Inspection on 05/02/08 for Summerville House

This inspection was carried out on 5th February 2008.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Summerville House 29/09/09

Summerville House 23/10/08

Summerville House 15/08/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Summerville House Fenway Heacham Kings Lynn Norfolk PE31 7BH Lead Inspector Kim Patience Unannounced Inspection 5th February 2008 10:30 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 Summerville House DS0000068947.V358996.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 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. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerville House Address Fenway Heacham Kings Lynn Norfolk PE31 7BH 01485 572127 01485 572548 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) ARMS Associates Ltd Manager post vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24) of places Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2007 Brief Description of the Service: Summerville is large detached, two storey, converted barn in the village of Heacham. The seaside town of Hunstanton is approximately five miles away. The home provides care for up to twenty-four older people with dementia. The home has sixteen single and four shared bedrooms. There is a large lounge and separate dining room. The home has a passenger lift and a chair lift for access to the first floor. There is a secure garden, which the residents have access to. The current fee rates are between £380 and £393. There are additional charges for items such as hairdressing and private chiropody. People are advised verbally of the relevant charges before the person is admitted to the home. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means that people using this service experience poor quality outcomes. This site visit was unannounced and took approximately 7 hours to complete. The report considers information gathered since the last inspection held in August 2007 and information gathered from this site visit. During the site visit, a tour of the premises was completed and records relating to residents, staff and the running of the service were inspected. Residents, relatives and staff were spoken with and observations of daily life in the home were made throughout the day. The manager was present during the visit and was helpful in facilitating the process. Feedback was provided in brief at the end of the visit. What the service does well: What has improved since the last inspection? A new manager was appointed and commenced in November 2007. Since then improvements have been made to residents’ care plans and associated records. The mealtime experience was much better than observed at the last inspection and the experience was enhanced by the improvements made to the dining room that aid recognition and make it more conducive to dining. Other improvements have been made to the environment such as the replacement of flooring and work is underway to create two new conservatories that will increase the amount of communal space and provide choice. New staff have been appointed and the home is following the correct recruitment procedures before any new staff commence work in the home. The Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 6 amount of training has been increased and staff are being offered the opportunity to undertake NVQ training. What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 7 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 Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good as people who use the service can be assured their needs will be assessed and they are offered the opportunity to assess the suitability of the service prior to moving in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure for new admissions. A service users guide is supplied to all people who express an interest in the service and a pre admission assessment is completed. Since the last inspection the home has introduced a new pre admission form. The file relating to one resident recently admitted was inspected. On this occasion a pre admission assessment was completed and provided sufficient information to determine whether the home can meet the person’s needs. Since the last inspection the Commission has received a complaint regarding the fees charged by the home for some services. During the investigation into Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 9 these matters it was identified that the home only issued privately funded residents with a contract and not those funded by the local authority. The home was advised that the regulations require that all residents should be provided with a contract and the matter has now been rectified. Other elements of the complaint were investigated by Norfolk County Council contracts section and the Commission. It was the view of both agencies that the additional fees charged were not acceptable as the fee should relate to service needed to meet people’s holistic needs. Additional charges for toiletries, advocacy and social activities are not acceptable. The provider agreed to review the arrangements and has updated the terms and conditions of the service, which is available on the homes website. The revised terms and conditions show that the Levy of £5.00 for social activities has been removed, however, the additional charges for advocacy and toiletries are still current. The home does not provide intermediate care services. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor as people using the service cannot be assured that the home has systems in place to ensure the health and welfare of people living in the home is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the quality of the residents’ records has improved and progress has been made to ensure that all residents now have care plans. The records relating to three residents were assessed in detail. Each was found to contain care plans, health assessments and risk assessments that were completed adequately. There was some detailed information relating to the individuals’ previous experiences and some had been translated into care plans to make them more meaningful and individual. The manager has completed care plan reviews on all residents with the involvement of relatives/advocates and this is good. The reviews enable people to comment on any concerns they may have and on Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 11 what they would like to change. The