Inspection on 14/11/05 for South Road (38)

This inspection was carried out on 14th November 2005.

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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Road (38) 01/05/08

South Road (38) 02/05/07

South Road (38) 26/07/05

South Road (38) 15/06/05

South Road (38) 06/01/05

South Road (38) 30/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 South Road (38) 38 South Road Bishops Stortford Hertfordshire CM23 3JJ Lead Inspector Angela Dalton Unannounced Inspection 14th November 2005 11:15 South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service South Road (38) Address 38 South Road Bishops Stortford Hertfordshire CM23 3JJ 01279 461 131 01279 466 332 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) Home Farm Trust Mrs Catriona Bacon Care Home 10 Category(ies) of Learning disability (10) registration, with number of places South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: 38 South Road is a large house in a residential street providing a care home for ten people with a mild to moderate Learning Disability. All the residents have their own rooms, which reflect their individual personalities, and all make full use of all the local community has to offer. The home has communal accommodation, which is well used by this well-established group of service users. Emphasis is given to active, positive quality lifestyles at the limit of each service users ability and independence. The home is owned by the Home Farm Trust. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one Inspector on 14th November 2005 between 11.15 am and 4.15 pm. The home has experienced a period of instability as there has been no registered manager in post for some time and the acting manager has decided to return to their role within the care team. Another manager has been seconded to the home but as yet does not feature on the rota. The service users spoke highly of the support that they received. No senior management representative was in attendance due to a previously arranged meeting. The inspector was assisted by members of the staff team despite challenging circumstances, as the heating was broken. What the service does well: What has improved since the last inspection? What they could do better: Providing good care is the focus of the staff team but staffing levels do not currently enable cleanliness of the home to be addressed. The inspector raised concerns about the shift pattern worked by staff. A member of staff who had worked until 3.30pm (but left the home later) was due to return for a waking night shift at 10pm. The rota evidenced that this was not an isolated incident. Previous requirements remain unmet: infection control within the home would be improved by the introduction of paper hand towels. Toilet Rolls are not in place due to the removal of them by a service user. Specialist dispensers have been required to ensure the availability to service users and staff. This would ensure both infection control and dignity are observed. Medication systems and recording continue to require attention and a previous requirement remains. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 6 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. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Prospective service users have an assessment in place to provide a baseline for care plans. Staff are not equipped to communicate effectively with service users. EVIDENCE: A requirement was made at the previous inspection to ensure that an assessment was in place for the service user who was due to move in. This has now been completed and is providing the basis for the care plan. A requirement has been made to evidence that staff are to attend Makaton training (a form of sign language) to assist in communicating with service users. Service users are losing their ability to sign, as staff have not been trained in Makaton. Some training is planned but has not yet been delivered. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Care plans do not reflect a daily reflection of service users’ lives. EVIDENCE: It is recommended that daily notes are recorded for new service users to the home. This would enable immediate review of care plans as records could be related to identified needs. Currently entries are only made sporadically so it is difficult to build a picture of if a care plan is effective. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected on this occasion. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 Medication practice does not safeguard service users. Care plans do not reflect individual funeral wishes. EVIDENCE: Medication requires some attention and a requirement has again been made to ensure the following: The temperature of medicines must be recorded to ensure appropriate storage. Medication must be dated on opening. Administration directions on the MAR (Medication Administration Record) sheet must be signed by a member of staff in the absence of a G.P. A doctor or pharmacist should sign and agree the homely remedies policy. Medication amounts did not reflect doses given when checked. As required medication (PRN) must only be signed for when given as records currently reflect that it has not been issued which is confusing. Where medication is no longer required the MAR (Medication Administration Record) sheet must reflect his as opposed to reflecting that the medication is not issued. Labels must not be used to reflect instructions on MAR sheets. As stated earlier there is little availability of toilet roll in the home as a service user removes them. This impacts upon the dignity of service users and staff. A requirement has been made to provide toilet roll through specialist dispensers to prevent their removal. A recommendation has again been made to ensure that service users’ wishes regarding funeral arrangements have been recorded. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected on this occasion. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Areas of the home are unclean and require maintenance. The home was cold on the day of inspection. EVIDENCE: The home was odour free and floors were clean but the Inspector noted that there were areas of the home that were unclean especially doors and paintwork. It appears that staffing levels may attribute to this, as the ratio is one member of staff to five service users with occasional additional one to one staff support. The home has also not had a registered manager in post for some time. Some areas of the home require decoration – paint was peeling from the ceiling in the hallway and from the window ledge in a bathroom. There was a large crack along the length of a wall next to a downstairs bedroom and the dining room walls are stained. A requirement has been made to send a maintenance plan to the Commission to evidence the plan of work scheduled to address identified issues. An immediate requirement was made during the Inspection to repair the heating. This had been intermittent over the weekend and broken early on the day of inspection. The home had no contingency measures as another home within the organisation was experiencing the same (unrelated) problem and was using the spare heaters. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 14 A fan heater was available in the lounge but the temperature within the rest of the home was cold at just above 16ºC (the minimum legal temperature to work in). The inspector remained in the home until 4.15pm when the heating engineer arrived. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Although staff are enthusiastic and supportive, numbers appear to be insufficient to meet all needs and staff appear to work excessive hours. EVIDENCE: A requirement has been made in conjunction with meeting service users’ assessed needs to ensure that staff are equipped to learn sign language. Staff vacancies currently exist (one of these being the permanent post of home manager) which are covered by additional hours and relief staff. As stated earlier staffing levels seem inadequate. A requirement has been made for evidence to review staff levels to demonstrate that they are adequate to be sent to the Commission. Nights are covered by a sleep in member of staff and a waking member of staff. The waking night is employed until 5.30am but the sleep in is not employed to work until 8am. This results in the service user whom the night staff is employed for being left without waking support between 5.30am and 8am. In reality sleep in staff rise early to cover this period of time but are not employed to do so. A requirement has been made to evidence that night staff have had a risk assessment completed to assess their fitness. As stated earlier the inspector was concerned about staff working a day shift only to return to work a waking night. This practice is unsafe and does not allow the staff to adequately rest or ensure the health and safety of service users. Copies of actual rotas worked must be submitted to the Commission at the end of each month to ensure sufficient staff are employed and service users are not placed at risk. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 The health and safety of service users is not assured. The home does not benefit from a qualified manager. A quality assurance process has not reflected the issues within the home. EVIDENCE: The home has been through a period of transition and although some support has been made available from headquarters it has not maintained morale within the home. This has been challenged over the previous eighteen months with some significant events but staff have successfully maintained momentum and consistency despite difficult circumstances. Senior management representatives were unable to attend the unannounced inspection due to a meeting taking place. A permanent manager is now required to ensure the quality of care provided is not affected and to support and guide the staff team. A requirement has been made to formally update the Commission regarding management arrangements. The inspector is aware of some interim measures by initiating contact with the organisation. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 17 An action plan and risk assessment must be submitted to clarify how a service users’ assessed risks are met when night staff have left the building. Waking nights were identified as being required as a service user who required supervision was leaving the house independently without staff being aware at night. A requirement has again been made for a safe and approved method of keeping one service user’s bedroom door open as there is currently no safe way for them to do this. A requirement has been made for the findings of the quality assurance audit to be sent to the Commission, as issues identified by the inspector do not appear to have been identified by the organisation, as they have not been addressed. South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 South Road (38) Score 2 X 1 2 Standard No 37 38 39 40 41 42 43 Score 1 X 2 X X 1 X DS0000019529.V264982.R01.S.doc Version 5.0 Page 19 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 YA3 YA33 Regulation 12(3) Requirement Evidence must be sent to the Commission for Social Care Inspection that staff have received Makaton training to enable effective communication to take place with service users. Toilet roll must be accessible to all service users and staff. Specialist holders are advised. THIS REQUIREMENT REMAINS UNMET FROM THE PREVIOUS INSPECTION. A foolproof medication system must be in place. The temperature of medicines must be recorded to ensure appropriate storage. Medication must be dated on opening. Administration directions on the MAR (Medication Administration Record) sheet must reflect the prescribed details and be signed by a member of staff in the absence of a G.P. A doctor or DS0000019529.V264982.R01.S.doc Timescale for action 28/02/06 2. YA18 12(4)13(3)& 13(4)(c) 31/12/05 3. YA20 13(2) 30/11/05 South Road (38) Version 5.0 Page 20 4. YA24 23(2)(b) 5. YA24 23(2)(p) 6. YA30 13(3)&13(4c) pharmacist must sign the homely remedies policy. THIS REQUIREMENT REMAINS UNMET FROM THE PREVIOUS INSPECTION. Issues identified below were identified at this inspection. Medication amounts did not reflect doses given when checked. As required medication (PRN) must only be signed for when given as records currently reflect that it has not been issued which is confusing. Where medication is no longer required the MAR (Medication Administration Record) sheet must reflect his as opposed to reflecting that the medication is not issued. Labels must not be used to reflect instructions on MAR sheets. Enforcement action will be taken if this requirement remains unmet. The home must be well 31/12/05 maintained and kept in good decorative order. A maintenance plan must be sent to the Commission. An IMMEDIATE 14/11/05 REQUIREMENT was left to ensure that heating is provided within the home. Infection control must be 12/12/05 observed by the provision of paper hand towels. Infection control training would further assist in this process. THIS REQUIREMENT REMAINS UNMET FROM DS0000019529.V264982.R01.S.doc Version 5.0 Page 21 South Road (38) 7. 8. YA30 YA33 23(2)(d) 18(1)(a) 9. YA33 13(6)&18(1)(a) 10. YA37 8(1)(a) 11. YA39 24 12. YA42 13(4)(c)&23(4)(c) THE PREVIOUS INSPECTION. The home must be clean. Staffing levels must be reviewed. Evidence to demonstrate that they are adequate to be sent to the Commission. Copies of actual rotas worked must be submitted to the Commission at the end of each month to ensure sufficient staff are employed and service users are not placed at risk. Night staff must have had a risk assessment completed to assess their fitness in line with Health and Safety legislation. Service users must not be exposed to staff who have not had adequate rest between shifts in line with DTI guidance. The Commission must be formally notified of management arrangements for South Road and be updated at regular intervals. A copy of the most recent quality assurance audit with its findings must be sent to Commission. An appropriate door closer system must be implemented on the bedroom door that is wedged open by the service user. Advice must be sought from the Community Fire Safety Officer. THIS REQUIREMENT REMAINS UNMET FROM THE PREVIOUS 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 31/12/05 South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 22 INSPECTION. 13. YA42 12(1)&13(4) An action plan and risk assessment must be submitted to clarify how a service users’ assessed risks are met when night staff have left the building. 05/12/05 South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 23 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 YA21 YA6 Good Practice Recommendations Service users wishes in how they will be cared for at the end of their lives and after death should be recorded. THIS RECOMMENDATION HAS BEEN MADE PREVIOUSLY. Daily records should be kept for new service users admitted to the home. This will enable care plans to be regularly monitored and changes noted South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Road (38) DS0000019529.V264982.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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