Inspection on 22/08/07 for The Limes

This inspection was carried out on 22nd August 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 but made no statutory requirements on the home.

Other inspections for this house

The Limes 16/11/09

The Limes 25/11/08

The Limes 23/01/08

The Limes 01/08/06

The Limes 15/11/05

The Limes 02/06/05

The Limes 21/10/04

The Limes 02/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Limes 41/45 Church Street Bridgwater Somerset TA6 5AT Lead Inspector Gail Richardson Unannounced Inspection 09:15 22 August 2007 nd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address 41/45 Church Street Bridgwater Somerset TA6 5AT 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) 01278 422535 angelbre2003@yahoo.co.uk MR BRIAN THOMAS MRS ANGELA MARGARET BREWER Care Home 28 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (23) of places The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered for 23 persons in category OP and 5 persons in category DE(E) An additional bathroom equipped with assisted bathing facilities will be installed within 10 months from Date of Registration The large pond in the rear garden is protected in a manner which prevent accidents to vulnerable service users, within 8 weeks of Date of Registration Date of last inspection Brief Description of the Service: The Limes is located in a quiet but central part of Bridgwater. It is currently registered with the Commission for Social Care Inspection to provide personal care to up to 28 people over the age of 65, this includes 5 people who have a dementia. Service user accommodation is arranged on 4 floors, with lift access to all floors. All communal areas are on the lower floors. The registered provider is Mr Brian Thomas and the registered manager is Mrs Angela Brewer. The home is well maintained and furnished in comfortable domestic style. There are twenty-four single bedrooms and two double rooms. Twenty-three of the bedrooms have en suite facilities. The homes fees range from £373.00 to £420.00 and does not include hairdressing, chiropody and hospital transport. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over 8 hours on the 23rd August 2007 by inspector Gail Richardson and 1.5 hours on 11th September 2007 by the CSCI Pharmacist Inspector Brian Brown. A tour of the home took place all of the bedrooms and all communal areas were seen. There were 22 people using the service currently residing at the home, this includes 1 person who is currently in hospital. The homes registration includes 5 places for people with dementia care needs, the registered manager confirmed that 5 people using the service are currently being re assessed to define if they meet this registration category. The inspector spoke to 9 people using the service and 6 members of staff ,the Registered Manager was available throughout the inspection. As part of this inspection the inspector surveyed the opinions of a random selection of service users and their representatives, GP’s, District Nurses and Care Workers 3 responses were received from relatives, 8 responses were received from people using the service and 10 responses were received from staff. Records relating to care, staff, finances and health and safety were examined The people using the service looked well cared and those able to express their opinion were complimentary about the care they received. Staff spoken to were happy about working in the home and were happy with the care being provided. Inspectors observed staff working and noted that people were treated with dignity and respect at all times. The inspectors would like to thank the people using the service and staff for their time and hospitality through out the inspection. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The pre admission assessment was noted to have a limited amount of detail and did not specify any specialist equipment which may be needed. Following discussion with the manager it was highlighted the importance of this as the home’s lift system is restrictive and cannot accommodate a wheelchair or large walking frame and therefore would limit the range of accommodation available. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 7 The registered manager must ensure that appropriate seating in the dining room is available to ensure the people using the service are safe, comfortable and their dignity maintained. The registered manager is required to ensure that plan of care is in place for each person using the service which is fully completed, regularly updated and contains all the relevant detail for each identified need. The registered manager is required to ensure the correct recording of all medications received into the home- this is with particular reference to controlled medications. The registered manager is required to ensure that all creams are named and dated when opened to ensure that the creams are not administered after the expiry date. The registered manager is recommended to review the provision of activities for people using the service who have dementia care needs to ensure they are appropriate. The registered manager is recommended to display the complaints procedure and ensure it is available in appropriate formats for example, large print for all people using the service to access. Further detail is required within the complaints record to give a clear audit trail of the complaints investigation including timescales for investigation and outcomes. The homes whistle-blowing policy does not contain the contact details of CSCI and is recommended to contain the address and contact details. The registered manager is required to ensure appropriate training for staff in abuse awareness is commenced to protect the people using the service. The registered manager is recommended to access both the updated Safeguarding Vulnerable Adult Policy for Somerset and the Mental Capacity Act to ensure the people using the service are supported by the current legislation. It is required for the protection of people using the service that all the required recruitment processes including the POVA check and 