Inspection on 14/05/07 for The Croft

This inspection was carried out on 14th May 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Croft 31/10/08

The Croft 29/02/08

The Croft 12/10/06

The Croft 07/09/05

The Croft 10/05/05

The Croft 07/10/04

The Croft 01/07/04

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 Croft (The) The Croft Buckland Road Reigate Heath Surrey RH2 9JP Lead Inspector Sandra Holland Unannounced Inspection 14th May 2007 10:00 DS0000013619.V335305.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 DS0000013619.V335305.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. DS0000013619.V335305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croft (The) Address The Croft Buckland Road Reigate Heath Surrey RH2 9JP 01737 246964 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) Heddmara Limited Post Vacant Care Home 22 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (15), Learning disability over 65 years of places of age (7), Physical disability (1), Physical disability over 65 years of age (2) DS0000013619.V335305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The minimum age of those accommodated will be 40 years. Service users within categories DE (E), PD and PD (E) must have a learning disability as their primary condition. 12th October 2006 Date of last inspection Brief Description of the Service: The Croft is a care home providing accommodation and personal care for male and female adults with learning disabilities of whom seven may be over 65 years of age. The building is a large, three storey detached house situated in its own grounds set in a semi-rural location opposite Reigate Heath. The home is within close proximity of shops and all community facilities in nearby Reigate town. Communal areas are located on the ground floor. These comprise two spacious lounges, a separate dining room, kitchen and utility room. Bedroom accommodation is mostly for single occupancy and arranged on all three floors. The home has a platform lift and communal bathing/ shower facilities and toilets are located on all floors. The home is fitted with an emergency call system. There is a mini bus and driver. The home’s car parking facilities are shared with staff and visitors of the day centre, which operates out of a separate building within the grounds. The day centre service is for adults with learning disabilities and operates under separate management, though under the same ownership. Weekly fee charges at The Croft ranged between £529.61 and £1635.69 at the time of this inspection. Additional charges applied for transport, hairdressing, holidays, toiletries, clothing and magazines. Prospective service users and / or their representatives can access information about the home’s purpose, care ethos, services and facilities directly from the home. A copy of the home’s latest inspection report is also accessible at the home. Alternatively the report can be obtained from the Commission for Social Care Inspection (CSCI) website at www.csci.org.uk or by telephone contact with the CSCI. DS0000013619.V335305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulation Inspector carried out the inspection over nine hours. Mrs Angela Haeems, Registered Provider was present for part of the inspection. Other assistance with the inspection was provided by the acting manager and the team co-ordinator on duty. A full review of the information held about the home was carried out prior to the visit. A pre-inspection questionnaire was supplied to the home and this was completed and returned within the requested timescale. Information from the questionnaire will be referred to in this report. A full tour of the premises was carried out and a number of records and documents were sampled, including residents’ individual plans, medication administration records and staff files. Twelve residents and nine staff were met or spoken with. A number of CSCI feedback forms were supplied to the home for distribution to residents, relatives or visitors and healthcare professionals. Two of these were completed by residents, with the support of staff and were returned. The inspector did not share the communication methods of some residents, and where this was the case, the residents’ responses were assessed by their facial expression, body language and interaction with staff. The people living at this home prefer to be known as residents and that is the term that will be used throughout this report. The inspector wishes to thank the residents and staff for their hospitality, time and assistance. What the service does well: The home offers a high level of personal support that is specific to the needs of each individual. Residents are encouraged to be as independent as possible, to make their own choices and to develop their skills. The individual plans for residents are well written and viewed from the residents’ point of view. The residents are supported by the home to be a part of the local community and there is a good range of activities in place for them to take part in. The home has its own vehicle to enable residents to get to their activities. DS0000013619.V335305.R01.S.doc Version 5.2 Page 6 Residents who were able, said they were happy, that staff are kind and residents spoke of enjoying the activities on offer. The home supports and encourages residents to keep in contact with their friends and family. A stable team of staff support residents and members of staff spoken with said that they are happy working at the home. Many of the staff have worked at the home for a number of years. What has improved since the last inspection? What they could do better: Although there are good outcomes for residents in some areas this is compromised by the lack of robust management and shortfalls in areas of health and safety. Ten requirements made following the last inspection have not been met and CSCI will