Inspection on 26/10/05 for Starboard House

This inspection was carried out on 26th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Starboard House 31/07/07

Starboard House 11/05/06

Starboard House 17/05/05

Starboard House 23/09/04

Starboard House 13/07/04

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Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOMES FOR OLDER PEOPLE Starboard House 105 Obelisk Road Woolston Southampton Hampshire SO19 9DN Lead Inspector Christine Hemmens Unannounced Inspection 26th October 2005 09:30 X10015.doc Version 1.40 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 Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 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 Older People. 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. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Starboard House Address 105 Obelisk Road Woolston Southampton Hampshire SO19 9DN 0208 2554433 023 8043 4317 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) The Regard Partnership Limited Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the LD category must be at least 45 years of age. Date of last inspection 17th 18th May 2005 Brief Description of the Service: Starboard House is registered to accommodate ten service users from 45 years of age who have a learning disability. However as the majority of service users are currently over the age of 65 years the home was inspected against the older persons standards. Starboard House is a unique detached home built over several floors including a basement and has a separate self-contained bungalow within the grounds of the home. The garden is small for the size of the home, however it allows areas to relax in, undertake hobbies and interests such as gardening and provides shaded areas. Starboard House is situated within a short walk of the shopping centre of Woolston and within a ten-minute drive from the city of Southampton, which has a range of shopping and leisure facilities. Since the end of May 2003 The Regard Partnership an expanding provider of learning disability services has owned the home. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of Starboard House this year and was held over two days. The newly appointed manager, three residents and two staff assisted the inspector with the inspection. At the previous announced visit held on the 17th and 18th of May 2005 the home was issued with twenty-four requirements. Progress has been made to meet the twenty-four requirements, however sixteen requirements were issued following this visit to the home, five of which have been repeated for a third time and two repeated for a second time. One is with the Commission for Social Care Inspection Providers Relationship Manager to coordinate at a national level. The registered providers must note that further failure to comply with the requirements may result in enforcement action being taken. The home has already been subject to enforcement action in 2005 and the inspector notes that further failures to comply with requirements remain. Since September 2004 the home has gone through some major disruptions and changes. In this period of time the home has had a succession of managers who have either been dismissed or asked to leave, and small number of staff have been asked leave or dismissed for misconduct. This has had unsettling and disruptive effect on the home. However a new manager already known to the organisation and who is aware of the organisation’s policies and procedures has been appointed, and a sense of some order and progress can be seen. The number of requirements unfortunately does not reflect the hard work the manager and his team have done to ensure the residents are supported to have an active and interesting lifestyle. The manager must now make application to register. What the service does well: What has improved since the last inspection? Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 6 There have been some improvements to the home since the last visit. The appointment of the new manager has played a big part in bringing stability and order to the home. Residents appear more settled and informed the inspector that they are happy with Mr Creek as the manager. The manager has brought order to the home’s administration and is making progress in eradicating institutional practices. It was observed at the time of the visit that the manager is developing trust and very good relationships with both residents and staff. Improvements to providing residents with tools to communicate effectively are being developed and a clear complaints procedure for the residents has been given to each resident. The manager with the support of the staff has made some progress in meeting some of the twenty four requirements issued following the last visit to the home, however it is recognised that the requirements have been inherited and have taken a little longer than the agreed timescale to complete. For example the manager is making progress in developing a person centred approach to the individual needs of the residents, this is a slow process as meetings have been arranged with the person centred planning co-ordinator for Southampton and individual meetings with residents and residents representatives. This is ongoing for the residents and therefore progress will be reviewed during the next visit. The manager has improved the numbers, skills and gender mix of the staff and deploys them in such a way to ensure they are working to meet the individual needs of the residents. Staff informed the inspector they feel very supported and are provided with time to undertake appropriate