staff must have training in manual handling. All staff responsible for writing risk assessments must have training in how to do so. All care staff must have formal, recorded supervision at least six times in every year. Comment: this is the second time this requirement has been made. All staff responsible for supervising staff must have training in supervision skills. DS0000032418.V341667.R01.S.doc 20/10/07 20/10/07 20/10/07 20/10/07 31/10/07 24 25 YA35 18 (1) (a) 30/11/07 30/11/07 YA35 26 YA36 18 (1) (a) 18 (2) (a) 20/10/07 27 YA36 18 (1)(c) (i) 30/11/07 Version 5.2 Page 37 28 YA39 26 29 YA42 23 (4) (e) 30 YA42 13 (4) (a) Copies of the report of the monthly monitoring visits to the home must be sent to the CSCI until further notice. Comment: this is the second time this requirement has been made. Fire drills must be carried out quarterly, according to the homes procedures. Comment: this is the second time this requirement has been made. The electrical cupboard must be kept free of hazardous materials. 30/10/07 20/10/07 20/10/07 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 4 5 6 7 8 Refer to Standard YA6 YA9 YA20 YA20 YA32 YA34 YA36 YA39 Good Practice Recommendations All staff should use the same system of recording daily events in residents’ lives. All staff should use the same format for risk assessments. The date should be recorded when a new “PRN” medication sheet is written for a resident. A matrix should be introduced to remind staff of when regular medication checks need done. Staffing levels should be reviewed in light of current residents’ level of need. All medical information requested of staff should be completed and clear evidence should be given of who is responsible for following up any gaps. All staff should have an annual appraisal of their work. A record should be kept of the responses made by the home to their residents’ survey. DS0000032418.V341667.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000032418.V341667.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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