determine what action will be taken to secure compliance. An immediate requirement was made at the time of the inspection that the receipt of all medication into the home must be recorded, so that it is possible to know how much medication should be present and to follow an audit trail. It is recommended that medication requiring chilled storage should be stored in a separate, sealed container, if it is stored in a fridge which is also used to store food. All food stored in the fridge must be labelled with the contents and the date. DS0000013619.V335305.R01.S.doc Version 5.2 Page 7 The recording of residents’ blood pressure should only be undertaken by a suitably trained person, to ensure correct action is taken if an abnormal reading is found. The complaints procedure and complaint record forms must be available for all who may wish to use them. Recommendations made by the occupational therapist should be carried out to ensure that residents’ needs are met. Areas of the home do not provide a pleasant, safe and valuing environment for the residents. The outside terraced area must be safe and secure. Work to upgrade bathrooms and toilets in the home must be completed. The roof must be assessed, repaired and made good the roof as leaks are still occurring. Remedial work to the hazardous flooring in the dining room, and a programme of replacement of the worn carpets on the stairs and corridors must be carried out. Other actions to safeguard the health and safety of residents must be taken, including assessing the risks when exiting the lift in the lounge, the risks associated with the use of electrically operated beds and armchair. The gate to the side of the property which has been fitted to safeguard residents must be used for that purpose. An immediate requirement was made at the time of the inspection that first and second floor windows must be risk assessed and restrictors fitted to minimise the risk of accidents. The recruitment procedure must be more robust to safeguard the residents and a record of the induction of staff must be maintained and kept in the home. Staff must have sufficient rest time between shifts to ensure they can provide safe care and support to residents and to safeguard the health of staff. 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. DS0000013619.V335305.R01.S.doc Version 5.2 Page 8 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 DS0000013619.V335305.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents would be assessed they would be invited to visit the home before admission. EVIDENCE: Staff stated that no new residents have been admitted to the home since the last inspection and most of the residents have lived together since the home opened. Staff were able to describe the admission process, which would include an assessment of the needs of any prospective resident. This assessment may be carried out under the care management process, but the staff from the home would also carry out their own assessment. Prospective residents would be invited to make a number of visits to the home, to ensure that it suits their needs, and to enable staff to fully assess these. Visits would also enable prospective residents to meet other residents and staff, and would be of increasing length and include staying for a meal and overnight. DS0000013619.V335305.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Informative individual plans are available to guide staff to the support needs of residents. Residents are well supported to make decisions. EVIDENCE: Staff advised that person centred plans had recently been introduced, although they have yet to receive training in this. Comprehensive individual plans have been drawn up for each resident to describe their support needs in all aspects of their lives. The plans have been divided into three sections for ease of use, these being the person centred care plan, a healthcare plan and a working file. The working file included the previously used essential lifestyle plan, risk assessments, daily care and support notes and a record of residents’ activities, both at home and in the community. The individual plans that were seen were in good order and contained the required information to enable staff to provide effective support and care. DS0000013619.V335305.R01.S.doc Version 5.2 Page 11 A brief, but detailed summary of each resident’s individual plan has been drawn up to provide an “at a glance” guidance to new staff or agency staff. It was clear that residents are encouraged and supported to make their own decisions. A resident was happy to speak of a forthcoming holiday, which was clearly being looked forward to. The resident advised that they would be going on holiday with their key-worker and other residents. Residents are encouraged to be involved in the running of the home, and staff advised that residents’ meetings are held. The minutes of the most recent meeting were not available, however. Residents have recently been involved in the staff recruitment and selection process, and have attended staff interviews. Staff stated that they support residents with their decision making by offering choices. In the case of holidays, residents would be supported to go to the travel agents to obtain brochures, photos of previous holidays would be shown and discussion would take place about the residents’ preferences. Assessments have been carried out of risks to residents, including the risks involved in mobility, falls, the home’s driveway, eating and drinking and being vulnerable to exploitation. It was noted that a number of residents were using electrically operated armchairs or beds, but the risks associated with using these had not been assessed. A requirement has been made regarding Standard 9. DS0000013619.V335305.