training What they could do better: There continue to be serious concerns that the home continues to fail to comply with requirements, and the time it is taking to improve standards in the home. These include providing the residents with an appropriate Service User Guide, ensuring care plans and risk assessments provide specific detail on how residents are to be supported, ensuring specific health care needs and treatments are recorded and medication is administered correctly and ensuring staff are correctly recruited to safeguard the residents from potential harm. The home could do better to ensure staff receive a full induction process, recording the outcomes and signed off by the staff member and manager. The home is required to make further improvements to the environment and seek advice from an Environmental Health Officer on the appropriate facilities and tools required in the home to prevent cross infection, improving the cleanliness and decoration of the downstairs toilet and purchasing the correct washing machine to meet the needs of the residents and home. Further improvements are required to the environment to improve the kitchen and redecorate some of the residents’ bedrooms. The manager must also ensure that he has taken every step he can to prevent the residents coming to harm by risk assessing areas in the home that may be Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 7 of potential risk to the residents. The manager must also ensure that staff are fully aware of the procedures for the expenditure of residents’ personal monies including fully ensuring the residents are aware of the expenditure and intended cause and promptly take action when irregularities occur. Residents monies continue to be held centrally with the “The Regard Partnership”, the issues concerning the systems used to hold residents monies has been forward to the Commission for Social Care Inspection Providers Relationship Manager who is currently investigating the systems the organisation uses. The manager must also ensure that when seeking the views of visiting professionals, staff and residents representatives that he includes the residents. A report of the finding of the quality audit must be sent to the Commission for Social Care Inspection. 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. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The home has made little progress in developing a Service User Guide and producing a contract that is accessible for the residents. EVIDENCE: The inspector viewed the latest version of the Service User Guide for Starboard House. The inspector had viewed the Service User Guide on several occasions and advised that changes be made in order that it truly reflected the service provided and was made accessible for the residents. Little or no improvement has been made to the guide, it is lengthy, is written in small text and complicated language and refers to the residents in various parts of the guide as “Clients”, “Service Users” and “People who use the service” this reads as though the Service User Guide has not been designed for the resident but for residents representatives and professionals. The requirement to develop an accessible Service User Guide has been repeatedly made. A further failure to comply with the requirement may result in enforcement action being taken. In addition to repeatedly requiring a Service User Guide, the home has been required to issue the residents with a contract Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 10 agreement between the home and the resident. This has now been achieved, however the room the resident is to occupy has not been incorporated into the contract detail. The manager spoke at length of the changing physical needs of the residents and the intentions to move residents to alternative rooms. The manager informed the inspector that advocacy will be involved. The manager must ensure that any moves are agreed in writing and signed by the resident where possible or their representative. Therefore the home is required to add this to the contract and consider developing the contract in an accessible version in order that the resident is provided with the tools to assist them to understand their rights. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 The home is making progress in adopting a person centred approach to meeting the health and welfare needs of the residents, however little progress has been made in making personal plans accessible for residents and staff and concerns remain regarding the safe administration and recording of medications. EVIDENCE: The home is in the progress of adopting a person centred approach to identify with individual residents their needs, wishes and desires. The manager informed the inspector that he and some of his staff had met with the person centred plan co-ordinator for Southampton for guidance and advice. The residents “personal” person centred plans are in the very early stages of planning, and adapted in an accessible format. The Commission for Social Care Inspection recognises that this is a big piece of work if to be done correctly, therefore progress will be reviewed during the next visit to the home. The home has also developed a very good approach to reviewing the health and welfare needs of the residents including daily activity and future wishes. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 12 There is evidence that needs, strengths and desires are reviewed and future plans are made with the resident. However the manager is advised to change the name of the meeting/form to resident monthly meetings from Keyworker meetings. Each resident has a personal plan that provides information and guidance for staff regarding the residents’ strengths, needs and potential risks. The home has been repeatedly required to address individual care plans and risk assessments to ensure they clearly identify the residents needs and “how” they must be supported correctly, consistently and to minimise risks. The inspector found evidence in the three personal plans viewed that the requirement issued following the last visit to the home remains unmet. The requirement will be repeated and a further failure to comply will result in enforcement action being taken. There is further evidence to suggest that staff have received little guidance on how to complete care plans that correctly reflect the residents’ needs, “how” they are to be supported and how to correctly record daily outcomes of specific support. This includes specific support required for health needs following visits to and from health care professionals. The home has been required following a number of visits to record outcomes of health care visit and devise care plans where required, i.e. applying topical lotions, regularly recording weights when requested by dietician. The manager informed the inspector that staff would be receiving training in November on care planning. Therefore the quality of the care plans will be reviewed during the next visit to the home, however the manager is advised if there is no significant improvement to the plans then further action will be instigated. The home has a history of poor practice regarding the safe handling, administration and storage of medication. Further areas of concern were identified during this visit. The home was required to produce a recording system to make routine checks on the administration of medication, a system is in place, however there was evidence that checks had not been undertaken. As a result of a failure to monitor the inspectors found discrepancies in the administration and recording i.e. medication not given, but signed for, and evidence that the manager had not checked medication dispensed by the pharmacist. The manager must address the areas of concern without delay and take appropriate action, a further failure to comply may result in enforcement action being taken. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 The home has adopted a person centred approach to meeting individual daily and sociable activities for the residents, and the home provides open and informative communication to support the residents to make choices. EVIDENCE: The inspector found evidence through talking to residents, staff and reviewing personal plans that the residents are supported to undertake a variety of activities and are provided with support to make choices. The residents spoke at length of the daily activities they are involved in, from going to planned activities such as day service to attending church, going to bingo and planning holidays. One resident was very keen to talk about a recent cruise he had been on and how his keyworker had supported him on the cruise and the fun they had. The resident informed the inspector that he chose the holiday and enjoyed every minute of it. Photographs supported the evidence that all had a good time. Other residents spoke of their more sedate but exciting holiday they had had. The residents informed the inspector that they can spend their day as they wish and there was not pressure on them to do anything they didn’t want to, they spoke kindly of the manager and his staff and said that they are very supportive. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 14 Throughout the course of the visit to the home the inspector observed a number of activities taking place from shopping to arranging to visit the Spinnaker Tower in Portsmouth. The manager has employed an energetic member of staff who is keen to support residents to experience a variety of activities, however the home must be mindful of the age of the residents, forward plan and ensure all risks have been explored and though through before undertaking the activity. A few residents were observed going about daily chores, making drinks and choices about what they were going to have for lunch. The manager respects that some residents have difficulty communicating and has started to improve the home to provide an open and informative environment. Pictures of the staff on duty for the day and a picture complaints procedure are displayed in the entrance area to the home. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has made progress in providing the residents with information on how to complain. The home has taken measures to provide staff with training and information on abuse, however further steps must be taken in line with standard 29 to ensure residents are protected from potential risk of harm from staff. EVIDENCE: There is evidence to suggest that the home is now taking seriously the rights of the residents to complain if they are unhappy. The inspector observed manager and staff on duty providing an open and respectful dialogue with the residents, providing them with relevant information and supporting them to make choices. This interaction and open respectful approach was reflected in the comments made by the residents who stated “the staff are very kind”, “they listen to us” and we can speak to them if we are unhappy” one resident said “ I have no worries about telling the manager if I am unhappy with something”. The manager has provided each resident with a complaints procedure, which was displayed on the back of the resident’s bedroom doors. The complaints procedure has been produced in an