Inspection on 31/05/07 for The Knoll

This inspection was carried out on 31st 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 no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Knoll 31/10/07

Similar services:

Claremont House

Chesham House

Argyll House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOME ADULTS 18-65 The Knoll 115 Southchurch Boulevard Thorpe Bay Essex SS2 4UR Lead Inspector Sarah Buckle Unannounced Inspection 31/05/07 and 12/06/07 12:45 The Knoll DS0000067787.V336295.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 The Knoll DS0000067787.V336295.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. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Knoll Address 115 Southchurch Boulevard Thorpe Bay Essex SS2 4UR 01702 586684 01702 586684 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) Minster Pathways Limited Miss Maria Baughurst Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6), of places Physical disability (6) The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection since registration. Brief Description of the Service: The Knoll is a large family house situated in a residential area. There are six bedrooms for residents within the home and it has a large lounge overlooking the front garden, a dining area and a quiet room. The home has a secluded rear garden. Southend on Sea, Thorpe Bay and Southchurch are close by and are accessible by bus. There is rail access to Southend and London from Southend East railway station. The current scale of charges for resident’s living at The Knoll is between £1,370 and £1,946.25. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced key inspection. The inspection included two visits to the home, the first of these on 31st May 2007 being undertaken by one inspector and the second on the 12th June 2007, by two. Three Immediate Requirements Forms were given to the service at the second site visit; these were in relation to care planning, staff recruitment and staff training and induction. Further details are contained within the body of this report. A meeting was held with the responsible individual and the operations manager for the home on 18th June 2007 owing to a large number of concerns being raised during the inspection. Two inspectors and a regulation manager were also present at this meeting. During the course of the inspection the views of residents, relatives and staff members were sought, a tour of the premises was undertaken and various required documents and records were examined. All of the findings have been reflected within the body of this report. What the service does well: The staff team within The Knoll work hard to try to meet the needs of residents with limited information and limited managerial support. What has improved since the last inspection? What they could do better: Initial assessment information does not always relate to The Knoll. Some information related to a different home called Newlands. Evidence of initial assessment was not available for all of the residents within the home. Information from initial assessment information provided by care management agencies needs to be translated into effective, person centred care plans for each individual resident. Care plans were not in place for two of the residents living at The Knoll. Both of these residents had complex needs and required both support and strategies for the management of their behaviour. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 6 Care planning does not reflect the needs of the residents and large areas of individual need are not addressed. Care plans do not cross-reference; for example, where a plan states that a behaviour-monitoring plan be implemented there is no evidence that this has happened. Risk assessments and support plans are not completed for all identified needs. Medication needs are not appropriately addressed. The staff recruitment process has large gaps within it, putting the residents at risk of potential harm or abuse. Induction is not undertaken within the company’s specified timeframe for new members of staff. None of the staff at The Knoll had evidence of induction training available at the time of both visits to the service. Training at The Knoll is not comprehensive. Some staff members had no evidence of training within their staff files. Specialist training regarding the complex needs of the residents within the home is not in place. Although the Commission has registered a manager for The Knoll there is no evidence to suggest that they have ever undertaken this role within the home. At the time of the site visits to the service there was no manager in post. There is no clear management structure in place within The Knoll. 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. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Application for admission to The Knoll may be agreed without an adequate needs assessment being undertaken, and without appropriate consideration of the specialist care the resident requires, or the skills, ability or knowledge of the staff that will be caring for them. People who live at The Knoll have specialist needs and the staff team are not adequately provided with the knowledge to be able to care for them according to these needs. EVIDENCE: Two residents were case tracked in relation to initial assessment. One initial assessment was examined in detail during the first site visit to the service. The transition file contained a letter from the consultant psychiatrist at the admitting hospital. A discharge document and minutes from a discharge meeting were also enclosed. The information contained within the discharge meeting notes on 18/01/07 was comprehensive. It stated that the person benefited from clear boundaries and structure to his behavioural management, that he has a short attention span, poor impulse control, loses his temper quickly, responds well to incentive schemes, smokes a lot, needs verbal and physical prompting, has challenging behaviours such as sexual disinhibition, shouting, swearing, urinates in bed, hoards food in pockets, raises fist. DeThe Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 9 escalation techniques are cited as “re-directing (the resident) out of the environment, but not to (their) bedroom as (they) like to spend long periods in (their) room on (their) own”. Minster Pathways “Summary of my Key