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in a range of activities and to be active members of their community. Residents are offered and supported to enjoy, a well balanced diet. EVIDENCE: Residents spoke of the activities they take part in and enjoy. Each resident’s preferred activities are recorded in their individual plan and on a board in the general office. Residents were observed to be coming and going to their planned or spontaneous activities including horse riding, throughout the inspection. Some residents attend the day centre next to the home, which is under the same ownership, but managed separately. Other residents attend a number of day services in the nearby towns of Reigate, Redhill and Horley. A resident advised that he “had retired and does not go to work any more”, but enjoys spending time in his room, which was well equipped with a television and DVD player. Staff advised that some residents receive one to DS0000013619.V335305.R01.S.doc Version 5.2 Page 13 one support from day services staff, which enables them to organise their own choice of activities. Photos displayed all around the home showed residents enjoying their activities and holidays. Two attractively arranged photo-wall displays in the entrance hall show each resident and each member of staff, and all are named for ease of identification. A resident was very happy to show his photo in the display. The home has a mini-bus vehicle to enable residents to be transported to their various activities, places of interest and shopping. A driver is also employed to ensure that residents can go out as they wish or require. Two CSCI feedback forms were completed and returned by residents, and both of these indicated that activities they could take part in were only available “sometimes”. Staff stated that residents are actively supported and encouraged to maintain family contacts, and a resident has recently established more regular contact with their family after a long period of little contact. Families are welcomed to visit residents and staff also support service users to go to visit their families. Where able, residents go to spend weekends with their families. A very detailed policy and procedure is in place to guide staff in their support of residents’ personal relationships. The policy refers to rights and responsibilities and to the legal aspects of supporting vulnerable people. A two-week menu was supplied with the pre-inspection questionnaire and this listed the two main meal options for each day. The menu appeared well balanced and staff advised that residents are encouraged to enjoy a healthy diet. A list of each resident’s likes and dislikes is held in the kitchen to guide staff. The cook advised that she is getting to know residents’ individual tastes and has been encouraging them to try new and more varied foods since her appointment last autumn. Residents were seen enjoying their light, lunchtime meal, in the colourful dining room. Staff advised that new tables and chairs had been obtained recently and the tables were attractively set with cheerful tablecloths and flowers. Jugs of soft drinks were available and residents were encouraged to be make their own choices and to help themselves. Although residents are encouraged to be independent, staff were available to support residents with their meal if required. Adapted cutlery and plate supports are provided to enable residents to eat as independently as possible. A prescribed product is obtained and added to some foods and drinks for residents who have swallowing difficulties, as this makes swallowing easier to control. The menu is not currently displayed, so residents have to ask the catering staff what is being served for meals. The cook stated that it is planned to introduce pictures of meals to assist residents in making their choice of meals. DS0000013619.V335305.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support in the way they prefer and their healthcare needs are well met. EVIDENCE: Staff were seen to support residents in a sensitive manner, whilst offering choice and encouraging independence. Personal care was provided discreetly and residents’ privacy was respected. Staff were seen to knock before entering residents’ bedrooms, toilets or bathrooms. The staff rota was seen to request staff of a specific gender for some shifts, to ensure that residents can be supported in the way they prefer. A key-worker system is in place to ensure that residents receive consistent support and a photo board is displayed in the general office to show residents who is supporting them from day-to-day. Staff stated that they are usually allocated to support their colleague’s key-residents to ensure continuity of support. DS0000013619.V335305.R01.S.doc Version 5.2 Page 15 An occupational therapist’s assessment has recently been carried out in the home. This was organised primarily to assess the changes needed in the home, to enable a named resident to be independently mobile. Some of the recommended changes, such as an improved handrail on the stairs have been carried out, but others are under review. A number of aids to support residents’ mobility are available in the home, including hoists, an easy access wet-room shower, a supported access bath, an electrically operated bed and electrically operated armchairs. Handrails have been provided in two toilets to aid residents’ independence and a lift enables residents to access all floors of the home. Information supplied in the pre-inspection questionnaire indicated that a number of healthcare professionals are involved in the support of residents. These include general practitioners (GP), district nurses, dietician, speech and language therapist, optician, dentist and occupational therapist. Most healthcare professionals are accessed through a referral made by the GP. Residents’ individual healthcare plans record the support received from the specific healthcare professionals. It was positive to note the plans also show that residents are