accessible format with pictures and large writing which informs the resident with whom they can speak with if they are unhappy. Some of the residents could confirm that they had seen the complaints procedure and knew where it was. The home has made some progress in ensuring that as far as feasibly possible it protects the residents from the potential harm of abuse. There was evidence that demonstrated staff had received information and training on abuse and Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 16 there are policy and procedures in place. The manager informed the inspector that he has joined the Southampton City Council’s Abuse Forum, which provides up to date information, advice, training and newsletters. This is seen as good practice, however the manager must ensure he fully protects residents from the risk of harm of abuse by adopting a robust recruitment procedure. (This will be covered in standard 29 (Staffing). Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home provides a warm, welcoming and clean environment to live, however the home is in need of redecoration and refurbishment in places, the manager must ensure all facilities accessible the residents are maintained in good order. And staff receive training in infection control. (Staff training will be addressed in standard 30). EVIDENCE: The house is very homely and domestic in style and has a well lived in look. A small-enclosed garden is to the rear of the house. The house is old and looking tired in places, especially the kitchen and downstairs toilet. The manager informed the inspector that plans were in place to refurbish the kitchen in the New Year. The residents with whom the inspector spoke said they liked their home as it was comfortable and clean. There was evidence that one bedroom had been recently redecorated to meet the needs and the wishes of the resident, however the bedroom identified at the time of the visit must be redecorated as it is tired and worn and does not reflect the interests or gender of the resident. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 18 At the time of the visit to the home one of the residents was having a new carpet laid in their bedroom and the home was in slight upheaval, however on the second day of the visit the home was in order and the resident appeared happy and at home in her newly carpeted bedroom. The requirement issued following the last visit to the home to ensure residents’ hot water supply to their sinks was working correctly has not been fully met. The manager informed the inspector that repairs had been made to the taps and plugs put in place. However the inspector found the sinks were not working correctly, no hot water, taps stiff to open and water slow to come through. A further requirement will be issued in respect to residents’ sinks. A further failure to comply will result in further action being taken. The home is kept clean and tidy, staff were observed going about domestic duties with the assistance of some residents. However it was noted it is difficult to keep the downstairs toilet clean due to regular use, and its need for redecoration. However the inspector found that the toilet had not been adequately equipped with toilet paper, soap and clean towels. The manager is advised to install paper hand towels, soap dispensers and ensure regular checks and cleaning of the toilet is made including replenishment of toilet tissue. The home has a domestic style washing machine and would benefit from a industrial type washing machine that will adequately deal with soiled laundry, the home supports residents who are doubly incontinent and therefore must have the appropriate washing facilities. The manager informed the inspector that staff have received training in MRSA, which was incorporated with health and safety, however the staff must receive full training in infection control. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The home has made improvements to ensure residents’ needs are met by mixed skilled and competent staff team, however serious concerns remain with the homes recruitment procedures. EVIDENCE: The manager has recently recruited to the team to improve numbers and skills mix. The home is adequately covered to meet the physical and social needs of the residents, the manager informed the inspector that he deploys staff to ensure there are sufficient staff at specific times of the day such as in the morning and evening. This was reflected in the staff duty rota. The home has a stable staffing structure and has recently appointed a senior support worker to work along side the manager and deputy manager. The staff were observed to go about their daily routines in a competent and efficient manner. The staff with whom the inspector spoke with informed the inspector that the new manager and changes to the staff team had brought stability to the home. “There’s no more stabbing in the back”, “it’s a nicer place to work now” The manager provided the inspector with a comprehensive training matrix for staff and assured the inspector that all staff attend regular training such as moving and handling, first aid, fire and health training and will be undertaking person centred planning and care plan writing in the near future. There was evidence that staff are fully supported to undertake training and National Vocational Qualifications (NVQ). The home must ensure staff receive infection control training. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 20 Following the previous visits to the home the manager was required to ensure all induction programmes were fully completed and signed off by the manager and member of staff. The newly appointed manager informed the inspector that all staff had to undergo an induction programme again to ensure all staff have been fully covered and aware of their roles and responsibilities. In principle this is good practice however the inspector noted from recently appointed staff that a member of staff who started in April 2005 still had not had their induction completed and signed off and other staff were alleged to have their induction books at home. The manager is advised further action will be taken in respect of the induction process if a systematic approach as detailed in the comprehensive induction package is not followed correctly. He home has made little progress in improving its recruitment procedures. The home has been subject to an enforcement notice in the past in respect of poor recruitment practices. The inspector found again there to be bad practice in obtaining acceptable references, evidence that staff have had POVA checks and poorly complete applications. Of the five records viewed by the inspector, the inspector found: The first member of staff only had one reference and no evidence of a POVA check or ID. The second filed showed no evidence of POVA check undertaken. For the third member of staff there was no evidence of POVA check. The fourth member of staff CRB transferred from another organisation with which the carer did not take up employment. References state “To whom it may concern”. A very poorly completed application, not giving full employment history or full details of referees. For the fifth member of staff there was no evidence of POVA having been undertaken, no ID, application poorly completed and no history of employment. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33, 35 and 36 Despite further disruptions to the home’s management and staff team improvements have been made to the ethos, leadership and support of staff. The home has made some progress in seeking the views of others on the quality of the service, however the home must consider the views of the residents as part of the quality audit. The manager attempts to provide a safe environment for the residents and staff, however further work is required to improve exterior risks. Concerns regarding the residents’ finances remain. EVIDENCE: Since the last visit to the home the service has employed another manager. Mr Creek is known to the “The Regard Partnership” and is aware of the Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 22 service’s policies and procedures and its ethos. This has assisted the organised approach to management and administrative systems in the home, however as detailed in the above report requirements have been repeated and serious concerns remain in how staff are recruited and inducted. Mr Creek is an experienced manager and was able to demonstrate his understanding of his roles and responsibilities as a registered manager. Mr Creek was observed to be open and honest and provide a warm and comfortable atmosphere for residents and staff. He was observed to be very caring and supportive towards the residents and took time to listen to what they had to say. Some of the residents and staff with whom the inspector spoke with said Mr Creek was very nice and approachable, staff went onto say he is fair and easy to get along with. Mr Creek is required to make application to the Commission for Social Care Inspection to become the registered manager of Starboard House. The manager informed the inspector that the home was currently undertaking a quality review of the service and quality questionnaires had been sent to residents representatives and professionals involved with the residents, however it was explained that the home has yet to include the residents views. The manager is aware that it is his role to ensure residents are happy with the service they are receiving. A copy of the final quality report must be sent to the Commission for Social Care Inspection. This is a repeated requirement. With the assistance of the manager the inspector viewed monies held on behalf of the residents. All monies counted matched the balance kept in the residents’ personal cash logbook. The cash logbook identifies monies in, out, balance, receipt number and reason for expenditure. The inspector identified some irregularities in reason for expenditure for two of the residents who would not have a full understanding of what was being asked of them. A record of £2.00 was taken out for a staff leaving present. The manager stated he was unaware of the inappropriate debit and stated he would investigate and immediately reimbursed the £2.00. The manager was advised to notify the residents care managers and report what action he had taken to the Commission for Social Care Inspection. The manager informed the inspector that all residents are involved in the transaction of their money and those that can manage their finances are supported to do so by cashing cheques and keeping their money safe. However the matter of all residents’ monies being paid to the “The Regard Partnership” including residents’ personal benefits remains. This area of concern remains with the Commission for Social Care Inspection Provider Relationship Manager and will be addressed by him. The manager ensures staff are regularly supervised and the role of supervising staff has been delegated between the managers. The manager has a specific agenda and requests staff to bring their own agenda. Clear objects are set and staff receive a copy of the notes made in the meeting. The manager as far as feasibly possible provides a safe environment for the residents to live, fire records indicate that all fire equipment and fire safety checks are regularly made. Service certificates on the home’s utilities indicate that these are also regularly checked. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 23 However the inspector noted whilst undertaking an inspection of the outside of the building that the trap door to what was a cellar/coal hole and now the utility room was open. The manager must ensure the safety of the residents at all times, therefore he must put measures in place to prevent the potential risk of the residents falling down the open door. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 1 3 X 1 Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP2 Regulation 4 Requirement The registered persons must ensure the contract details the room the resident will occupy whilst living in the home. (A change of room must be clearly discussed, agreed with and signed by the resident or representative where possible). 2 OP1 5(1) 5(2) The registered persons must adapt the Service User Guide in an accessbile and person centred format for the residnets and include how they can gain access to the latest inspection report. A copy must be sent to the Commission for Social Care Inspection by the stated date. The registered persons must ensure residents care plans and risk assessments provide specific detail on how residents must be supported. This requirment has been repeated for a third time. A further failure to comply will result in enforcment action Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 26 Timescale for action 31/03/06 31/03/06 3 OP7 15(1) 28/02/06 4 OP9 13(2) being taken. The registered persons must implement a recorded procedure for making routine checks on the administration and recording procedures for medication. This requirement has been repeated for a third occasion. A further failure to comply will result in enforcment action being taken. The registered persons must ensure a record is kept of the outcomes and treatment required following a visits to and from health care professionals. This requirement has been repeated. A further failure to comply will result in further action being taken. The home must ensure all wash hand basins in residents’ bedrooms are working correctly. Baths and wash hand basins must be fitted with plugs unless residents are individually assessed as at risks. This requirement has been repeated for a third time. A further failure will result in enforcement action being taken. The registered providers must refurbish the: 1.Kitchen 2.Downstairs toilet 3.The bedroom identified at the time of the visit. An action plan must be sent to the Commission for Social Care Inspection by the stated timescale detailing when the works will be carried out. 28/02/06 5 OP8 17(1) 28/01/06 6 OP21 13(4) 23(2) 28/01/06 7 OP19 16(2) 23 28/01/06 Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 27 8 OP26 13(3) 23(2) (Times scales will be negotiable). The registered providers must ensure the downstairs toilet is cleaned regularly and toilet tissue replenished as required. The registered providers must seek advice from the appropriately authority on maintaining a hygienically environment with regards to cross infection. I.e. Toilet areas 28/02/06 9 OP26 13(3) 16(2) 23(2&5) 28/02/06 10 OP26 13(3) 23(5) 16(2) The registered providers must seek advice from the appropriate authority with regards to the correct laundering facilities required in the home. The registered persons must ensure staff receive infection control training. The registered providers must ensure that staff fully complete their induction in a timely fashion as per TOPSS guidelines and adopt an induction process such as the Learning Disabilities Award Framework which is resident specific. This requirement has been repeated. A further failure to comply will result in further action being taken. 28/02/06 11 OP30 18 31/03/06 12 OP30 18(1) 18(2) 28/02/06 13 OP29 19 The registered providers must operate a thorough recruitment procedure and ensure all staff have the appropriate checks undertaken on them prior to employment. This requirement has been 01/11/05 Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 28 subject to enforcement notice 17th May 2005. The Commission for Social Care Inspection will consider taking further action if the requirement is not complied with. 14 OP31 8(1) The registered persons must make application to the Commission for Social Care Inspection to register a manager. The home must produce a quality audit that includes the views of the residents, commissioners, relatives and professionals by the given date. The quality audit must then be forward to the Commission for Social Care Inspection. This requirement has been repeated for a third time. A further failure to comply will result in enforcement further action being taken. 16 OP14OP17 OP35 16(2) 5(1) The organisation must establish a robust system to support residents who can manage their own financial affairs including rent. This issue is currently with the Commission for Social Care Inspections Providers Relationship Manager. 28/02/06 31/12/05 15 OP33 12(2&5) 24(1&2) 06/03/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 29 No. 1` 2 Refer to Standard OP2 OP30 Good Practice Recommendations The registered persons are advised to produce the contract in an accessible format for the residents. The registered persons are advised to ensure all records pertaining to staff are kept in the home. I.e. Induction records. Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Starboard House DS0000042317.V277282.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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