Support Needs” document was examined. This contained a pen picture, briefly outlining the person’s history. It outlined needs regarding mobility, daily living and self care, health, mental health, housing, social functioning, community living, support network. The resident’s reason for moving to the Knoll is cited as “(The resident) came to The Knoll to gain more independence and further skills in a less supported environment…”. Daily living and self care states that the resident can meet all of their personal care and hygiene needs but requires support to shave, and that they are being taught skills around cooking, eating, meal planning, shopping, laundry, cleaning, using the telephone to make appointments. Housing states, “The resident currently requires 24 hour support in a residential care home environment”. Social functioning states that the resident will raise their fist, shout, threaten, and invade someone’s personal space with or without cause or reason. The section concerned with community living states, “(The resident) requires support in the community around inappropriate behaviours towards females, particularly young females” and “If left to his own devices the resident will approach any young female and ask her to have sex with him”. The support identified in relation to this is that staff are to put a boundary with the resident around these behaviours before going out outlining what is and what is not acceptable, and that “..the resident will follow this direction…” Additional Risks/hazards are identified as violent behaviours/arson/property damage/nocturnal urination/cigarettes/unsteady gait/social interaction with others/inappropriate sexual behaviours towards females/sexual inhibition/ sexual assault/behaviours relating to being in a locked environment/finances/ self-neglect/ refusing care/ refusing meds/ risk of making allegations/ substance abuse/accidents from hazards relating to health and safety/ exploitation/ abuse. This section also states that, “These were the risks identified before the resident moved in, but few have presented themselves. The resident has responded to clear firm boundaries and the behavioural management employed by staff at The Knoll. Many of these risks staff must be aware of but is no longer daily issues”. There was no evidence seen during the inspection of behavioural strategies or management plans. The Transitional strategy indicates that the resident had opportunity to visit the home prior to moving in. A Pre-placement assessment was also completed. This document stated that the resident has both epilepsy and short-term memory loss. Neither of these The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 10 needs are referred to again and there are no support plans in place in relation to them. The pre placement assessment is a task-based document regarding the residents’ abilities and support needs in the bedroom/ kitchen/ bathroom/ clothes and laundry/ sight and sound/ communication/ literacy and numeracy etc. Challenging behaviour is identified as, verbal aggression, shouting, swearing, banging doors and objects, physical aggression, trying to kick staff, punching, spitting on the floor, urinating on the bedroom floor and in bed overnight, physically overpowering when (the resident) wants to be, very unpredictable, no clear signs of triggers or when they might display behaviours, inappropriate sexual behaviours and displays anger. The protocols and procedures identified within the initial assessment in relation to this are, “Physical restraint: SCIP ruk used in more than two people holds. Remove from situation but not to (their) bedroom, usually the garden”. The action plan stated, “(The resident) requires constant 1:1 supervision from a male member of staff. During the day (they are) observed every hour and over night every two hours”. There was no reference to this information within the resident’s care plan. The Individual Needs Assessment was a thorough document, however, it appeared to be generic, because although it specified (the resident) as the person being assessed, it referred to Newlands throughout i.e. “Personal Support Needs” stated it’s ‘requirement’ as, “Behavioural management strategies to be effective in dealing with challenging behaviours displayed” – There was no evidence of any behaviour management strategies within the care plan. The ‘how this will be met’ section stated, “Behavioural guidelines and risk assessments detailing control measures implemented to support (the resident) in the management of his challenging behaviours” and “ clear boundaries for the management of challenging behaviours” and “staff employed at Newlands are trained and qualified with experience in dealing with challenging behaviour clients”. It also states, “Staff (are) trained in SCIP ruk to meet needs relating to challenging behaviours displayed” and “Behaviour monitoring undertaken and reviewed”. None of the information detailed regarding how the resident’s needs would be met was in place within the care plan. There were no support plans or risk assessments in place regarding restraint, nor was there evidence of multi disciplinary reviews regarding the use of restraint. One of the staff members on duty at the time of the inspection had been at the home for one week, another had been there since February, and one other The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 11 since March. One staff member said they had completed SCIP ruk training but there was no evidence to support this. There were no behaviour management strategies or guidelines in place nor were there any risk assessments relating to behaviour management. There was no evidence of behaviour monitoring, although an uncompleted behaviour monitoring pro forma was contained within the care plan. On the second site visit, the initial assessment, transition notes and care plan for a second resident were requested. A senior staff member in the presence of the deputy manager stated that there was no care plan or assessment in place for this resident. She said the resident had been in the home for approximately 1 month. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 12 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 poor. This judgement has been made using available evidence including a visit to this service. Care plans that are in place within The Knoll are poorly developed and do not adequately reflect the complex needs of the residents. Some people who use the service do not have care plans and therefore their needs are not appropriately identified or met. Risk assessments are not adequate and are not in place for all areas of risk to the residents. The Knoll infringes the rights of people who use the service. EVIDENCE: On the first visit to this service one care plan was examined. There was a copy of the service user guide within the care plan and this was in a pictorial format, however this was stored in a file in the office. This was also true of the complaints and information regarding abuse awareness. Personal details were completed as were likes and dislikes in relation to activities and food. A photograph was contained within the care plan. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 13 The Service User Handling assessment form stated, “Fully able to walk independently with good perception of potential risks. Can tire after long distances. Will hold onto objects for support but does not need to do this. Will stop when reminded not to”. An Independence assessment was completed which contained information regarding tasks that the resident was able to complete and those that required prompting or support. i.e. the ‘bedroom assessment stated, ‘Independent and prompt’, “(The resident) is fully able to manage (their) own bed times but may choose not to. Will respond to verbal prompting from staff”. “Able to clean and tidy (their) bedroom and change (their) bed linen but requires verbal prompting to do so….”. There were guidelines in place to support the assessments. Guideline 1 ‘getting up in the morning’ was completed on 25/01/07. It was reviewed on the 26/02/07; 14/03/07; 22/04/07 and 26/05/07. Every review stated, “To continue”. The guideline stated the resident can lack motivation to get up. “The first time staff go in they should give (the resident) a few minutes to respond and wake up” – use activity planned for motivation “If you don’t get up we are not going to have time to go into town this morning”. Where the resident carries out their morning routine without prompting praise and reward should be given. This was signed as read by staff. Guideline 3 related to Personal hygiene and was completed on 25/01/07. This was also reviewed monthly stating, “To continue”. The action plan said, “(The resident) has chosen the bedroom with the en suite shower but has agreed to use the shower on a daily basis…(they) should be reminded that (they have) been told that (they) will be moved to a bedroom without an en suite shower if (they) continue(s) not to use the shower and the facilities in the room (they have) chosen” and the resident should be reminded that “Young ladies won’t want to spend time with him, these days they expect their men to smell nice”, and “Staff should encourage (the resident) to take pride in (their) appearance by making sure that when (they go) out that (they have) matching socks, tied (their) shoe laces properly and look presentable. Staff should explain they do not want to be seen with someone who looks untidy and not neatly presented”. The guideline regarding personal laundry had an action plan, which said that, “Staff should remind (the resident) that other people do not like being near people that are unwashed or dirty. (The resident) should take pride in (their) appearance if (they) want(s) to find a girlfriend and go to college”. Reviewed monthly, “To continue” The guideline ‘prepare and cook a meal’ had some good elements to it, i.e. “may feel overwhelmed by learning to cook new meals – if process is getting too much for (the resident) staff should stop and further break down pattern of The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 14 how to cook – smaller less complicated sections”, but also, “Encourage (the resident) by saying it is important to learn how to cook lots of different meals and food so he can impress girls and work towards cooking for himself in his own flat”. The guideline in relation to foul language/shouting said that staff members should observe and be aware of agitation in the resident. This is contrary to initial assessment information, which states there are no triggers or obvious signs regarding the resident’s behaviour. It suggests that staff remain calm and direct (the resident) to stop. It states that staff members should not engage with (the resident) if they are shouting and swearing and not to continue with any activity. The guideline in relation to anger management and raising fists states that the most likely cause is the resident not getting their own way. It tells staff to ask the resident politely to stop shouting and to go somewhere quiet to calm down. It states that the resident needs strong consistent boundaries, however it does not outline what these should be or in relation to what. The only outlines in place state that the resident will calm down quickly if you show no interest in their behaviour and if the resident raises their fist as a joke or in anger say ‘Put your fist down’ in a stern voice. The guideline regarding inappropriate sexual behaviour states that if the resident comments or invades personal space change the subject and use distraction techniques. The guideline does not state what these distraction techniques should be. It directs staff to say “Personal space”, and says, “if (the resident) apologises and moves back staff should re-direct his attention….”, if he continues say “Don’t touch”, and “Move back”. Staff should be careful of backing themselves into a corner. Male staff should not intervene if female member is dealing with the situation, but be nearby to intervene following the same approach if the resident does not respond. It does not state at what point the male staff member should intervene, nor does it detail what to do if the resident does not respond positively. It goes on to say that the staff should take the resident out of environment and re-direct their attention as final response. There are no details included regarding the use of restraint as identified in the initial assessment. There were no guidelines in relation to inappropriate sexual behaviour in the community, to epilepsy, poor short-term memory, nocturnal urination, hoarding food in pockets, sexual disinhibition and what this means for this specific resident. The