supported to have regular health screening checks to prevent ill health. It was noted that care staff had taken and recorded residents’ blood pressure. It is recommended that staff trained to do so only takes this, to ensure that correct action is taken if an abnormality is present in the recording. Staff stated that medication is supplied to the home in “blister” packs by a local pharmacy, with each blister containing separate doses of individual medications. Printed medication administration record (MAR) charts are also provided by the pharmacy. Medication is stored centrally in a locked provision and medication requiring chilled storage is stored in a locked food fridge. It is recommended as good practice, that medication items stored in a food fridge are stored in a separate, lidded container. Although the receipt of the majority of medications had been recorded, it was noted that a number of medications had been received for one resident, but the receipt of these had not been recorded. It would not be possible to know how much medication should be present, or to follow an audit trail. A detailed medication policy and procedure is in place and a shorter picture version was available for residents. It was noted that the medication policy and procedure states it should be reviewed each year and was dated for review in September 2006, but this has yet to be carried out. DS0000013619.V335305.R01.S.doc Version 5.2 Page 16 An immediate requirement regarding Standard 20 was made at the time of the inspection, that the receipt of all medication into the home must be recorded so that it is possible to know how much medication should be present, and to follow an audit trail. DS0000013619.V335305.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints have been managed appropriately and staffs are aware of their responsibilities in the safeguarding of residents. EVIDENCE: The home’s complaints policy and procedure was seen and it was noted that this needs to be updated, as it refers to the previous manager who has since left the home. The complaints procedure is not currently displayed in the home and this is recommended, so that it is available to all who may wish to use it. A pictorial version of the complaints procedure was seen on notice boards in resident bedrooms. Staff stated that residents would usually address any concern or dissatisfaction to them, to the manager or to the team co-ordinator verbally, and this would be addressed immediately. The provider visits the home regularly and can be approached by residents if they feel their concerns had not been resolved to their satisfaction, staff advised. A number of residents have limited verbal communication methods and would have to rely on staff to recognise their unhappiness. Staff advised that if residents were not happy, they would quickly recognise changes in the residents’ facial expressions, their body language or their behaviours. In these instances, staff would look to find the cause of the problem to resolve it. DS0000013619.V335305.R01.S.doc Version 5.2 Page 18 Information supplied in the pre-inspection questionnaire indicated that a small number of complaints had been received during the last year, all of which were responded to within the stated timescales and were substantiated. The complaints record was seen and it is recommended as good practice, that this is changed to a style of record that meets the requirements of the Data Protection Act. Staff advised that in the event of an allegation or suspicion of abuse of a resident, they would inform the acting manager or the person in charge. In the event of an allegation or suspicion of abuse, the home would follow the Surrey Multi-Agency Procedure for Safeguarding Adults (formerly protection of vulnerable adults), staff stated. An up to date copy of the procedure was held in the home. A requirement was made following the last inspection, that the home’s policy and procedure on abuse and Whistle-blowing, must be reviewed to ensure they were compatible with the Surrey safeguarding adult’s procedures. The policies were marked to indicate they had been reviewed in November 2006. It was noted however, that the abuse policy does not refer to the Surrey procedure in the main body of the policy, although it is noted on the abuse policy flow chart. The home’s policy must refer to and reflect the requirements of the Surrey Safeguarding Adults procedure if the home is to follow this. Senior staff stated that residents are supported to manage their finances, and monies are held for safekeeping on behalf of residents. To safeguard residents, only senior staff have access to these monies and two signatures are recorded for transactions. Receipts are kept for any expenditure over £5.00 and a description of how the money was spent, is maintained for expenditure below £5.00. A personal money policy and procedure is held in the home and a pictorial version of this is available for residents. Staff stated that a specified amount of residents’ money is held in a pooled facility for day to day use. This is reconciled on a weekly basis, with the receipts and records of expenditure for each resident. The weekly reconciliation was due to take place on the day of inspection, so it was not possible to check these amounts. The balance of other monies held for residents were checked with the records held and these accurately matched. The previously made requirement regarding Standard 23 has still to be met. DS0000013619.V335305.