2 satisfactory references are completed before staff commence employment. The registered manager is required to maintain the environment of the kitchen to maintain satisfactory standards of hygiene in the care home. This is with reference to the missing tiles and units requiring repair in the kitchen. The registered manager is required to ensure suitable hand-wash facilities for staff in people using the service bedrooms to prevent the risk of cross infection. It is further required that the registered manager ensures that communal toiletries are not used in bathrooms. The registered manager is required to ensure that all parts of the home to which service users have access are as far as is reasonably practicable are free The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 8 from hazards to their safety. This is with particular reference to the unguarded radiator and unrestricted wardrobe. An Immediate Requirement was made on the 23/08/07 that the 6 unrestricted upper floor windows are risk assessed and restricted by 24/08/07. The registered manager is also required to address issues including the storage of furniture, commodes, towels and blankets around the home and the call bells identified with exposed wires and ensuring that the call bell system is routinely serviced. The manager is recommended to review staff deployment to ensure that people using the service who spend their day in the downstairs lounge have appropriate supervision and access to staff to ensure that they can summon help as required. The registered manager was advised to ensure that all areas of induction indicated by the Skills for Care Common Induction Standards are covered by the homes induction. 3 recruitment files were examined and were noted to be inadequate in the areas, which may place the people using the service at risk of abuse. The registered manager is recommended to develop a system to record how staff are supervised in the period of time between the POVA and the Criminal Record Bureau Check had been received. The manager is recommended to review the induction process to include all areas indicated in the skills for care Common Induction Standards. The manager is also recommended to ensure that 50 of staff have successfully completed an NVQ in health and social care. The registered manager is required to ensure that all substances hazardous to health are stored in line with the COSHH guidance. Immediate requirement issued 22/08/07. The storage of dental tablets is required to be risk assessed and the registered manager must ensure correct storage to ensure that there is no risk of accidental ingestion. The registered manager is required to undertake a fire risk assessment to cover all areas of the home. The registered person should ensure that monies held at home on behalf of service users does not exceed £50. It is strongly recommended that records and balances are audited at least monthly. The registered person should maintain appropriate records relating to staff supervision which is to take place a minimum of 6 times per year and is to include all areas outlined within the National minimum Standards. The registered manager is recommended to audit all accidents monthly to look for trends and repeated incidences to help prevent accidents. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 9 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 Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home continues to be able to provide prospective residents and relatives with sufficient information in the format of the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective people who will use the service receive a pre admission assessment by the registered manager to ensure the home can meet the assessed needs identified. This assessment is recommended to contain more detail to ensure all needs identified can be met by the home. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide which is made available to prospective people using the service and their representatives. This is unchanged since the last inspection. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 12 Prior to admission the people using the service and their representatives have the opportunity to visit the home to view prospective rooms and communal areas. 8 surveys were returned to the inspector and both of these confirmed that they received enough information prior to admission. People using the service confirmed “I was given information while I was in hospital and chose to come to the limes.” and “Angela came to visit me and gave me the information I needed, I also visited the Limes.” Five people who use the service, records were examined. The pre admission assessment was noted to have a limited amount of detail and did not specify any specialist equipment which may be needed. Following discussion with the manager it was highlighted the importance of this as the home’s lift system is restrictive and cannot accommodate a wheelchair or large walking frame and therefore would limit the range of accommodation available. It was noted that SAP assessments were received from Social Services prior to admission. Contracts were examined by the inspector and it was noted that people using the service who were funded by Social Services did not receive a contract from the home and therefore were not aware of the terms and conditions of the home. It was discussed with the manager that this would create a clearer communication with people using the service and their relatives of what the home provides. 8 Residents surveys received stated that 4 had received a contract. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has a care plan, the assessed areas of need were not all reflected in this plan of care and the detail recorded did not ensure that staff were advised of care all the care needs identified. The management of medications systems meets the required standard in most areas. Staff were observed to treat the people using the service with dignity and respect at all times and residents felt well cared for. EVIDENCE: Five care plans examined and were found to have varying degrees of information. The registered manager explained that currently she is receiving some assistance to improve the care planning system specifically for the people using the service with dementia care needs. One care plan examined of a person using the service, who had physical care needs which may need the The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 14 support of visiting health professionals did not have sufficient care planned detail to support staff to give the care required. The current practice is to use the needs assessment to highlight the care needs and review that assessment monthly. There is no actual plan of care to advise staff of any specific care interventions. The registered manager is advised that training in care planning for staff would be beneficial to both the people using the service and the staff. 2 people using the service have learning disability and 2 people using the service have physical disability but their care plans do not highlight a plan of care for these identified needs. Some risk assessments were in place but did not give guidance to staff in how to minimise the risks identified, these risks included the risk of abuse. Screening tools for nutrition had been completed.Social care plans were not fully completed and lacked documentation of social choices and preferences. There was no input by people using the service or their relatives in the care plans seen and reviews had not all been undertaken on a regular monthly basis. The Inspector observed that the people using the service appeared comfortable and cared for and all the people using the service who were asked were complementary about the care they were receiving. When asked does the care home support the people using the service, 2 surveys said always.8 surveys confirmed that staff listen and act on what the people using the service say. Comments received include “My relative is well looked after”,” I find the staff very helpful ”,”I have a routine that I always use and staff know” and “The staff are always very busy but they always do the things I ask for” All 8 surveys received confirmed that people using the service felt the staff treated them well. All residents are registered with G.P. Regular appointments are upheld for visual, dental, chiropody, speech and specialist care requirements. 10 staff surveys received, confirmed that 7 of those staff were involved in care planning for residents. The management of the medication systems requires further attention; there were some gaps seen in the Medication Administration Records which would indicate that prescribed medications had not been given. We also found that some medicines had not been given as stock was not available, the home were found to have taken appropriate action in these circumstances. Most Medication Administration Records contained a photograph of the person using the service and creams stored in bedrooms were noted to not be named and The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 15 dated when opened. The practice of leaving the medication keys and lunchtime medications unsupervised in the dining room is poor practice and should not be undertaken. This was discussed with the registered manager at the time of inspection. We found also that although members of staff spoken to, were aware of the needs of people prescribed medicines to be taken “when required”, there was no clear guidance on how to take and manage these decisions in the interval’s care plan. A homely remedy policy is not in place but all people using the service have their own stocks of paracetamol. Dressings are undertaken by the District Nurses and stocks are maintained at the home. All medications were stored safely and securely with systems in place for ordering and disposal. Controlled medications stored at the home were audited as correct but records relating to medications received were incorrect with the amount prescribed being recorded instead of the amount received. More robust systems must be in place to record controlled medications received and used. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a range of opportunities for social stimulation and residents are supported to join in with organised activities or pursue their own interests. Activities for people using the service with dementia care needs are poor and recommended for further development. The meals in the home are of a good quality and a wide range of choice is available. Seating arrangements are recommended to be reviewed to ensure the dignity of all people using the service. EVIDENCE: The inspector spent time talking with people using the service and observed people reading newspapers and chatting to other people and staff. The people using the service are advised in advance of the planned activities and confirmed that activities take place regularly and are varied and include visiting entertainment, bingo and quizzes and trips out. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 17 The people using the service, who were able, confirmed that they regularly go out and are assisted by staff to maintain contact with relatives and community activities. The home employs an activity coordinator twice a week for 2 hours and there is an activity volunteer one morning each week. People with dementia care needs have limited scope for moving around the home and are seated in a separate lounge on ground floor of the home. On the day of inspection people using the service had the opportunity to do a quiz and the TV was on in the lounge. People using the service with dementia care needs were observed to spend periods of time throughout the day unsupervised with the music playing. On these occasions people were noted to be either sleeping or silent, only one person was seen wandering around the lounge. Staff spent some time in the morning assisting these people using the service to do felt tipped colouring with pre printed outlined pictures of a bear. Discussion with staff highlighted a lack of understanding of appropriate activities for people with dementia. It was discussed with the registered manager that