CARE HOME ADULTS 18-65
Southernwood 148 Plantation Road Amersham Bucks HP6 6JG Lead Inspector
Chris Schwarz Announced 20 June 2005 09:30 a.m. 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 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 Stationary 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. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Southernwood Address 148 Plantation Road, Amersham, Bucks, HP6 6JG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01494 721607 Royal Mencap Society Mr David Stringer Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 6 residents with learning disabilities, physical disabilities Date of last inspection 12 April 2005 Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 5 Brief Description of the Service: Southernwood is a purpose built home, registered to provide accommodation for up to six adults with learning and physical disabilities. Each person living at the home has considerable care needs. The home is staffed by Mencap and is within a mile or so of local shops, and the towns of Amersham and High Wycombe are a few miles away. The home is not directly accessible by public transport. The home provides single bedroom accommodation with rooms of a good size, personalised and decorated to individual tastes and interests. There are lounge and conservatory areas and a kitchen/dining room. The home has two bathrooms with all necessary adaptations and lifting equipment. There is an enclosed garden that can be accessed through patio doors leading from the conservatory. All of the service users facilities are on the ground floor with just the office and staff bathroom on the first floor. There is parking at the side of the building. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This announced visit was arranged to meet with the registered manager and look at a selection of National Minimum Standards. A pre-inspection questionnaire was sent to the home prior to the inspection, with comment cards for distribution. It took place between 9.15 am and 1.50 pm and involved discussion with the manager and examination of some required records. What the service does well: What has improved since the last inspection? What they could do better:
Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 7 Some improvement is needed to medication practice through acquiring more detailed authorisation from the doctor to reflect staff practice of adding prescribed drugs to food. Medication administration practice needs to be looked at following notification that a service user had been able to take another person’s medicines. Recruitment practice is not thorough enough to protect service users from potential abuse, as the full range of required checks was not evident on the sample of files looked at. There have been previous concerns about recruitment practice and a statutory enforcement notice was served on 24th June 2005, in light of the inspection findings. A checklist of all required documentation should be used by the manager to assist with the recruitment process. The complaints procedure needs to be amended to reflect that CSCI is the regulatory body. The home is not maintaining an accurate log of complaints and details of a relative’s complaint were not available at the home. Evidence of effective self-monitoring by the provider is not wholly apparent, as a detailed report is not prepared following monthly visits. There was no evidence of monitoring in December 2004 and January 2005. A previous requirement to notify the Commission of any serious incidents within 24 hours of occurrence and confirmed in writing within three working days, is not being fully met. Adult protection practice could be improved through making use of free training run by Buckinghamshire County Council. A copy of the local authority inter-agency adult protection procedures should also be available, for reference. Training on epilepsy is advisable, to supplement the range of training courses undertaken by staff and to increase their awareness. Detailed records should be maintained of one person’s challenging behaviour, to help identity any triggers. 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.
Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the standards in this section were assessed. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the standards in this section were assessed. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 11 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 standard(s) EVIDENCE: None of the standards in this section were assessed. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 12 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 standard(s) 20 Service users are not sufficiently protected by the home’s procedures for dealing with medicines, which could place them at risk of harm. EVIDENCE: The medication cabinets were locked and secure when not in use. Records of drug administration were in good order and a requirement made following the inspection in April this year was being complied with. Five service users have their medications added to foods. Written consent had been obtained from the doctor, with one letter covering all service users. The letter granted permission for medication to be taken with food. Staff are actually adding drugs to food, crushing tablets where necessary and also emptying a capsule. The written instruction from the doctor needs to make clear whether this is acceptable practice, as the coatings of prescribed drugs and their time release mechanisms are likely to be destroyed through these practices. Revised authorisation is therefore needed from the doctor, with a copy added to each applicable service user’s care plan. Notification of a drug administration error was made shortly after this inspection whereby one service user had been able to consume another service user’s drugs which had been added to a drink. Written confirmation of the details had not been received within three days, as required. A requirement is
Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 13 made to address this. The manager must also ensure that any staff handling medication are competent to do so. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 14 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 standard(s) 22 and 23 The home has complaints procedures to listen to the views of service users and their representatives but records do not show that these are effectively used. There are adult protection procedures in place to safeguard against the risk of harm. EVIDENCE: The home has a complaints procedure in its policies manual. It refers to the National Care Standards Commission being the regulatory body and will therefore need revising to reflect that this is now CSCI. A displayed, laminated version had the correct details. A relative made a complaint two months before the inspection, however, the log book did not contain this information and the manager was unable to locate any paperwork relating to this. A requirement is made for a copy of the complaint and how it was responded to, to be forwarded to the Commission. A second requirement is made for the complaints log to be accurately maintained. The home has an adult protection policy in place and there had been training for staff in June this year. Careline pamphlets are available by the front door to refer concerns to the local authority. Advice was given to make use of the Buckinghamshire County Council free adult protection training, to supplement training already undertaken, and also to obtain a copy of the local authority inter-agency adult protection guidelines. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 15 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 standard(s) EVIDENCE: None of these standards were assessed on this occasion. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 The home has good induction and training programmes for staff, to ensure that service users are cared for by competent persons who understand their needs. There are sufficient numbers of staff on duty to ensure that service users’ needs are met. Recruitment practice is not robust enough, placing service users at potential risk of harm. EVIDENCE: Rotas showed that sufficient cover appears to be in place and the home is not currently needing to use agency staff. Six staff are undertaking NVQ level 3 and the manager is progressing with the Registered Manager’s Award. The training log showed that staff have been undertaking training and updates; it is recommended that staff have input on epilepsy as this is a significant care need at the home. One person’s induction folder was seen. This was a comprehensive introduction, incorporating self-learning with assessment by the supervisor. The foundation folder, completed after induction, was seen of another member of staff and this too was a comprehensive self-learning tool. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 17 The recruitment files of three staff were looked at. There were deficits in each case with the full range of required checks not evident and a previous requirement had not been complied with. A statutory enforcement notice was served on 24th June 2005 to address this. One relative commented that there sometimes appears to be a lack of communication between the home and day services, which the manager agreed with. The relative considered staffing levels to be sufficient at times when she visits and commented that overall staff were very caring. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41 and 42 Self-monitoring is undertaken by the provider, to evaluate service users’ quality of care. More needs to be done to demonstrate that this is being done effectively, to protect service users’ wellbeing. Records have improved overall at the home, to safeguard service users’ best interests. Health and safety is being promoted to reduce risk of harm to service users. EVIDENCE: A review of the quality of care had been undertaken by the provider in April this year and a report was available of findings. Self-monitoring is undertaken by the provider. Monitoring forms for December 2004 and January 2005 had not been forwarded to the Commission. A recommendation to prepare more detailed reports is not being actioned; the forms currently in use do not demonstrate thorough monitoring as they need to be in a detailed report format. A requirement is made to address this.
Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 19 Records were in better shape with dates and signatures added. The only issue has been referred to under the complaints section, with the complaints log not being accurately maintained. Accident reports were examined. One service user who is self-harming featured predominantly and there was evidence that outside agencies are involved in his care. Some reasons had been suggested for the behaviour and a recommendation is made to keep detailed records of these incidents, to try and establish whether there is a trigger. Service user risk assessments were up-to-date. Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 20 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 x x x x Standard No 22 23
ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Southernwood Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 3 x
Version 1.30 Page 21 H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc 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. 2. 3. Standard 22 22 22 Regulation 22(7) 17(2) schedule 4 (11) 22(8) Requirement The complaints procedure is to be revised to reflect that CSCI is the regulatory body. The complaints log is be accurately maintaned. Details of the missing complaint and how it was responded to are to be forwarded to the Commission. All staff are to be vetted in accordance with the regulations and documentary evidence of checks is to be retained at the home. Outstanding documentation must be obtained for each member of staff and no staff are to be permitted to commence duties in future until all required checks have been obtained. Statutory enforcement notice served. A detailed report is be prepared following self-monitoring vists. Evidence of self-monitoring during December 2004 and January 2005 is to be forwarded to the Commission. Notifications under regulation 37 are to be made within 24 hours Timescale for action 15th July 2005 15th July 2005 15th July 2005 5th July 2005 4. 34 17(2) 19(1)b schedule 4(6) 5. 6. 39 39 26(4)c 26(5)a 5th July 2005 5th July 2005 from 20th June 2005
Page 22 7. 20 37 Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 8. 20 13(2) of occurrence and confirmed in writing within three working days. Previous timescale of 12th April 2005 not met. Only competent and trained persons are to administer medication, in accordance with the homes procedures and following training. from 28th June 2005 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. Refer to Standard 20 Good Practice Recommendations Revised authorisation is needed from the doctor regarding staff adding medication to food, including crushing tablets and emptying the contents of capsules. This authorisation is to be placed upon care plan folders. The home is to make use of the adult protection training offered by Bucks County Council. A copy of the local authority inter-agency adult protection guidelines are be available at the home. A checklist of all required documentaion is to be devised and used to assist with obtaining recruitment checks. Training on epilepsy is to be undertaken by all staff. Detailed records are to be maintained of the challenging behaviour, to help identify any triggers. 2. 3. 4. 5. 6. 23 23 34 35 42 Southernwood H53_H02_S23022_Southernwood_V226429_AI_200605_Stage 4_Final_CAS_ces.doc Version 1.30 Page 23 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close, Aylesbury, Bucks, HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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