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Most of the home was clean and tidy, but there remain serious shortfalls in the standard required, to ensure residents live in a safe and fully accessible home. EVIDENCE: The home is a large, detached building set in its own extensive grounds on the outskirts of Reigate. Additional facilities were provided when the home was extended two years ago. Most resident bedrooms are for single use, with a small number of double rooms. Residents sharing the double rooms choose to do so as they have lived together for many years, staff advised. Most areas of the home that were seen were clean, tidy and homely, with furnishings of a domestic style. Residents’ bedrooms had been personalised with their own belongings including televisions, music facilities, pictures, ornaments and photos. A number of requirements regarding the premises were made following the last inspection in October 2006. Two of these requirements have been DS0000013619.V335305.R01.S.doc Version 5.2 Page 20 partially met, with work started but not completed, but five of the requirements have not been met. These have a daily impact on the residents’ lives, and some of them may affect residents’ safety. A large gate has been fitted beside the home to safeguard residents coming out of the dining room door at the side of the house. Residents were seen using this door throughout the day as the main access point into the home. A photo board has been fitted to the rear of the door to encourage residents to use this to indicate when they are in or out of the house. It was noted however, that the gate was left open throughout the inspection, so it is not safeguarding residents from vehicles that drive into the area. A requirement to upgrade toilets and bathrooms has been partially met. One toilet has been refitted, but the tiling behind the toilet and the replacement of the flooring in the room have yet to be carried out. The requirement that the roof must be assessed and work carried out to prevent further flood damage, has not been fully met. The provider stated that the roof has been examined and repairs have been carried out, but a recent leak into the ceiling of a resident’s bedroom was seen on the day of inspection. The acting manager stated that the ceiling had leaked three weeks previously, and was now dry, but it was observed to be dripping. A notice on the resident’s notice board in the room stated “caution carpet wet”. The acting manager and provider could not explain why the resident had been allowed to continue using the room in this condition, when vacant rooms were available nearby. The resident was consulted and with their agreement, was moved into another room on the same floor. Work to repair the damage to rooms by previous leaks has been partially carried out. The staff sleepover room is still out of use, as the water damage has not been repaired or decorated. The acting manager and provider stated that they had been waiting to see if the repairs had been successful before decorating the room. It was also required that remedial work must be carried out to the dining room floor, which is hazardous to residents with mobility problems. The work has yet to be carried out, but the acting manager stated that estimates for this work were being obtained. Estimates have also been obtained for the work to replace the worn carpets on the stairs and corridors, but the work has yet to be carried out. This was, and is urgently required, as one resident has already sustained a fall on the stairs. A requirement was also made that residents must be provided with an accessible, safe and secure outside terraced area, but this has not been met. DS0000013619.V335305.R01.S.doc Version 5.2 Page 21 The timescale for this requirement has now been outstanding for over one year. Previously made requirements remain outstanding. DS0000013619.V335305.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A team of trained staff are employed to support residents. Recruitment practices in the home must be improved to fully safeguard residents. EVIDENCE: Information supplied in the pre-inspection questionnaire indicated that a team of staff are employed to meet residents’ needs. The majority of the team are support workers, who provide personal care as well as support in other aspects of residents’ lives, such as activities. Other staff include catering staff, housekeeping staff and a maintenance worker, who also drives the home’s mini-bus. It was clear that many of the staff have worked at the home for at least two years, and some for much longer, providing residents with continuity of support and care. Staff were observed to speak to residents in a relaxed and friendly manner, whilst maintaining dignity and respect. A number of staff have undertaken and achieved a National Vocational Qualification (NVQ) in care to Level 2 or above and the home meets the recommended target of 50 staff trained to this level. DS0000013619.V335305.R01.S.doc Version 5.2 Page 23 Staff advised that agency staff are rarely used to cover unexpected gaps in the staffing of the home, as these are usually covered by the home’s own staff. It was noted that a member of staff who had worked the previous night on a waking night shift, was resting in the home for a number of hours before returning to work on the afternoon shift. Staff said that the member of staff was covering the afternoon shift at short notice due to the sickness of another member of staff. The European Working Time Directive specifies that there should be an eleven hour interval between staff shifts. Sufficient time off must be allowed to ensure staff are rested enough to provide a safe standard of care and support to residents, and to safeguard the health of staff. It was also noted that a member of staff had covered a sleep-in shift the night before the inspection and a small number of hours during the peak morning period on the day of inspection, but these had not been entered on the staff rota. Staff recruitment files were seen and most, but not all of the required information and documents had been obtained. It was noted that the dates of employment listed on the application form for one member of staff, did not match the dates given in a reference or on the applicant’s curriculum