further development should be undertaken to provide a more appropriate and stimulating activity programme for people using the service with specialist dementia care needs to ensure their social and recreational needs were being met. The home undertakes an audit of people’s activity preferences and all activities are recorded. It was discussed with the registered manager the need to promote one to one activities for people using the service who remained in their rooms or who have specific needs. One person was seen to sit in their room with the radio on throughout the inspection with no record of activities maintained. One comment received was “Not enough time spent in the garden when the weather is nice, they are always inside and need more fresh air” People using the service confirmed that visitors were always made welcome to the home. Some people using the service’s rooms were decorated in a manner, which reflected their tastes and lifestyles, however some rooms were quite bare in decor. Evidence was seen in some cases of people’s own furniture in their bedrooms. Those people who were able confirmed that they could get up and go to bed within a reasonable time of request, however 2 people using the service stated that they had to get up early for breakfast as it was only served between 8am and 9 am. This was fed back to the manager at the close of inspection who said this would be discussed at the next residents meeting. Lunch observed was appetising and plentiful, the menu offers a choice and people using the service were complimentary about the choice of food and the quality of the meals provided. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 18 No special diets are currently required at the home and no people using the service currently require any assistance with eating. Meals were served both in the dining room and in service users bedrooms if preferred. The dining room is located in the basement floor of the home adjacent to the kitchen and people using the service use the lift to access this area. One person was seen to use a commode as a seat in the dining room. This was discussed with the registered manager who confirmed that the commode was not used for any other purpose but the lift was not large enough to accommodate a wheelchair. The homes Statement of Purpose, states that prior to admission an assessment is made to ensure that the home can meet the persons needs. It is require that the registered manger undertakes a more detailed assessment of all needs including environmental considerations to ensure the dignity of all people using the service. On the day of inspection lunch consisted of Sausage Plait with potato, broccoli and cabbage. No alternative was available as staff had asked people using the service their choice and stated that everybody had requested the same thing. Desert was flapjacks and custard. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 17 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff and people who use the service are confident that the homes management team would appropriately deal with any complaints or concerns. Training is not available to staff to ensure they have the knowledge to prevent service users from the risk of abuse. The policies do not contain all information required to support the reporting processes and the registered manager does not have access to current legislation available to support Safeguarding Vulnerable Adults and the Mental Capacity Act. Recruitment procedures do not protect service users from the risk of abuse. EVIDENCE: The home has a complaints procedure which was not displayed in the main body of the home, the registered manager stated that each person receives a copy on admission. The registered manager is recommended to display the complaints procedure and ensure it is available in appropriate formats for example, large print. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 20 The homes AQAA states- We listen to all complaints either from outside or within. We follow them up and deal with them effectively. The records available did not support this. CSCI have received 1 complaint about the home and one concern remains ongoing. The homes complaints record contained 2 complaints. There was no visible audit trail to confirm the dates the complaints were completed and if the complaint was substantiated. There were no copies of correspondence between complainants and the home. Further detail is required to support the complaints process to ensure that all complaints are fully investigated and recorded. 3 relatives surveys and 7 people using the service surveys, confirmed that they knew how to make a complaint and surveys confirmed that people knew who to speak to if they were unhappy. Comments received included “I would speak to Angela or one of the carers” and “I can see the manager in the office at any time and the carers if I have any problems”. Staff confirmed that should they have any concerns or complaints they would have the opportunity to express these to the manager and would be confident that they would be dealt with appropriately. All staff who were asked were aware of the whistle-blowing policy. 10 staff surveys confirmed that they were aware of policies about protecting vulnerable adults and how you report any concerns about poor care practice or allegations of abuse. The registered provider stated that those people using the service who she felt had the capacity were registered to vote. However the provider had no knowledge of the Mental Capacity Act to support this decision and was recommended to read the recent legislation to ensure best interest is maintained. No people using the service are currently using an advocate but the manager confirmed that this service would be accessed if needed. The homes policy regarding protection of people using the service, states that staff abuse awareness training will be given , however staff training records and discussion with staff confirmed that no staff have undertaken any abuse awareness training and this topic is not covered on the homes induction process. The registered manager is required to ensure appropriate training in abuse awareness is commenced. The registered manager is recommended to access both the updated Safeguarding Vulnerable Adult Policy for Somerset and the Mental Capacity Act to ensure the people using the service are supported by the current legislation. The homes whistle-blowing policy does not contain the contact details of CSCI and is recommended to contain the address and contact details. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 21 3 staff recruitment records examined evidenced that 2 of those staff employed at the home commenced employment prior to the home receiving the Protection of Vulnerable Adults (POVA) check and 2 satisfactory references. The registered manager confirmed that this is regular practice. It is required for the protection of people using the service that all the required recruitment processes are completed before staff commence employment. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is a large building with some parts of the building suffering from wear and tear that would be typical of a building of similar age and usage. Maintenance is seen to be ongoing, the standard of hygiene is adequate but the home is untidy. Some areas of the home present a high risk of accident/injury to people using the service. The gardens are attractively laid out and suitable for people using the service use. EVIDENCE: A tour of the home was made by the inspector and a selection bedrooms and all communal areas were seen. All the bedrooms seen were comfortable and The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 23 some people using the service had been supported to personalise their own rooms and some rooms appeared quite bare. The inspector found the home to be showing signs of wear and tear associated with its use. The homes call bell system showed evidence of exposed wires in 2 rooms, the registered manager confirmed that the call bell system has never been serviced but confirmed that an electrician would be contacted. The communal areas were pleasantly decorated and the home appeared clean and no malodours were noted. The kitchen was noted to have tiles missing or one wall and units in need of repair, these issues had also been raised by the Environmental Health Officer on 18/07/06 and no repair has not yet been undertaken. There are suitable and sufficient toilet and bathing facilities for all people using the service. It was discussed with the registered manager that each bathroom contained communal toiletries including soap and shampoo and that this practice is recommended to be stopped as it increases the risk of cross infection. The bedrooms seen all had hand-wash available but did not have paper towels and foot operated flip top bins to enable staff to have suitable hand-wash facilities when assisting people using the service with personal hygiene The homes AQAA states- We make the home safe for all adults to move about during the day. All communal facilities are safe and comfortable to use. All furniture is now screwed to the walls in their rooms. We have a program for maintenance and refurbishment. All toilet facilities are clean and fully equipped. It was noted during the inspection that the home was untidy with commodes, blankets, books and ornaments stacked in various corners of the home. The registered manager must be aware of the risks of trips and falls associated with this level of untidiness. The outdoor garden space is laid to enable access by people using the service and staff stated that the garden is well used. 8 residents surveys confirmed that the home is always clean and fresh, one comment made was “The bedroom is always clean and tidy”. The home was seen to have one unguarded radiator and one unrestricted wardrobe which may present a risk of injury to people using the service. It was also observed that 6 upper floor windows were unrestricted and may present a risk to people using the service as some rooms were accessible by people with dementia care needs. It was noted that this was a requirement made at the previous key inspection on the 1st August 2006 with a timescale for action of 20/08/06. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 24 An Immediate Requirement was made that these windows be restricted by 24/08/07 and risk assessments with the appropriate action taken be taken in the interim period. One window was noted to be broken and not able to close and this was reported to the registered manager at the time of inspection. The inspector returned to the home on 31/08/07 to establish that the windows had been made safe for people using the service and was able to confirm that all windows identified are now restricted. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate to meet the assessed needs of service users and staff training is promoted to support people using the service. An induction process for staff has been developed but lacks some areas related to protection is not consistently completed within an acceptable timescale. Recruitment practice is poor and may put people using the service at risk of abuse. EVIDENCE: The homes AQAA states that - Our staff are committed. We do not have a large turnover of staff. Staff work regular hours so residents get used to a face. We do not use agencies this results in good continuity. Staff rota’s examined evidence that this is the case and people using the service were very complementary about the kindness of the staff. Staff were also complimentary about working at the home and both staff and people using the service felt that staff numbers were adequate to meet peoples needs. Staff felt that they worked well as a team. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 26 On the day of inspection there was the registered manager, the owner, one care assistant on duty from 8-1 am , a further carer was on duty from 8-2 and 2 carers were on duty 8-6. 