guidelines on the management of behaviours are vague and are not comprehensive. The plan of care is not thorough or person centred. A challenging behaviour daily monitor dated 16/04/07 was contained within the care plan, however, nothing had been completed on the document, even though the resident’s daily notes, examined from 09/05/07 onwards, The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 15 demonstrated numerous incidents relating to behaviour i.e. 11/05/07 am “There was an incident of (the resident) getting angry but staff defused it before he began to shout by making him laugh”, and pm, (another resident) called (the resident) a girls name, (the resident) didn’t shout but pulled table hard and banged (the other resident’s) legs with the table. The resident went to their room calmly and came down for tea. On 12/05/07 am an incident is recorded where the resident grabbed another resident’s wrist and began shouting and pm, (The resident) pulled (another resident’s) hand hard because he called him a girls’ name. On 17/05/07 the resident was agitated and so was asked to go to his room. On 18/05/07 the resident was shouting and swearing but did calm down. On 19/05/07 the resident was agitated and asked to leave and cool down. On 22/05/07 the resident slapped another resident on the shoulder blade/back, left a red mark, and therefore their activities are on hold. On 24/05/07 pm, “The resident spoiled his evening by getting angry with another client. The resident very angry and needed lots of calming down. Deputy manager made the decision to keep the resident in tonight as very irritable”. On the 26/05/07 the resident was asked to go and calm down in his room. This is contrary to the information received in the initial assessment which clearly states do not ask him to go to his room as he likes to spend long periods of time in their on his own. During the first site visit the resident was overheard expressing anger. This incident was recorded in the daily notes as ‘pm found in (another resident’s) room using the Internet, “(the resident) is quite aware that he is not allowed in (another resident’s) room. (The resident) began shouting at staff. Becoming very frustrated. (The resident) soon calmed down. (Two staff members) asked (the resident) to leave (the) room, which he did….”. There was evidence in the daily notes that the resident was going to the local shops unsupported, however, there was no risk assessment or support plan in place in relation to this. No strategy was in place for ensuring his behaviour was managed in the community. At the second site visit, the care plan for a second resident was requested. The senior on duty stated that there was no care plans in place for this resident even though they had been in residence within the home for a month. However, there was a medication file, which was examined and this detailed some of the complex needs of this resident, which included a diagnosis of schizophrenia, bi-polar disorder, recurrent depression and aggressive behaviour. The daily notes for this resident were also examined and these detailed challenging and inappropriate behaviours such as touching other residents ‘private parts’ and attempting to hit another resident. One record states, “(the resident) has left quite a lot to be desired this afternoon. Has made a few remarks about masturbation and sex. Has also made a few attempts at touching male member of staff”. No outcome is recorded in relation to this. A second record states “ (The resident) was not keen on going to bed, had to be The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 16 bribed with a cigarette before (they) would co-operate”. The daily notes log constant examples of inappropriate sexual behaviours towards staff and other residents. There is also evidence of the resident trying to hit and bite staff, urinating on their bed, not listening to staff when they were asked to stop inappropriate behaviour and hitting other residents. There are no support plans or risk assessments in place for this resident. A further care plan was requested for another resident and the senior carer stated that there was no care plan in place for this resident either. A stair gate is in place within the home at the bottom of the stairs. There is no information regarding the infringement of residents rights contained in those care plans that are in place in relation to this. One resident who smokes stated that they did not like not being able to have a cigarette when they wanted one. There was also evidence within the daily notes for this person that cigarettes were being used as bribes and punishment. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The staff team within The Knoll are generally aware of the need to support residents to partake in activities. Residents are given the opportunity to take part in activities in the home and in the community. The food within the home meets the dietary needs of the residents. EVIDENCE: A weekly activities planner was contained within the case tracked residents file, however this did not tally with the information contained in the daily notes. The planner includes from 07/05/07 onwards; a trip to local shops/ baking/ trip to internet café/ trip to Southend library/ lunch out/ room tidy/ laundry/ weekly food shop/ board games/ card games/ bowling/ trip to local shops/ personal shopping/ arts and crafts/ room tidy/ laundry/ relaxing at home/ visit The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 18 to pub/ home visit/ return from home visit. On 09/05/07 am the daily notes state that the resident played a board game and pm played cards with other residents; on 10/05/07 daily notes state that the resident helped to wash up after lunch, played monopoly and went to the shops to get cigarettes and a paper and pm, played cards and played games in the lounge. On 11/05/07 the resident walked to the local shops to buy cigarettes and pm, played the play station and games in the lounge; 12/05/07 the resident went to the shops ‘unsupported’, played dominoes and pm, played cards and went to the pub with other residents. On 13/05/07the resident went to mums; On 14/05/07 am, went to library which was shut, so went to internet café for an hour, walked home, played monopoly and pm, played monopoly and watched TV. There was no evidence of the resident attending college or undertaking