vitae (C.V.). For another member of staff, no record was held of the person’s entitlement to work in the UK or that a satisfactory Criminal Record Bureau (CRB) disclosure had been obtained. Another member of staff had not signed their application form and the acting manager stated she would ask the staff member to do this. The acting manager advised that residents had been involved in recent interviews which were held to select staff to be employed in the home. Interview record forms were enclosed in staff files, but these had not been completed. Induction records were held on file for two newly recruited staff, but were not available for two other staff. The induction record sheet covers areas that have been “explained, understood and capable”, but for one member of staff who had a poor grasp of the English language, this had not been completed. This member of staff would need to understand about possible hazards in the home, but it was not possible to know how this has been assessed. Information in the pre-inspection questionnaire indicated that all staff have received first aid training and senior staff advised that they have received the more extensive, four day training in first aid. Other training undertaken or planned included fire safety training, moving and handling, food hygiene, infection control and Makaton, which is a form of communication using signs. A training record is maintained for each member of staff and these were seen. DS0000013619.V335305.R01.S.doc Version 5.2 Page 24 The staff team is made up of males and females, which is reflected in the resident group. The cultural and racial diversity of the staff group is not reflected in the resident group, who are of British background. Requirements have been made regarding Standard 34 and 35. DS0000013619.V335305.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needs to have a registered manager in post, needs to be effectively managed in a robust way, and needs to be fully supported by the provider. EVIDENCE: The number of requirements that remain unmet since the last inspection and the shortfalls in the standard of the premises indicate that the home is not being managed to the required standard. The registered provider was present for part of the inspection and the outstanding requirements were discussed with her. The provider stated that the majority of residents are funded by local authorities, but that the funding levels are too low to provide the level of care and support that residents now require. It was explained that CSCI have no remit with regard to fees or funding. The expectation is that providers would discuss the funding levels for individuals with care managers at resident reviews. DS0000013619.V335305.R01.S.doc Version 5.2 Page 26 Information supplied in the pre-inspection questionnaire indicated that the home’s registered manager has left the home since the last inspection in October 2006, and staff confirmed that the manager left in January 2007. The questionnaire stated that the current acting manager is undertaking training with the support of external consultants, with a view to submitting an application to be registered as manager later this year. The management situation was discussed with the provider, as it is not good practice to leave the home without a registered manager for an indefinite period, and the shortfalls in meeting the required standards confirm this. Staff acknowledged the progress and positive changes that had been made in the home, under the direction of the acting manager. A recommendation was made at the last inspection that consideration should be given to the appointment of an administrator. This would release the senior staff from many administrative tasks and enable them to carry out their designated roles more effectively. The acting manager stated that a survey had recently been supplied to residents and others involved in their support. A number of responses have been received, but these have not been reviewed or summarised. The acting manager stated that this would be carried out in the next few days and agreed to forward a summary to CSCI. Two CSCI feedback forms were completed and returned by residents, who had been supported by staff. Their responses were mainly positive, although both respondents felt that activities they could join in with were only available sometimes. Visits to the home under Regulation 26 of The Care Homes Regulations 2001 (As Amended), have previously been carried out by the external consultants, who have been providing support at the home. These visits are carried out by, or on behalf of providers, who are not in day-to-day control of the home. The visits should involve discussions with residents and staff and a review of the premises. The person carrying out the visit must write a short report on their findings and leave a copy in the home. Staff stated that these visits have not been carried out recently, and the last record of a Regulation 26 visit was dated October 2006. As mentioned previously at Standards 24 to 30, relating to the premises, a number of improvements still need to be made in the home to ensure that residents live in an environment that promotes and protects their health, safety and welfare. A requirement made at the last inspection that a window restrictor must be fitted to an unsecured window on the second floor has been partially met. DS0000013619.V335305.R01.S.doc Version 5.2 Page 27 Staff said that a restrictor was fitted to that window the day after that inspection, but at this inspection three other unsecured windows on the second floor were noted. One of the windows was fitted with a removable restrictor and this had been removed, leaving the window unsecured. This was immediately replaced by staff. Two other windows in a nearby bathroom were unsecured, although the flex of an extractor fan limited the opening of one window. This could be