3 care staff were on duty 6-10pm and 1 care staff 5-9pm. 2 carers are on duty over night. ! cook was on duty but the domestic staff were on holiday and were being covered by the care staff. No laundry staff are employed and staff confirm that they do ironing in the afternoons. The manager is recommended to review staff deployment to ensure that people using the service who spend their day in the downstairs lounge have appropriate supervision and access to staff to ensure that they can summon help as required. The homes management have recently promoted a member of staff to a supervisors position which the manager feels will help to develop staff supervision within the home. Observation of staff files by the inspector confirmed that whilst mandatory training takes place no training is undertaken for abuse awareness (See Standard 18) as indicated in the homes Statement of Purpose. The induction program for staff was noted to not contain any signatures to indicate that the staff had understood all of the areas covered and had not been completed within a 12 week period. The registered manager was advised to ensure that all areas of induction indicated by the Skills for Care Common Induction Standards are covered by the homes induction. 3 recruitment files were examined and were noted to be inadequate in the following areas which may place the people using the service at risk of abuse. Not all staff files contained a photograph of the staff member 2 staff had commenced employment before the Protection of Vulnerable Adults (POVA) check had been received. • 3 staff files evidenced that staff had commenced employment prior to the management receiving 2 satisfactory references. • 1 verbal reference had been received which had not been followed up by a written reference • 3 files evidenced gaps in employment histories which had not been explored and documented. The files also contained insufficient detail of previous employment dates and details. • No evidence was available of how staff were supervised in the period of time between the POVA and the Criminal Record Bureau Check had been received. All 10 staff surveys received confirmed that they had received a Criminal Record Bureau Check and examination of recruitment files confirms that these check were undertaken before staff commenced employment. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 27 • • . The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 35 36 37 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff and people using the service spoken to were positive about the management and felt able to raise concerns and felt that their ideas are listened to. The financial procedures require further development to protect people using the service. Staff are not currently adequately supervised. Further improvements are required to ensure the health and safety of service users, staff and visitors to the home. EVIDENCE: The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 29 The registered manager of the home is Angela Brewer. She has been the registered manager for 6 years but has been employed at the home for 19 years, both staff and people using the service stated that they were confident in Angela’s management ability. The manager advised that she liaises with other relevant health professionals and appears to have a good understanding of people using the service needs. The homes AQAA states- The home holds residents meetings every 3 months to listen to their views. These are recorded as a report and discussed by senior carers and manager. Concerns or changes that they may wish to have incorporated in their daily living is made possible if feasible. Quality assurance records were not seen at inspection as no recent quality assurance has been undertaken. Records seen at this inspection were appropriately and securely stored and staff have access as required. The home manages personal monies for 2 people using the service. The records of these monies were examined at this inspection. Financial transactions were recorded and signed by one of the owners of the home. It is recommended that 2 people sign for all transactions. Receipts were kept and the owner advised that the money is audited regularly. When the money held was checked against the balances there was excess in cash held. The amounts ranged from 5pence to £1.70. This was also noted to be the case at the previous key inspection and is recommended that a more robust auditing and recording system is used. The inspector was very concerned by the large amounts of money being held for people using the service, this also was discussed at the previous key inspection and the previous inspector was advised this was being addressed. It is recommended that this issue is further addressed. The manager confirmed that one to one staff supervision has recently been implemented and records supported this. The registered manager is recommended to ensure that this not be supervision of tasks but include areas of discussion must include the topics outlined in the National Minimum Standards. Accident records were viewed and it is recommended to the registered manager that the accidents must be audited monthly for trends and regular occurrences and action taken to reduce any risks of further accidents taking place. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 30 The home now has a qualified First Aider on each shift. Maintenance records were reviewed and the findings were as follows : Fire Safety. Alarms systems are checked weekly and the fire equipment was last serviced on 21/08/07. The servicing of the fire detection system is due on the week commencing the 24/08/07 and records of completion are to be forwarded to CSCI offices. The home does not currently have a Fire Risk Assessment, the registered manager is to attend a course to learn how this is to be completed. Emergency lighting is tested monthly but records of the service to the system were not available. Electrical Safety – The home has a hard wiring certificated dated 31/07/03 which is valid for 5 years. The last PAT certificate is dated 14/06/05 and is required to be reviewed. Gas Safety - The home has an up to date annual Landlords Gas Safety certificate dated 03/01/07. Some issues of concern are : Cleaning solutions stored in the kitchen were accessible to people using the