Inspection on 09/08/06 for Summerville

This inspection was carried out on 9th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12 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 10/02/06

Summerville 21/06/05

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 Key Unannounced Inspection 9th August 2006 12:00 Summerville DS0000028712.V302336.R01.S.doc Version 5.2 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.V302336.R01.S.doc Version 5.2 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.V302336.R01.S.doc Version 5.2 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 Post Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th August 2002 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. Fees are: £1,100 to £2,600 pre week. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection consisted of an unannounced visit to the home on 9th August by one inspector. The inspection takes account of information received from a variety of sources including written information from the registered providers, care managers. The previously made requirements and recommendation from other inspections were inspected and all key standards. The inspectors spent time observing and talking to service users to gain their views. A partial tour of the premises was conducted. Documents and records were seen and service users files were case tracked. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to ensures that information is cross-referenced between the various sections of the service users file and is kept up to date, by conducting audit of the files regularly. The annual quality assurance programme needs to be implemented and a report produced. Sufficient numbers of care staff should be provided at all times to meet the service users needs and comply with their care plan. The registered provider needs to conduct monthly Regulation 26 visits to the home and a report produce. The procedures used to recruit new staff need to improve to ensure they are fully vetted before they start work. The environmental certificates needs to located and renewed accordingly. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 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.V302336.R01.S.doc Version 5.2 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): 125 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” A formal documentation for the assessment of needs of a prospective service user is being developed. The service user contract and statement of purpose have not been reviewed and updated. EVIDENCE: The Commission has not been provided with a copy a revised statement of purpose and staff at the home were not able to produce a copy of it. The company has produced a new pre-admission assessment tool. At the time of the inspection visit, the home did not have any service user vacancies. The service user contract needs updating and does not include the provision of care and care staff under the section for “ what are included in the fees”. Although these are referred to in other sections of the contract. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 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): 679 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Service users files have provide adequate information to provide care to meet service users needs. Behaviour needs are met with evidence of good multi disciplinary working taking place. Confidential information is stored securely. EVIDENCE: Service users care plans identify their needs including aspects relating to behavioural issues. The daily records now provide a clear picture of the service users day, the care provided and the service users behaviours during the day. Each service user has their own risk assessments, although these had been reviewed, an observed change in practice for staff and service users is in direct conflict of the service users risk assessment, therefore this should be reviewed immediately. The risk assessment states the service users should Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 10 not be in the kitchen whilst hot appliance (oven) were in use or left unsupervised, however it was observed that a meal was being prepared whilst the service user was seen sitting at the kitchen table during lunch being prepared. All of these documents provided evidence that they are supported to participate in daily living activities. Multi-disciplinary agencies are regularly involved in the reviews of individuals needs. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 17 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Service users are supported to participate in activities of their choice. A nutritious and varied diet is provided. At this inspection visit Standard 12 is not applicable. EVIDENCE: All of the service users have needs that impact on their ability to find appropriate employment and to attend further education. Service users go on holidays every year and records showed that a caravan holiday has been arranged. Activities include going out on trips as well as day-to-day independent living activities. 1:1 support is provided for short periods of time for one service user to focus on an activity within the home. Service users require 2:1 support to go out, reduced staffing levels could be impacting on the frequency of trips out. Meals are chosen daily by service users according to their preferences, with staff ensuring a balanced diet is achieved, although there is a menu to follow if needed. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 12 Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 13 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): 18 19 20 21 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Service users are supported with dignity and respect when personal care is provided. The health needs of service users are met and there is some evidence of good multi disciplinary working taking place. Staff are aware of emotional and behavioural triggers and respond appropriately. Medication is not administered and recorded following safe practices and procedures. EVIDENCE: A new medication cupboard has been acquired and installed and medication cupboard is no longer stored in the kitchen. The company medication policy has been reviewed and now includes procedures for emergency medicines. The medication audit revealed a number of poor practices by staff; the keys were left in the medication cupboard door, there were gaps in the signature on the MAR charts and discrepancies in tablet numbers. At the time of the Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 14 inspection no records of medications received into the home have been completed. Although staff state that the acting manager conducts regular medication audits, no recorded evidence of these could be located. Daily reports record that personal care and emotional needs are being met. 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. Observations of interactions between staff and service users were positive and dignified. One service user had started to perform a repetitive behaviour, the carer remained calm and spoke to the in a peaceful, gentle manner. Records show that health care professionals are accessed appropriately and service users are supported to attend appointments. The new policy for managing the needs of an ageing service user needs does not include action to be taken by the home to support them staying in the home rather than having to relocate them. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 15 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 23 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Policies and procedures are implemented for dealing with complaints and adult protection issues. EVIDENCE: One new complaint has been received since the last inspection visit. Accounts and receipts are kept of service users monies and a recent review by care managers stated that these were in order. However the procedure for recording monies is a single signature one. Changes in recording of self-injury have been implemented to help provide evidence of such incidents. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 16 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 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The building is reasonably maintained and meets the needs of the service users. Some staff do not adhere to infection control procedures. EVIDENCE: An annual maintenance programme has been produced, however the acting manager has also taken on the role of maintenance person, resulting in much of the work has not been completed. The outside of the home would benefit from being redecorated. Service users were observed enjoying the communal areas of the home. Internally there is damage evident caused by the service users. One carer stated that they are still hand sluicing soiled bed linen. However other care staff confirmed that they use the alginate bags for this. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 17 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): 32 33 34 35 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Recruitment procedures are poor and place service users at risk. Staff have gained appropriate knowledge and skills via their training programme. New staff have not completed induction training EVIDENCE: Service users require 1:1 support at times within the home and 2:1 support to go out; at the time of the inspection there were two carers on duty. The care staff also undertake cooking, cleaning and laundry duties. The duty rotas show that the staffing numbers are barely adequate when all staff are available, however many work overtime and there is no allowances for staff holidays, sickness and training. The acting manager has implemented training programmes to ensure all staff complete the required mandatory courses, as well as other appropriate training. 45 of the care staff have completed the NVQ training. The company needs to ensure that this has included the Learning Disability Award Framework. The induction programme has been update to comply with the guidance from “Skills for Care”, however in the acting managers absence there was no evidence of new staff completing it. The senior carer stated that they believed staff are given the induction book Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 18 when they start work. The two newly recruited members of staffs files were assessed. Both staff started work before the POVA First and CRB checks were completed. There was no interview record and clarification of work permits is needed. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 19 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): “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The quality of service provided is not assessed and monitored. The health & safety and welfare of both staff and service users are not ensured by current procedures. EVIDENCE: At the time of the inspection visit, the acting manager has not made a formal application to become the registered manager. The acting manager has taken on the role of company maintenance person, which takes him away from his responsibilities as manager. Policies and procedures have been reviewed and updated by the company. Records such as daily reports have improved significantly these now provide a clear account of the service users day, including care provided and the detailing of behaviours and outcomes. The company representative confirmed that no regulation 26 visits have been conducted and that the annual quality assurance programme has not been carried out. The majority of the environmental certificates could not be Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 20 located. The fire log book showed that most of the fire checks are conducted on time with the occasional date missed. A fire company has the contract for the servicing and maintenance of the fire equipment. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 21 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 Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 N/A 2 1 3 2 1 X Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 22 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. Standard YA1 Regulation 4 5 sch 1 Requirement To update the statement of purpose and send the amended copy to the CSCI. Previous timescale: 31/05/06 The manager must use a crossreferencing system between the care plan and other sections of the service users file such the guidelines. Individual service users risk assessments must be amended promptly once a change has been in practice and/or need has been identified. All staff must comply with the risk assessments. All staff must adhere to the homes policies and procedures for the safe handling of medicines. The Keys must not be left in the medication cupboard. All medication must be signed for when administered. Records of medication received into the home must be kept. DS0000028712.V302336.R01.S.doc Timescale for action 30/11/06 2. YA6 12-15 17 30/11/06 3 YA9 13 30/08/06 4 YA20 12 13 14 17 sch 3 30/08/06 Summerville Version 5.2 Page 23 Prescribed medication must only be given to the person it was prescribed for. Regular audit need to be conduct with a record of the findings and action taken produced. 5. YA24 13 23 The registered person must ensure the maintenance programme is acted upon and appoint a person other than the acting manager to carry out the work, within this home and the other homes owned by the company. Sufficient numbers of care staff must be provided at all times to meet the service users needs and comply with their care plan. These levels must be kept under regular review. Previous timescale: 31/05/06 A thorough recruitment procedure must be implemented ensuring the safety and welfare of the service users. Previous timescale: 31.08.05 & 31/05/06 All new staff must complete an induction programme, progress should be monitored and evidence of completion available in 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 & 30/06/06 For an application to be made to appoint a registered manager. Gas and electrical servicing and certificates must be located and if not able to locate them DS0000028712.V302336.R01.S.doc 30/11/06 6. YA33 18 15/09/06 7. YA34 7 8 9 19 sch 2 30/08/06 8 YA35 12 18 30/08/06 9. YA39 10 12 15 24 30/11/06 10. 11. YA37 YA42 8 9 10 4 13 17 23 37 30/11/06 30/11/06 Summerville Version 5.2 Page 24 replacements obtained. Copies of the certificates to be sent to the CSCI. Previous timescale: 31.08.05 & 30/06/06 12 YA43 25 The registered provider is required to write to the CSCI detailing the financial status of all of the care homes owned by Manor Care Homes Ltd. 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA30 Good Practice Recommendations The manager needs to ensure all staff adhere to infection control procedures. Summerville DS0000028712.V302336.R01.S.doc Version 5.2 Page 25 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. 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