loosened however, and could not be relied upon to safeguard residents. During the course of the inspection, it was noted that the vacuum cleaner flex was left trailing across a room and a corridor, which created a tripping hazard for residents and staff. A member of staff placed a warning sign near the flex once this had been pointed out. The lift which provides residents with access to all floors opens into the lounge on the ground floor. It was noted that when leaving the lift in this room, the edges of the fireplace mantle shelf and hearth which are very close by, limit free access and may create a hazard to residents and staff. This should be risk assessed. A number of food items were stored in the fridges, but the containers were not labelled to state what they contained or the date on which they should be used by. All food stored in the fridge must be labelled with the contents and the date for consumption. An immediate requirement was made at the time of the inspection regarding Standard 42, that first and second floor windows must be risk assessed and restrictors fitted to minimise the risk of accidents. Requirements have also been made regarding Standards 37 and 39. DS0000013619.V335305.R01.S.doc Version 5.2 Page 28 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 X 2 X 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 1 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 2 X X 1 X DS0000013619.V335305.R01.S.doc Version 5.2 Page 29 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 YA9 Regulation 13 (4) Requirement The risks associated with the use of specialist equipment must be assessed, including electrically operated equipment, such as beds and armchairs. Timescale for action 28/05/07 2 YA24 23(2b) 3 YA3 YA24 12(1), 13(4), 23(2)(b)(o ) The registered person must 17/08/07 upgrade and redecorate bathrooms and toilets in the original building as necessary and replace worn and malodorous floor coverings in these areas. Timescale of 12/01/07 has not been met. The registered person must ensure 17/08/07 completion of work to provide residents with an accessible, safe and secure outside terraced area. Timescales for completion of this work by 07/03/06 & 31/3/07 have not been met. The registered person must be 17/08/07 proactive in ensuring the safety of the construction and state of repair of the roof. This needs to be properly assessed by a suitably competent person and work carried out if necessary to prevent further occurrences of flood damage and risk of the roof DS0000013619.V335305.R01.S.doc Version 5.2 Page 30 4 YA24 23(2)(b) collapsing. Timescale of 30/11/06 has not been met. 5 YA24 23(2)(d) The registered person must ensure the making good of the decoration of rooms that have been water damaged at the time of recurrent leaks in the roof. Timescale of 12/12/06 has not been met. The registered person must arrange for remedial work to be carried out to the floor covering in the dining room which is hazardous to residents with mobility problems or replacement of the same. Timescale of 30/11/06 has not been met. The registered person must institute a programme with timescales for replacing worn and shabby carpets on stairs and corridors. Timescale of 12/01/07 has not been met. The registered person must ensure recruitment practice is in accordance with the home’s procedures and statutory requirements, including a full and accurate employment history, confirmation of entitlement to work in the UK and a satisfactory CRB disclosure. Timescale of 13/10/06 has not been met. 17/08/07 6 YA24 12(1) 13(4)(a)(b )(c) 23(2)(b) 17/08/07 7 YA24 23(2)(b) 17/08/07 8 YA34 19 Sch2 3, 8. 28/05/07 9 YA35 17 Schedule 4 & 18 8 10 YA37 All persons employed to work at 15/06/07 the home must receive structured induction training. A record of the induction training must be maintained and kept in the home. The registered provider must 28/06/07 appoint a manager and must notify CSCI of the name of the person and the date from which the appointment is effective. The person who is appointed to DS0000013619.V335305.R01.S.doc Version 5.2 Page 31 manage the home must submit an application for registration by CSCI in line with the provisions of the Care Standards Act 2000. 11 YA39 24 A summary of the outcomes of the survey to assess the quality of the service provided, must be made available to residents and a copy provided to CSCI. The registered person must review the home’s systems for monitoring health and safety environmental risks and frequency of carrying out these checks to ensure these are sufficiently robust. Timescale of 17/11/06 has not been met. 13/07/07 12 YA42 12(1)13(4) (a)(b)(c)23 (2)(b) 15/06/07 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 YA22 Good Practice Recommendations For the registered persons to display the home’s complaints procedure in the home and consider reissuing copies of the procedure to all relatives/representatives of residents, to ensure they are aware of how to make a complaint. It is also recommended that a system of recording complaints, that meets the requirements of the Data Protection Act, is used. For the registered persons to consider recruiting an administrator to support managers with clerical and bookkeeping responsibilities. This would alleviate pressure on management time which would assist managers in allocating more time to care planning until such time as team coordinators and key workers are trained to be delegated care planning responsibilities. It is recommended that residents’ blood pressure is only measured and recorded by staff trained to do so, to ensure appropriate action is taken if an abnormal reading is found. 2 YA37 3 YA19 DS0000013619.V335305.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000013619.V335305.R01.S.doc Version 5.2 Page 33 - 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. 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