CARE HOME ADULTS 18-65
Summerville Prices Avenue (39) Margate Kent CT9 2NT Lead Inspector
Clair Brown Unannounced Inspection 14.15 10 February 2006
th Summerville DS0000028712.V266502.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 Summerville DS0000028712.V266502.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. Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Summerville Address Prices Avenue (39) Margate Kent CT9 2NT 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) Manor Care Homes Ms Lianne Elizabeth Rollins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: Summerville is a large detached property providing accommodation on two floors. There is a pleasant walled garden to the rear of the property with parking for 3-4 cars. Unlimited off street parking is available. The Home is situated within walking distance of some of the local amenities. The aim of the Home is to provide long term care for the service users enabling them to live as independently as possible in a homely and stimulating environment. The Home employs a registered manager and care staff. The staff carries out meal preparation and domestic work as part of their duties. At night there are waking night staff. Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the Homes unannounced inspection. The registered provider owns a total of three small homes within the area, all providing a similar service. The Summerville inspection was conducted by one inspector in one day and the duration was 3.5 hours. A partial tour of the building was conducted, documents and records were examined and service users files were case tracked. What the service does well: What has improved since the last inspection? What they could do better:
Medication for internal and external use needs to be stored on separate shelves. It would beneficial for the home if it obtained and installed proper medication cupboards. All staff need to be made aware of the new complaints form and the procedures when receiving a complaint. A maintenance programme for the building needs to be produced for 2006/07. The dining furniture needs replacing with a more appropriate style of table and chairs. Recruitment procedures should be thorough to ensure the safety and welfare of the service users. All staff need to complete mandatory training courses, with training records kept up to date and any gaps in training identified with appropriate courses attended. Staff that prepare and cook meals should attend basic food hygiene training and adhere to the procedures. Staffing levels should correspond with the needs of the service user as detailed in the individual care plans. The annual quality assurance programme needs to be
Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 6 completed with Regulation 26 visits conducted and a report produce. Daily reports are needed to clearly record all aspect of care provided, linking them to the care plan. All records have to be kept within the home. Gas and electrical servicing and certificates must be conducted at the correct intervals with fire safety tests, drills, instructions and servicing of equipment conducted at the required intervals. The fire risk assessment needs to be regularly reviewed. 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. Summerville DS0000028712.V266502.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 Summerville DS0000028712.V266502.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): 12 The statement of purpose does not provide up to date information to enable prospective service users to make an informed decision. A formal documentation for the assessment of needs of a prospective service user is being developed. EVIDENCE: A new statement of purpose has not been updated to reflect the current management status of the home. The home has no service user vacancies, however the home needs to be prepared in case the situation changes. Therefore the company is developing a pre-admission assessment tool for assessing the needs and suitability of prospective service users. Summerville DS0000028712.V266502.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): 69 There are care plan systems with risk assessments and records of emotional / behavioural triggers in place to provide staff with the information they need to meet service users needs. There are some contradictions between the care plan and the actual care provided. EVIDENCE: The service users files contain detailed care plans, risk assessments and details of emotional/behavioural triggers. These documents were very detailed and specific to each service users particular needs. There are six monthly review meetings of the service users, with care managers and relatives invited to join the meeting. Some reviews of the care plans were overdue and all needs to ensure all current information included. One service user has a need relating to their bowels, which was not included. Some of the documents were old and should be archived. Daily reports did not detail aspects of care provided and some days would just record that someone had watched television. The acting manager stated that 2 service users only require 1:1 support outside of the home the other service user required 1:1 support within the home and 2:1 outside of the home. However the service users care plans stated that at least 2 of the service users require 1:1 support within the home. At the time of the inspection there was one carer for two service users, of which at least one required 1:1 support.