employment on their weekly activities sheet; however, on 19/05/07 the resident did attend a college open day with a view to starting a course in September. The resident has been accessing the local community by visiting the local shops either with a staff member or unattended. However, there is no risk assessment or support plan in place regarding how this is managed to prevent the resident or members of the public being at risk of harm. Family links are supported within The Knoll and there is evidence within the daily notes of family involvement in resident’s lives. One resident is visited frequently by family members and goes home some weekends. Another resident spoken with during the inspection stated that they had been home and had been doing some gardening at The Knoll supported by a family member. The hanging baskets, flower tubs and raspberry canes that they had planted were seen during the inspection. One resident survey received said that the service could be improved by ensuring that their resident could visit family more frequently. On the day of the first site visit, one resident was asking to go to the library. The senior on duty stated that he went in the morning. A care worker said that he did not go to the library in the morning but that he went to the local shops. The weekly activities planner did list a library visit for that morning. The afternoon planned activity stated ‘lunch out’, there was no evidence of this. There was evidence seen in the daily notes of some residents being involved in making their own breakfast and washing up. However as previously stated a stair gate was in place at the foot of the stairs restricting access to the upper part of the house, and some residents bedrooms, cigarettes were recorded as being used as bribes and being withheld i.e. on 02/06/07 the daily notes for one resident state that they were constantly asking for a cigarette once they had finished eating, but were made to wait until everyone else had finished eating before being given one. This resident was spoken with during the The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 19 inspection and they stated that she was happy at the home most of the time, but not when she wasn’t allowed her cigarettes. The food available at The Knoll is varied. An example of one resident’s menu over a three-day period is, Monday – coco pops, juice/ hotdogs, spaghetti, bread and butter, squash/ roast chicken, rice, veg, chocolate log, custard. Tuesday – coco pops, juice/ ham, chicken, cheese salad/ ham, mashed potatoes, salad, rice pudding and jam. Wednesday – frosties/ cheese and onion rolls/ sausage, onion, mash, carrots, sweetcorn, cauliflower, juice, cake. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. There is adequate evidence in medication care plans of health care treatment for residents, however, intervention is not always apparent. It is not possible to judge whether the residents receive personal care in a preferred manner as not all care plans have been completed. Inadequate care planning prevents the physical and emotional needs of residents being met to an acceptable level. Medication systems do not always follow safe practice guidelines. EVIDENCE: The guidelines within the care plan, which outline the required support for the resident, did not demonstrate that personal support was offered in the way they preferred. Two residents did not have care plans at the time of the visits to the service and consequently have not had their needs identified or support plans appropriate to themselves put in place. The physical and emotional health needs of the resident require further care planning to ensure they are met to an acceptable level. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 21 The medication needs of the case tracked resident are not met, as since moving into the home they have refused to take their medication. Refusal to take medication is noted as an area of risk on their initial assessment documentation; however, there is no evidence of GP awareness or any outcome to this on going refusal of medication. Information in their mediation file states that the resident’s family and GP are aware of their refusal to take medication, however, the GP records have only one appointment recorded on 09/03/07, which is listed as a new patients appointment. There was evidence on 01/03/07 of an optician’s appointment and on the 21/02/07 of a new patient check-up at the dentist. The medication at The Knoll is stored in the home’s office. There are no daily temperatures recorded to ensure that the medication remains at a temperature below 25 degrees. The medication administration file was examined and there was no list of staff names, signatures and initials of those able to administer medication to residents. The operations manager identified four staff members as being able to administer medication; of these only one had evidence of any training. The operations manager advised that two of the other staff had received Boots MDS training, however there were no certificates available to support this. One person who administers medication had no evidence of any training on their staff file. Handwritten medication profiles were not double signed by a witness to ensure mistakes were not made in the recording. A number of omissions were noted. On 05/06/07 in the morning one resident did not have a signature to suggest their Amisulpride had been given, and on 05/06/07 in the evening one further resident had no signatures on their MAR sheet to suggest that their Zopiclone and Trazodone had been administered. Both of these medications were prescribed as ‘take one at night’. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 22 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 poor. This judgement has been made using available evidence including a visit to this service. The procedure for making a complaint is not made clear, is not displayed or made widely available within the home. There is limited staff training in awareness of abuse and staff members were not aware of where the policies and procedures for Safeguarding Adults were stored. Restraint is considered a means of dealing with challenging behaviour, however, there is little evidence of staff training in this area. EVIDENCE: A complaints file was examined during the inspection, and the pro forma was a detailed document. There have been no complaints to the service since it’s registration, however, one resident survey completed stated that they would not know how to make a complaint if they needed to. The comment stated, “We would speak to the deputy manager (we don’t know who the manager is at the moment)”. The complaints procedure is available in pictorial format (widget); however this is contained within the resident’s care plan, which is stored in the office. Care and support plans are not in place to ensure that residents are protected from abuse, neglect and self-harm. There was little evidence of staff training contained within their files. One staff member had a half-day of adult protection training with a staff member who The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 23 had been listed as the home manager, however they did not know where the adult protection policies and procedures were kept. There was no further evidence of adult protection training. Restraint is considered a means of dealing with challenging behaviour within the home, as detailed previously within this report, however, there was only paper evidence that one member of the staff team had completed SCIP ruk training. A second staff member stated that they had; however, there was no evidence to support this. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was completed as part of the inspection. The environment at The Knoll is newly refurbished as the home has been recently registered. Two residents bedrooms were looked and these were spacious and contained personal items. One of the bathroom/ toilets at The Knoll was looked at. There was no toilet paper in place within this room and no bin available for the disposal of paper hand towels or other items. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 25 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, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels within The Knoll do not adequately meet the needs of the residents. The home does not have evidence of practising individualised person centred support. There are significant shortfalls in the staff recruitment procedure at The Knoll. There is little evidence of staff training or induction. Supervision is inconsistent and inadequate. EVIDENCE: All of the staff files were examined during the second site visit to The Knoll for the purposes of looking at the recruitment process. There were large gaps in this and an Immediate Requirement notice was given to the operations manager in relation to this, as the residents are not being adequately safeguarded from possible harm or abuse. One file examined had a completed application form, however, there was a one-year period in the history that was not explained. There was no recent photograph on the file, and there was only one written reference rather than the required two. There was no record of induction contained on the file, although they started in employment at the The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 26 home on 08/02/07. The home’s Training Programme Targets regarding induction states that it is to be completed within the first three months of employment. A second file examined had a completed application form, however there were no written references, no evidence of a POVAfirst and no completed CRB check. Again there was no photograph on the file and no evidence of induction. The employee started working at the home on 24/05/07. A third file examined had a completed application form but not all of the employment history contained dates to and from. Proof of ID was contained within the file, however, there was no photograph and only one written reference, and this was from a family member rather than from the last employer. Evidence of a POVA first was seen dated 06/02/07 and a CRB was also in the file dated 21/02/07. The employee began working at the home on 08/02/07. There was no evidence of induction on this file. Three further files seen contained no photograph and no record of induction. Two of these had just one reference and one of these was from a friend rather than a last employer. One file seen had a CRB dated 26/04/07 when the person had started work on 23/04/07. There was no evidence of a POVAfirst on the file. The declaration of health was not signed. A number of staff members had not completed the section on the application form regarding education and training. A further file had two references but one of these was from a friend not from the most recent employer. Staff training was examined. One staff member had completed SCIP ruk on 17 and 18 January 2007. This was a two-day introductory course. They had also completed care of medicines training 07/07/06, food hygiene 22/05/06, appointed first aid 22/05/07, and other training courses relevant to the care of children. There was no evidence of manual handling training, health and safety training, fire safety or POVA. There was also no specialist training relating to the needs of residents within the home, i.e. training regarding brain injury, epilepsy, schizophrenia etc. Three staff files had no evidence of any training being completed and no evidence of induction. One staff member had completed food hygiene 10/11/06 and first aid for child carers 08/07/06, one had completed a half day POVA training course delivered by the previous home manager. They advised that they had completed SCIP ruk and medication training. There was no evidence within the file of manual handling, food hygiene, first aid or fire awareness training. There was also no specialist training regarding the complex needs of the residents at The Knoll. A further staff member had evidence of NVQ 3, but no evidence of any other training, and a final file had evidence of first aid training on 13/04/06, but nothing further. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 27 An Immediate Requirement notice was given to the operations manager at the time of the inspection in relation to training as it is not of an adequate standard and places residents at the risk of possible harm. It was of concern to note that some of the residents within the home had been identified as needing constant 1:1 support. Two of the male residents are required to have the 1:1 support of a male staff member. There is currently one male staff member working at The Knoll. It was noted in the initial assessment details for a further resident that they required the support of two carers to help them shower, which would mean that five further residents were being supported by one carer. When two of these are identified as requiring the ongoing support of one carer each, the staffing levels within the home are not appropriate to meet the specified needs. At least three of the residents within The Knoll are identified as requiring 1:1 support at all times. A staffing level of three in the morning and three in the afternoon, with one waking night and one sleep in staff does not meet the expressed needs of the residents. The Minster Pathways policy on staff supervision states that “…the company and this house fully complies with Standard 36 – supervision and support of the National Minimum standards for Care homes for Adults”, however, the supervision matrix was examined during the inspection and according to the information recorded therein, the deputy manager received supervision with the previous home manager on 23/03/07, and three other staff members received supervision with the deputy manager in March 2007. There was evidence that three further staff members received supervision during June 2007. No staff member had received more than one supervision session and at least two staff members had no record that they had received any formal 1:1 supervision. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 28 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. There is no manager in post at The Knoll. Training, development and supervision of staff is inconsistent and staff lack leadership. Quality assurance is not implemented as a core management tool. Staff members have not had sufficient training to allow them to work safely. The people who use this service are not adequately protected or safe in this home. EVIDENCE: The Commission registered a manager for The Knoll at the time of its initial registration; however, there is no evidence to suggest that they have worked in this role within the home at any time. The rotas were examined and a different person was named as home manager, however they are no longer in post. At the first site visit the staff on duty did not seem to know who the The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 29 registered manager was, or if there was one. This was reiterated in information received from relatives. The lack of management within the home is an issue of concern, and although the staff team on the whole manage the best they can with limited information about the residents, limited training and limited support, this is not sufficient to safeguard the residents and ensure they have a good quality of life. At the first site visit information relating to quality assurance and health and safety were requested, however there was no one available within the home that was able to locate these documents. It was therefore not possible to examine residents meeting minutes or other quality assurance documentation to ascertain whether the views of residents are important within the home. The registered manager from a different Minster Pathways home did arrive to support the inspection, however they were not aware of where health and safety certificates were kept. There was a note on the wall detailing dates regarding health and safety however no certificates were seen to verify that the appropriate checks had been carried out. The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 30 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 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 X LIFESTYLES Standard No Score 11 X 12 1 13 2 14 X 15 2 16 1 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 1 X 1 X 1 X X 1 X The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 31 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement The registered person must ensure that the needs of prospective residents are assessed in consultation with the prospective resident or their representative, prior to their residing within the home, and this assessment of needs must be kept under review. Timescale for action 30/06/07 2. YA6 15 This is in relation to one resident living at The Knoll and having no evidence of an initial assessment. The registered person must 17/06/07 ensure that after consultation with the resident or their representative, that a plan of care is developed detailing how their needs will be met in respect of their health and welfare. This is in relation to two residents within The Knoll having no care plans in place and to a third care plan with insufficient support plans regarding the identified needs of the resident. An Immediate Requirement The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 32 3. YA7 12(2) Notice was given to the home in relation to this. The registered person must 17/06/07 ensure that the residents living at The Knoll are enabled to make decisions with respect to the care they receive. This is in relation to one resident having no evidence of an initial assessment or a care plan and to a further resident have no evidence of a care plan. Without the involvement of the resident in the planning of their care and required support there is no evidence that residents are enabled to make decisions. The registered person must ensure that risk assessments are in place for activities that residents partake in and that unnecessary risks to health and safety are identified and as far as possible eliminated. 4. YA9 4(b) and (c) 15/08/07 5. YA12 16(n) This is in relation to limited evidence of risk assessments contained within the residents care plan, and to risk assessments not being completed regarding accessing the community, refusal of medication, aggressive and challenging behaviours towards other residents and staff, inappropriate sexual behaviours towards other residents and staff, epilepsy, diabetes etc The registered person must 15/08/07 ensure that the residents are consulted about a programme of activities and that this is implemented around their needs. This is in relation to the weekly activity planner within the home saying one thing and the daily The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 33 6. YA16 12(3) records saying something different i.e. one resident’s daily planner said they were to go to the library on the morning of the first site visit, but this did not happen, instead they went to the shops. The resident was asking