Inspection on 21/06/05 for Summerville

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Summerville 07/08/08

Summerville 08/10/07

Summerville 09/08/06

Summerville 10/02/06

Summerville 20/12/04

Summerville 12/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Summerville Prices Avenue (39) Margate Kent CT9 2NT Lead Inspector Clair Brown 21 st Announced June 2005 10.10 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. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Summerville Address Prices Avenue (39), Margate, Kent, CT9 2NT 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) Manor Care Homes Ms Lianne Eilzabeth Rollins Care Home 3 Category(ies) of Learning Disability (3) registration, with number of places Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12.07.04 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 carry out meal preparation and domestic work as part of their duties. At night there are waking night staff. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Homes announced inspection. The registered provider owns a total of three small homes within the area, all providing a similar service. It was agreed that the three homes would be inspected together, spending a day in each home, with the registered provider and /or his representative present at all three homes. The Summerville inspection was conducted by one inspector in one day and the duration was 5 hours. A tour of the building was conducted, documents and records were examined and service users files were case tracked. The Home accommodates three services users, two of their relatives completed inspection questionnaires. This was the inspectors first time at the Home and so not to unsettle the service users time was spent observing how the Home and its staff operate. What the service does well: What has improved since the last inspection? What they could do better: The Home needs to develop a document to assist with the assessment of prospective service users. The long-term upkeep and maintenance of the buildings needs to be planned in advance. The procedures for preventing the spread of infection needs to be improved and the registered manager must ensure the appropriate equipment is provided, such as gloves and aprons, liquid soap and paper towels. Mandatory training such as first aid and movement & handling needs to be completed by all staff. The processes used for recruiting staff need to ensure that all of the safety checks are conducted Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 6 prior to staff being employed. A monitoring system is required for assessing the quality of service the Home provides. Health & safety checks need to be conducted at the required time and recorded. This includes fire, electrical and gas inspections. 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 H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 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 standard(s) 1,2,3 The statement of purpose does not provide up to date information to enable prospective service users to make an informed decision. There is no formal procedures and documentation for the assessment of needs of a prospective service user. The service users needs are individually met. EVIDENCE: The statement of purpose has not been reviewed recently and the registered provider was awaiting the judgement on one Homes document before writing the others. Due to the service the home provides this document would benefit service users being presented in an appropriate format. Relatives expressed the service users were content living at the Home, receiving a quality of care and lifestyle they enjoy. The Home does not have a pre-admission assessment tool for assessing the needs and suitability of prospective service users. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10 There are clear and consistent care plan systems with risk assessments and records of emotional /behavioural triggers in place to adequately provide staff with the information they need to meet service users needs. Confidential information is stored securely. 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. Assessments tools were up to date and the information was collated to identify patterns of behaviour and occurrences of events. There are six monthly review meetings of the service users, with care managers and relatives invited to join the meeting. A report following this meeting is produced. The Home is looking at introducing “person centred” plans. The Home is now registered with Data Protection and confidential files were stored in a locked cupboard. See text for standard 22. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16,17 Service users are supported to participate in activities of their choice and to attend further education. A nutritious and varied diet is provided. EVIDENCE: The registered manager spoke of the activities and the many holidays the service users have been on and these were supported by documentary evidence. Activities include going out on trips, going to the local nightclubs as well as day-to-day independent living activities, such as going food shopping. Additional staff are provided to support service users individually to fulfil their choice of activity. The service users go on several holidays a year, which vary in destination and type of holiday, such as holidays abroad and caravan holidays in England. Meals are chosen daily by service users according to their preferences, with staff ensuring a balanced diet is achieved. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 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 standard(s) 18,19,20,21 Service users are supported with dignity and respect when personal care is provided. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. Staff are aware of emotional and behavioural triggers and respond appropriately. Medication is not administered, stored and recorded following safe practices and procedures. There is no plan in place for preparing of the ageing of service users. EVIDENCE: Daily reports record that personal care and emotional needs are being met. The registered manager was able describe how behaviour triggers are monitored. Staff are aware of what can cause a service user to become agitated or distressed and the appropriate action to take to pacify the situation, or even avoid it occurring. Relatives’ responses to the pre-inspection questionnaires say their family member is well cared for and they are happy with the care provided. Medication were seen to be stored in a locked kitchen cupboard, with internal and external medicines stored together. There were out of date emergency medication. There was evidence of two service users receiving medicine from one packet of prescribed medication. No records are kept of medicines received into the Home or returned to the chemist. The preparation for the Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 12 ageing of service users was discussed; the registered manager stated that no plans had been made to date. This needs to be kept under regular review to ensure these needs are not over looked. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 13 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) 22,23 Service users and relatives opinions are listened to and taken seriously. Procedures are implemented to protect service users from abuse. EVIDENCE: On the inspection questionnaires one relative have said they know who to talk to if they have any concerns and are confident the matter would be dealt with promptly. Another relative was not aware of the Homes complaint procedure, but had never needed to make a complaint. A revised complaints procedure has been seen. This procedure stated “making entries in a complaints book”, which could raise issues of confidentiality. The complaints procedure does not include the required timescale of 28 days for responding to a complaint. The Home has purchased the Multi-disciplinary team adult protection procedure and added this to the Homes own procedure. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 14 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) 24,25,26,27,28,29,30 The Home provides suitable accommodation for the service users. Management of the maintenance of the building is inadequate. Standard 29 is not applicable. Infection control procedures do not prevent the possible spread of infections. EVIDENCE: The Home is a large detached house with accommodation provided over two floors. The Home has three large single bedrooms and sufficient communal space to meet the needs of the Home and the service users. There are a selection of communal rooms which are utilized according to individual preferences. The current service users do not have any mobility problems and are easily able to access the building and do not require any aids or adaptations. Therefore standard 29 is currently not applicable but it will necessary for the registered manager to keep this under constant review as needs change. Although maintenance has been carried out there are no formal maintenance programme and no records of work being completed. The Home is pleasantly decorated and the bedrooms contain personalized with possessions. The first Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 15 floor bathroom is heavily worn and needs repairing or replacing. At the time of the inspection care staff sluice by hand soiled linen, this is an unsafe practice. Staff must be provided with the equipment to adhere to infection control procedures, such as liquid soap, paper towels, gloves, aprons and alginate bags for soiled laundry. These must be supplied in all areas where personal care is provided. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.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) 32,33,34,35,36 Care staff are provided in sufficient numbers to meet the needs of the service users. Recruitment procedures are not thorough and do not ensure the safety and welfare of the service users. A TOPSS induction programmes have been accessed but not implemented. Individual staff training programmes and a training matrix have been introduced. Staff have not completed mandatory training. Existing staff are regularly supervised. EVIDENCE: The Home employs one registered manager and ten support workers. At night staff are currently employed to work an awake shift. This was implemented when the registered manager reviewed the staffing levels and the service users needs and identified the Home needed to employ waking night staff rather than sleep-in staff. 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. No written references had been obtained, although a CRB & POVA check had been completed. New staff are initially started on the Homes basic induction programme, which covers areas of providing basic care and being introduced to the Home layout and basic procedures. The Homes has acquired the TOPSS Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 17 induction programme but has not fully implemented yet. 40 of care staff have achieved NVQ level 2 or 3 qualification in care. Individual training programmes and training matrix have developed to identify staffs training needs and to monitor what training is provided. Currently very few staff have completed the mandatory training required such as movement & handling. Staff files show records of formal staff supervision, these sessions have occurred at least six times in the last 12 months. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.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) 37,38,39,40,41,42 The manager is appropriately qualified and who has the skills to lead the staffing team. The quality of service provided is not regular 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 the registered managers award qualification. The registered manager was very open and keen to identify areas that required improvement. There is no quality assurance programme in place and the monthly visits have not been conducted. Routine health & safety checks and servicing has not been conducted as required. The electrical certificate had expired. The fire safety checks have not been tested quarterly by the specialist engineer despite the Home having a contract with a company for these checks. The Homes policies and procedures have not been reviewed since 09.04, although some have not been reviewed for a longer period of Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 19 time. The legibility of some handwriting in the daily reports was almost impossible and will need to be improved. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.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 2 2 3 x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 N/A 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Summerville Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 2 x H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 21 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 YA2 YA20 Regulation 14,15 12, 13, 14, 17, schedule 3 Requirement A pre-admission assessment tool must be developed and implemented. Records of medicines received into the Home and those returned to the chemist must be kept. Medication for internal and external use must be stored seperately. Medication must not be shared between service users from one prescription. To review the Homes compalints procedure to ensure data protection and confidentiality. Also to include a 28 day time frame for responding to a complaint. The manager must produce and implement a maintenance programme for the building. Records of maintenance work completed must be kept. The bath on the first floor must be repair or replaced. Infection control procedures that protect both staff and service users must be implemented. These must include the provision of liquid soap, paper towels, Timescale for action 31.12.05 31.08.05 3. YA22 17,22 31.10.05 4. YA24,27 13,23 31.12.05 5. YA30 12,13,16, 23 31.10.05 Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 22 6. YA34 7,8,9,19 schedule 2 12,13,18 7. YA35 8. YA39 10,12,15, 24 9. YA42 4,13,17,2 3,37 10. YA1 4,5, schedule 1 gloves, aprons and foot operated bins. Infection control procedures for handling soiled linen must include the use of alginate bags. A thorough recruitment procedure must be implemented ensuring the safety and welfare of the service users. All staff must complete manadtory training courses. Staff to be trained in First Aid. previous timescale:31.12.04 An annual quality assurance programme to be developed and implemented. Regulation 26 visits to be conducted and a report produce and sent to CSCI. This was a previously made requirement :timescale Gas and electrical servicing and certificates must be conducted at the correct intervals. Copies of the certificates to be sent to the CSCI. Fire tests and servicing of equipement must be conducted at the required intervals. To review the statement of purpose and send the amended copy to the CSCI 31.08.05 31.12.05 31.12.05 31.08.05 31.12.05 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. Refer to Standard YA20 YA21 YA40 Good Practice Recommendations 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. To review the Homes policies and procedures, ensuring their accessability for all. H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 23 Summerville 4. 5. YA41 YA42 That clear handwriting is used in all written records. To consider the provision of the fire precautions and equipment for the kitchen door. Summerville H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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 H56-H02 S28712 Summerville V225307 20062005 Stage 4.doc Version 1.30 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. 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!