Summerville DS0000028712.V266502.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: Summerville DS0000028712.V266502.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 Medication practices and procedures have improved. EVIDENCE: Medication was seen to be stored in a locked wooden cupboard. The policy and procedure would benefit from the inclusion of emergency medicines. Internal and external medications were stored together rather than separately. Records of receipt and returns of medicines are now kept. The same prescribed medication is no longer shared between service users, now the service users individual medicine is administered. Summerville DS0000028712.V266502.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): 22 The staff are not aware of their role and the procedures for the handling of a complaint. EVIDENCE: The company has developed a new form for the recording of complaints, which should maintain confidentiality. When talking to the acting manager, staff are not fully aware of the new form and do not know what to do if they received a complaint. Summerville DS0000028712.V266502.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): 24 28 30 The environment has been improved to benefit both the service users and the staff. EVIDENCE: A number of changes have been made to the environment, which has enhanced the living environment for the service users. A bathroom has recently been refurbished. Liquid soap and paper towels have been provided throughout the home. The dining room would benefit from some new and more appropriate furniture rather than plastic garden chairs. A maintenance programme is needed for the coming year. Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 14 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): 33 34 35 Care staff are provided in sufficient numbers to meet the needs of the service users the majority of the time. Recruitment procedures are not thorough and do not ensure the safety and welfare of the service users. EVIDENCE: The Home employs one acting manager and a team of support workers. At night, staff are currently employed to work an awake shift. At the time of the inspection there were 3 service users and 3 support workers plus the acting manager. Two support workers had taken one service users out shopping. (See text for individual needs and choices). The numbers of carers on duty at any one time will vary according to the day to day needs of the Home and the service users. Additional staff are provided to cover outings and activities and holidays. The most recently employed member of staffs recruitment file was assessed. This showed that recruitment procedures had not been followed; the CRB & POVA First check had not been completed. There was no interview record although there two written references and copies of proof of identity. Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 15 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 38 39 40 41 42 The acting manager is newly appointed and is developing their own management style. The quality of service provided is not regularly assessed and monitored. The health & safety and welfare of both staff and service users are not ensured by current procedures. EVIDENCE: The registered manager has resigned on health grounds and the home is currently managed by an acting manager. The acting manager is eager and enthusiastic and stated he had gained a lot from this inspection, he was very open and keen to identify areas that required improvement. . Environmental health &safety certificates such as the gas and electrics were not within the home. The fire risk assessment has not been reviewed since 2004 and there had not been a fire drill / instruction for a year. Staff preparing food for the evening meal where using the hand washbasin for food preparation. The sending out of questionnaires has started the quality assurance programme but the process needs completing by collating the information gathered and producing a report and action plan. The registered provider does not complete regulation 26 visits and reports. Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 16 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 2 2 X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X 2 N/A 3 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 1 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Summerville Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 2 2 X DS0000028712.V266502.R01.S.doc Version 5.0 Page 17 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 Standard YA1 YA6 Regulation 4 5 sch 1 12-15 17 Requirement To update the statement of purpose and send the amended copy to the CSCI. The manager must ensure that cross-referencing between the various sections of the service users file is up to date and completed. Old documents should be archived. Medication for internal and external use must be stored separately. Previous timescale:31.08.05 All staff must be aware of the complaints form and the procedures when receiving a complaint. The registered person must develop and implement a maintenance programme for the home for 2006/07. To review the dining furniture and consider more appropriate style of table and chairs. Sufficient numbers of care staff must be provided at all times to meet the service users needs and comply with their care plan.
DS0000028712.V266502.R01.S.doc Timescale for action 31/05/06 31/05/06 3 YA20 12 13 14 17 sch 3 17 22 31/05/06 4 YA22 31/05/06 5 YA24 13 23 30/06/06 6 7 YA24 YA33 13 23 18 30/06/06 31/05/06 Summerville Version 5.0 Page 18 8 YA34 7 8 9 19 sch 2 9 YA35 12 13 18 10 YA37 38 11 YA38 38 12 YA39 10 12 15 24 13 YA41 15 17 These levels must be kept under regular review. A thorough recruitment procedure must be implemented ensuring the safety and welfare of the service users. Previous timescale:31.08.05 All staff must complete mandatory training courses. Previous timescale: 31.12.04 & 31.12.05 Training records must be kept up to date and any gaps in training identified with appropriate courses attended. All staff that prepare and cook meals must complete basic food hygiene training and adhere to the procedures. The registered provider is required to confirm in writing the current management arrangements of the home. The registered provider is required to confirm in writing the current management arrangements of the home. An annual quality assurance programme needs to be completed. Regulation 26 visits to be conducted and a report produced and sent to CSCI. Previous timescale:31.12.05 Daily reports must clearly record all aspect of care provided, linking to the care plan. 31/05/06 30/06/06 17/02/06 17/02/06 30/06/06 31/05/06 14 YA42 4 13 17 23 37 All records must be kept within the home. Gas and electrical servicing and 30/06/06 certificates must be conducted at the correct intervals. Copies of the certificates to be sent to the CSCI. Fire tests, drills, instructions and servicing of equipment must be conducted at the required intervals. The fire
DS0000028712.V266502.R01.S.doc Version 5.0 Page 19 Summerville risk assessment must be regularly reviewed. Previous timescale:31.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA20 YA20 YA21 YA41 Good Practice Recommendations To include emergency medicine procedure / prescription in the medication policy. To consider purchasing a medication cupboard and to site it in an area other than the kitchen. To develop and implement a procedure for monitoring the ageing needs of the service users and then actioning how to meet these needs. That clear handwriting is used in all written records. Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Summerville DS0000028712.V266502.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