manager should ensure that relatives/advocates are asked to sign in agreement with the review. The home has introduced new care plans and associated records and it was noted that some of the key information from the old records has been lost during the transfer of information. For instance, for one resident the old records stated that he wears glasses at all times, observations showed that he did not have glasses on and this information did not show in the updated records. When questioned, the manager stated that he has never worn glasses, but clearly he had been assessed as needing them at one time. In addition, for the same resident, old records showed that he has his own teeth, yet there is no mention of oral hygiene in the new care plans and how staff will support with this task. All care plans must accurately reflect people’s needs and a recommendation is made that all care plans are reviewed along with old records to ensure that all relevant information has been transferred effectively. The home has introduced a personal hygiene checklist and this is a good way of showing whether needs are being met in accordance with the care plans. However, these were not completed consistently and therefore it appeared that some needs were not being met. For instance, for one resident it appeared as though he had not had a bath for several weeks, but the daily records showed he had a bath 2 weeks previously. The resident’s preferences in relation to bathing were not written in the care plan. The manager must now continue to make progress with care plans and associated records to make them more individualised and to include personcentred information such as personal preferences based on their previous life experience. The manager must also work toward eliminating inconsistencies in record keeping as some did not contain important information such as GP visits and medical intervention records. Some health assessments such as nutritional needs, pressure care assessments and falls assessments had been completed. However, these were not necessarily followed up with a care plan/risk assessment setting out the action to be taken in response to risks identified. For instance, an assessment showed there was a high risk of falls, but there was no guidance for staff about what steps should be taken to minimise risk. Another example is where a nutritional needs assessment identified a risk of obesity there was no action plan in place to address this. Risk assessments must be in place for all risks including those relating to hazard within bedrooms. (see standard 19) Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 12 Daily records were examined and found to lack sufficient information about daily events. Care staff must be provided with further training on the importance of recording accurate daily notes containing sufficient detail so that the reader can determine what daily life is like and what decisions have been made on behalf of the person and why. This is essential to demonstrate compliance with the new ‘Mental Capacity Act’ (MCA) and this was discussed with the manager. Staff have not yet received training in the MCA and it is essential that they do so as a matter of priority. (see standards 27-30) Accident records were inspected and showed that 11 accidents had occurred in January. Whilst the records were completed and stated what had occurred the follow up and investigation was inadequate. For instance where people had experienced falls the follow up stated ‘observe over the next 6 hours’ but did not offer any longer term solution to minimising the risk. The home does not audit accidents and it is recommended that they do so, to enable them to identify reasons why they occur and what action should be taken in response. At the last inspection there were some concerns in relation to privacy and dignity. Some of those concerns have now been resolved, for instance, net curtains have been placed across the front windows and the small observation windows in some bedroom doors have been covered. However, the manager needs to make further progress in this area to ensure that staff understand how to promote privacy and dignity in all aspects of care. For instance, ensuring that all toiletries are individually named, that they address people appropriately using their preferred form of address, that they promote an appearance that is consistent with their previous preferences. It was noted that some residents appeared unkempt, unshaven and clothing was soiled. In some bedrooms incontinence aids were visible, for instance a male urinal and incontinence pads. In addition, the home must stop the practice of using any resident’s room for hairdressing, as this does not promote the privacy of the individual. An inspection of the medication standard was undertaken on 11/02/08 by the Commission’s pharmacist inspector. This inspection follows the previous pharmacy inspection of 16/08/07 when issues of a serious nature were identified. During this inspection, the inspector found that medicine storage arrangements remain unchanged. Medicines are stored in a small room adjacent to the sitting room on the ground floor. This was untidy, cramped and could compromise safe medicine management. Medicines requiring refrigeration and medicines stored at room temperatures were being stored at excessive temperatures. Concerns were raised in relation to the security of keys to medicine storage. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 13 Procedures followed by staff for the administration of medicines at lunchtime were satisfactory. The inspector noted that staff had difficulty finding out if residents needed their prescribed painkillers. He gave advice on the assessment of residents’ pain so that painkillers are given when needed by residents. It was found that some improvements have been made to systems in place for medicine administration such as the availability of helpful information to assist staff administering medicines and the removal of medicines no longer in use from the medicine trolley to avoid confusion. There was no evidence of the non-availability of medicines for residents. This is seen as an improved outcome when compared to the previous inspection. The inspector looked at the use of medicines of a psychoactive (and potentially sedative) nature prescribed for use at the discretion of care staff. There are residents who are still prescribed higher (some combined) doses of these medicines. It