to go to the library, and this resulted in challenging behaviour and the resident using a computer in another resident’s room. The registered person must ensure that the service provided by The Knoll takes into account the wishes and feelings of the residents. This is in relation to a stair gate being in place at the foot of the stairs, restricting access to the upper part of the house and to one resident having their cigarettes used as bribes and withheld. The registered person must ensure that resident’s needs regarding the care they are provided are met in their preferred manner. This is in relation to there being no evidence of care plans for two residents and therefore no information regarding their preferences and requirements. It is also in relation to a care plan seen not having sufficient information regarding the needs of the resident. The registered person must ensure that provision is made to meet the health care needs of residents. This is in relation to one resident refusing their medication on an on-going basis, and to no GP 15/08/07 7. YA18 12(3) 17/06/07 8. YA19 12(3) 15/08/07 The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 34 9. YA20 13(2) outcome being recorded regarding this. The registered person must ensure that there are procedures in place for the safe recording, storage and administration of medication within the care home. This is in relation to the room temperature not being recorded where the medication is stored, to omissions on the MAR sheets and to one resident refusing their medication on an on-going basis. The registered person must ensure that all residents and their representatives have copy of the complaints procedure and are aware of how to make a complaint if appropriate. 15/08/07 10. YA22 22(5) 15/08/07 11. YA23 13(6) This is in relation to complaints forms being contained within a care plan in the office and to a relative of a resident not being aware of how to make a complaint. The registered person must 30/07/07 ensure measures are taken to prevent residents being placed at risk of harm or abuse. This is in relation to limited staff training in POVA, to lack of staff awareness regarding where policies and procedures are stored and to a lack of risk assessments. The registered person must 15/08/07 ensure that suitably qualified and competent people work at The Knoll in numbers appropriate to the needs of the residents. This is in relation to limited and in some cases no evidence of 12. YA32 18(1)(a) The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 35 13. YA34 19(1)(b) and Sch 2 staff training, to no evidence of training in areas specific to the complex needs of the residents at The Knoll, and to at least three residents being identified as needing constant 1:1 support, when only three staff are on duty. The registered person must 12/06/07 ensure that staff members employed at The Knoll have all of the required information prior to commencing employment. This is in relation to gaps in the recruitment process as detailed in the body of this report. Gaps in recruitment place residents at risk of possible harm or abuse. An Immediate Requirement Notice was given to the operations manager in relation to this issue. The registered person must ensure that all of the staff team at The Knoll receive training appropriate to the work they are to perform, including a structured induction programme. This is in relation to limited evidence of staff training being available during the inspection, to some staff having no evidence of training, to no evidence of induction being available and to a lack of specialist training relating to the specific needs of the residents within the home. An Immediate Requirement Notice was issued during the inspection in relation to these issues. Induction training to be commenced with immediate effect. The registered person must 15/08/08 DS0000067787.V336295.R01.S.doc Version 5.2 Page 36 14. YA35 18(1)(c) 12/08/08 15. The Knoll YA36 18(2)(a) ensure that people working at the home are appropriately supervised. This is in relation to limited evidence of supervision being seen during the inspection. See the main body of this report for further details. The registered person must ensure that where a manager registered to The Knoll proposes to be absent for a continuous period of 28 days or more; notice in writing is given to the Commission. This notice to detail the length of expected absence, reason for absence, arrangements made for the running of the home during their absence, their name and qualifications and the arrangements made for appointing another person to manage the home. The registered person must also ensure that where a person other than the registered person manages the home notification is given in writing to the Commission. 16. YA37 38(1)(b) and (2) 39(a) 30/07/07 17. YA37 8(1)(a) This is in relation to the registered manager remaining in the role of operations manager and not taking up the post within The Knoll. It is also in relation to a different person being placed on the rota as home manager and to the Commission not being made aware of this. The registered person must 30/09/07 ensure that an individual is appointed to manage the care home. This is in relation to the manager registered to work within The The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 37 17. YA39 24 Knoll maintaining their position of operations manager and therefore the home having no on-going registered manager in post. The registered person must ensure that a system for reviewing and improving the quality of care provided by The Knoll is established and maintained and that residents and their representatives are consulted with regarding this. A report of these findings must be forwarded to the Commissions ands to the residents. This is in relation to no evidence being available within The Knoll regarding a quality assurance system. The registered person must ensure that the home is conducted in a manner that promotes and makes proper provision for the health and welfares of residents. This is in relation to no evidence being available during the inspection regarding health, safety and maintenance of the premises, or fire drills and risk assessments. 15/08/07 18. YA42 12(1)(a) 15/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 The Knoll DS0000067787.V336295.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!