was established that the home had no records of prescriber reviews of these medicines for approximately one year so their need may no longer be valid. It was of concern to find that frequently there was no recorded reference to deteriorating psychological agitation and that some residents experienced excessive sedation after the medicines were given to them. For example, a resident was given lorazepam when daily care records indicate the resident was in a ‘foul mood’. There were no records indicating that the resident or other residents were at risk because of challenging behaviour. The inspector found there to be a lack of detailed resident-focussed care planning relating to both the management of residents’ challenging behaviour and the use of such medicines. There was also no detailed written guidance for staff when giving medicines covertly without residents consenting. We also found that for a resident regularly refusing medicines there were no records indicating that the home has taken action by referring this to the prescriber. The home’s medication record-keeping practices are still poor. There were numerous gaps in records for the administration of medicines so it could not be confirmed that residents have received their medicines as prescribed. Failure to record the administration of medicines immediately following their administration is unsafe practice. It was also found that for medicines not administered as scheduled, records frequently do not accurately record why medicines were not given. The inspector conducted sample audits of medicines to establish if they could be accounted for. Discrepancies were noted for a significant number of these medicines. Where there are deficit discrepancies it is of concern that doses exceeding prescribed limits have been given to residents. Where there are surplus discrepancies, it is of concern that records of medicine administration have been completed but corresponding medicines have not been given to residents. The manager confirmed that the home was no longer conducting its own audit of medicines. Controlled drug register records indicated that a fentanyl patch 25mcg was unaccounted for from 16/10/07. It was also confirmed there was an erroneous medication incident the week previous to inspection where a resident was Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 14 given another resident’s medicine in error. The manager was asked to investigate these incidents and provide the Commission with written reports. A full pharmacy inspection report has been sent to the registered provider listing a total of 9 requirements (7 repeat) and 6 recommendations. The report is available to the public, subject to request. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate, as people who use the service cannot be assured that they have some control over their lives, but the home is working towards providing a service that meets individual needs and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been active in gathering peoples previous life history and incorporating this information into care records. However, social care plans are limited and there does not appear to be any clear information as to how people’s social needs should be met. There is little evidence that activity is planned in an individualised way and little evidence of activity taking place. On the day of inspection, the activities board stated one to one sessions, but observations showed that staff just sat with the residents and there was no individual meaning to that time spent. However, the home does provide some group activities and the plan is displayed in the entrance hall. The manager also stated that some residents had been involved in gardening. Further progress needs to be made in this Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 16 area and the manager must develop social care plans so that meaningful activity can be provided. The mealtime experience was assessed through discussion with the cook, examination of records and brief observation of the lunch and teatime meal. The cook on the day of inspection was previously a domestic and has taken on the role of cook on the days the main cook is not scheduled to work. She has completed a basic food hygiene certificate and showed knowledge of people’s individual dietary requirements. The meal for the day was displayed on a white board in the dining room, the home could make this more meaningful by adding pictures and clear text. The cook had asked people what they would they would like for lunch and their choice was recorded in a menu book. People had a choice of two meals but most residents had chosen the same option. However, observations of mealtimes showed that people were given alternatives as they wished. For instance, one resident had some toast. One resident needed some assistance to dine and the care assistant was seen to sit discretely by her side to give her the help she needed and this is good. When asked, residents stated that they liked the food and most appeared to enjoy the meal. One representative stated that the food looked good and her friend always ate well. Improvements have been made to the dining room to make it more homely and familiar. One resident said ‘look at the lovely tables and all the different colours’ she was referring to the new tablecloths and table accessories. The mealtime experience seemed much calmer and much better than previously found. During the inspection, visitors were seen coming in and out of the home without restriction. One visitor stated that she visited at various times in the week and was always welcomed. On this occasion people did not appear to have their freedom limited in any way and were seen to walk freely around the home. Staff were heard to offer people choices about what they wished to do and this is good practice. The home should consider the use of assistive technology in order to ensure that the privacy of some residents is not compromised by those who like to walk into other rooms. This could also be improved by meeting the individual needs of those trying to orientate independently back to their rooms. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate as people who use the service can be assured that there are systems in place to deal concerns and complaints they may have, however the way complaints are handled and reporting of concerns to the Commission could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that is well publicised in the service users guide and in the homes entrance hall. The manager states she has an open door policy and has informed relatives that she welcomes feedback at any time. The monthly care reviews also provide people with an opportunity to express any concerns they may have. A complaints log is maintained and did not show any complaints on this occasion. However, when we looked at the home’s quality assurance surveys returned by relatives there was a letter of complaint attached to one that had not been dealt with in accordance with the procedures. The manager stated that she had dealt with it, but only as feedback. She was advised to record it as a complaint as it clearly raised concerns about the standard of care to one individual. The Commission has received two safeguarding adult concerns and two complaints since the last inspection. The proprietor was aware of these matters Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 18 and dealt with the issues promptly. However, there was a lack of awareness about the responsibilities as a registered person to report incidents of this nature to the Commission in a timely manner and there was a failure to maintain appropriate communication. All staff have been trained in the protection of vulnerable adults and there have been no new adult protection concerns since the last inspection. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate as people who use the service can be assured that the home provides a reasonable standard of accommodation and an ongoing plan of improvement. However, the home must ensure that the environment is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was completed and some residents’ rooms were entered. Work is underway to improve the range of communal accommodation and two conservatories are being built to the rear of the main lounge and dining room, this will benefit residents and provide more choice. On the day of inspection the home was found to be clean and tidy, however, odours could be detected in places. For instance, the main lounge has a stale Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 20 odour and one resident’s room also had an offensive odour. When discussed with the manager she stated that the resident’s room carpet and flooring had been replaced in order to resolve the problem. The communal facilities were entered and found to be in reasonable order. The bathrooms could be improved by making them more homely and comfortable. Some of the bathrooms contained unnamed toiletries, which indicates that people do not have a choice of products they prefer to use. In addition, there is an issue of safety and these products are potentially hazardous if misused. Similar products such as razors, shampoo and prescribed creams were found in resident’s rooms. When discussed with the manager, she stated that all staff had been told that these products must be stored away safely following use. Risk assessments had not been completed and the home must do so in order to determine what the risk is and what action should be taken to minimise the risk of harm. One bathroom did not have a lock on the door and the handle was broken, this may compromise people’s privacy and dignity. During the tour of the premises the laundry door was found open and the room could be entered without restriction. There were many hazards within the room such as chemicals that could cause harm. A member of staff said the door is usually closed and was aware of the potential risks. In addition, the room in which clean laundry is stored was open and the light was on inside. The room is very small and contains the hot water tanks and was very hot inside, this presents a hazard to people who may accidentally enter the room and are unable to get out. The home must have procedures in place that promote the maintenance of a safe environment. Residents’ rooms entered were of a reasonable standard with many personal items on display. Room doors were open so that people could enter their room without restriction and this is good. However, the home must consider the use of assistive technology to ensure that people’s privacy is not compromised by others entering the room and also to enable staff to provide adequate supervision. The home has made improvements to signage and some directional signage and signposting can be seen around the home. At least one resident was observed to wander around the home and into other resident’s rooms looking for their own room. The home should ensure that individual needs are met and this person may benefit from signage that supports recall and orientation. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor, as people who use the service cannot be assured the home will have adequate staff available to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of the staff rosters were taken and later analysed. The rosters showed that between the 31/12/07 – 03/02/08 the home has not maintained adequate staffing levels. The manager stated that the home was accommodating 21 residents all with a diagnosis of dementia and the home’s target staffing levels were 4 care assistants on duty during the waking day. The rosters show that staffing levels have fluctuated between 1 and four care assistants on duty (four on only one occasion) and in the two-week period the manager appeared on the rota 4 times. Staff spoken with said it had been a difficult time and they have struggled to meet people’s needs. In addition, the home does not have a cook or kitchen assistant at teatime and care staff are required to undertake this role. The home must have staff available in sufficient numbers at all times. Improvements have been made to training and a plan has been developed for the coming year. Staff are provided with mandatory training such as moving and handling and fire safety. The training plan shows that staff are to be trained in areas such as dementia awareness, challenging behaviour and health and safety awareness. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 22 No new staff have commenced employment since the new manager was appointed and during discussions regarding the home’s induction programme the manager seemed unclear about the induction programme used. She was advised to look at the home’s induction package and ensure it meets the common induction standards. This will be assessed at the next inspection. The home is making progress with NVQ training and 6 care assistants are qualified to NVQ level 2, one is in progress and 3 have been registered to start. The home currently employs 18 staff and so should meet the workforce training targets when all staff have completed the training. Four new staff have been appointed recently and the home are awaiting the completion of pre-employment checks. Their paperwork was inspected although the manager said it was not yet complete. Each had completed an application form and attended a face-to-face interview. One application form was not completed in full, it did not show details of previous work history and the application form was not signed. There was no record of interview but the person had been offered a position pending completion of the necessary checks. There were inconsistencies in recruitment practice in all four files and this was discussed with the manager. The manager stated that she knew what the organisations recruitment procedures were, however the files suggest they were not complied with. This will be assessed further at the next inspection. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is poor as people who use the service cannot be assured that the home has management systems in place that promote their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a new manager has been appointed. The manager has significant experience of working in care settings and previously held a deputy managers position in another care home. At the time of this inspection the manager had only been in post 3 months and has made notable improvements in a short period of time. However, significant improvement is still needed before it can be said that the home promotes the health and welfare of residents. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 24 The Commission has not yet received an application for registration of the manager, however the manager states it is her intention to submit an application once she has the agreement of the provider. The home has a quality assurance process that includes stakeholder surveys. At the time of the inspection surveys had been sent to residents and relative and some had been returned. The manager stated that she had taken action in response to the comments made on the surveys and had dealt with them on an individual basis. However, the home needs to collate the responses and find a way of publishing the results and action plan so it can be shared with all stakeholders. Since the last inspection the provider has completed some regulation 26 visits. However, these reports have not been provided consistently on a monthly basis. The manager has started staff appraisals with senior staff. However, there was no evidence of supervision for care staff. The manager must establish and implement a plan of supervision. A number of health and safety issues have been identified in this report. For instance, the home must have effective risk assessments for the maintenance of a safe environment. Accidents must be recorded and action taken to minimise the occurrence of further accidents. The home must have adequate numbers of staff on duty to ensure that in the case of an emergency, such as a fire, residents would be evacuated safely. The home must ensure that these are resolved so that the health and welfare of people living in the home is promoted. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 25 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X 1 Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP9 Regulation 13.2 Requirement People who use the service must be have their medicines safely managed so that their health and welfare is safeguarded. People who use the service must be assured that their health, care and social needs will be set out in an individual plan that provides staff with guidance as to how those needs should be met. So that peoples health and welfare is safeguarded. People who use the service must be assured that all risks to their safety and welfare are identified and action taken to minimise as far as possible. So that the health and welfare of people is safeguarded. People who use the service must be assured that their privacy and dignity is promoted at all times. So that their health and well being is promoted. People who use the service must DS0000068947.V358996.R01.S.doc Timescale for action 29/02/08 2. OP7 15(1,2) 26/04/08 3. OP8 13(4c) 26/04/08 4. OP10 12(4a) 26/04/08 5. OP26 16(2k) 26/04/08 Page 27 Summerville House Version 5.2 be assured that the premises will be free from offensive odours. So that their health and welfare is safeguarded. 6. OP22 23(2n) People who use the service must be assured that equipment that is suitable for their needs will be provided. So that their health and welfare is safeguarded. People who use the service must be assured that suitably qualified, competent, experienced staff are working in sufficient numbers at all times. 26/04/08 7. OP27 18(1abc) 26/04/08 8. OP31 10(1) People who use the service must 26/04/08 be assured that the home will be managed by a person who has been assessed as fit to do so and has sufficient skills and competence. So that their health and welfare is safeguarded. People who use the service must be assured that there needs will be met by staff who are adequately supervised. So that their health and welfare is promoted. People who use the service must be assured that the home is run in their best interests and that the home establishes a way of publishing the results about the quality of the service. So that their health and welfare is promoted. People who use the service must be assured it is continuously self-monitored and regulation 26 visits are conducted monthly. So that their health and welfare is promoted. 26/04/08 9 OP27 18(2) 10. OP33 24(1,2,3) 26/07/08 11. OP33 26 26/04/08 Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 28 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 OP7 OP7 OP38 OP19 Good Practice Recommendations It is recommended that residents/relatives are asked to sign care plans and reviews to denote their agreement. It is recommended that the home reviews information written in pre existing care plans to ensure it has been transferred effectively to new care plans. It is recommended that the home complete regular audits of accidents. It is recommended that the home provides signage to meet peoples individual needs. Summerville House DS0000068947.V358996.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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