service and an Immediate Requirement was made to ensure that Substances hazardous to health are stored securely in line with the COSHH guidelines. Dental tablets were accessible to people using the service and may present a risk of accidental ingestion and are recommended to be risk assessed and stored appropriately. Carpet identified in the flats area is a risk of trips and falls and is recommended to be repaired. Some portable electrical items had a PAT certificate dated 2003 whilst some were dated 11/07/06. The registered manager agreed to forward an updated PAT certificate covering all items to the CSCI offices. There were no records available of routine hot water temperature checks. The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 2 18 1 1 3 2 3 3 3 1 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 2 2 2 1 The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 32 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 OP3 Regulation 14(1)(a) Requirement The registered manager must ensure that pre admission assessments are completed in sufficient detail to ensure that the home can provide prior to admission for the care needs identified, this is required to include any environmental considerations with particular reference to the lack of accommodation of wheelchairs in the lift. The registered person must ensure that care plans are fully reflective of an individual’s assessed needs and that they contain clear instructions for staff. Particular attention must be given to psychological/mental health needs. Previous timescales of 31/12/05,10/09/06 and 30/04/07 not met. The registered manager ensure that all creams are named and dated when opened to ensure that the creams are not administered after the expiry date. DS0000015987.V347294.R01.S.doc Timescale for action 30/09/07 2. OP7 15(1)(2) 30/09/07 3. OP9 13(2) 30/09/07 The Limes Version 5.2 Page 33 4. OP16 22(3) The registered manager is 30/09/07 required to ensure that under the homes complaints procedure all complaints are fully investigated and documented to include timescales for completion and outcome. The registered manager is required to provide training for staff in abuse awareness to support people using the service and prevent the risk of abuse. The registered manager is required to ensure that prospective staff to be employed at the home receive a satisfactory POVA check and 2 satisfactory references prior to commencing employment to prevent people using the service from the risk of abuse. 01/11/07 5. OP18 18(1)(a) and 18(c)(1) 6. OP18 18 Schedule 2 30/09/07 7. OP19 13(4)(a)(c The registered manager is ) required to ensure that the environment of the home is tidy and free from risk of trips and falls for staff and people using the service. This includes the storage of furniture, commodes, towels and blankets around the home. 16(j) The registered manager is required to maintain the environment of the kitchen to maintain satisfactory standards of hygiene in the care home. This is with reference to the missing tiles and units requiring repair in the kitchen. The registered manager is required to ensure that all parts of the home to which service users have access are as far as is reasonably practicable are free DS0000015987.V347294.R01.S.doc 30/09/07 8. OP19 01/11/07 9. OP19 13(4)(a) 30/09/07 The Limes Version 5.2 Page 34 from hazards to their safety. This is with particular reference to the call bells identified with exposed wires and ensuring that the call bell system is routinely serviced. Further more areas identified at inspection including carpet in the flats which may present a risk of trips and falls. 10. OP21 13(3) The registered manager is required to ensure suitable hand-wash facilities for staff in people using the service bedrooms to prevent the risk of cross infection. It is further required that the registered manager ensures that communal toiletries are not used in bathrooms. 30/09/07 11. OP25 30/09/07 13(4)(a)(c The registered manager is ) required to ensure that all parts of the home to which service users have access are as far as is reasonably practicable are free from hazards to their safety. This is with particular reference to the unguarded radiator and unrestricted wardrobe An Immediate Requirement was made on the 23/08/07 that the 6 unrestricted upper floor windows are risk assessed and restricted by 24/08/07. 19(1)Sche The registered manager is dule 2 required to ensure that for the protection of the people using the service : • all staff files contained a photograph of the staff member • all staff have received a Protection of Vulnerable Adults (POVA) before commencing employment. • The manager must have DS0000015987.V347294.R01.S.doc 12. OP29 30/09/07 The Limes Version 5.2 Page 35 • • received 2 satisfactory references before the staff commence employment Any verbal references have been followed up by a written reference All gaps in employment histories must be explored and documented. The files must also contain sufficient detail of previous employment dates and details. 30/09/07 13. OP38 13(4) 14. OP38 13(2) The registered manager is required to ensure that all substances hazardous to health are stored in line with the COSHH guidance. Immediate requirement issued 22/08/07. • The storage of dental tablets is required to be risk assessed and the registered manager must ensure correct storage to ensure that there is no risk of accidental ingestion The registered manager is required to undertake a fire risk assessment to cover all areas of the home. • 30/09/07 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 OP12 Good Practice Recommendations The registered manager is recommended to review the provision of activities for people using the service who have dementia care needs to ensure they are appropriate . DS0000015987.V347294.R01.S.doc Version 5.2 Page 36 The Limes 2. 3. OP12 OP15 The registered manager is recommended to ensure that activity provision on a one to one basis is made for those people who remain in their rooms. The registered manager must ensure that appropriate seating in the dining room is available to ensure the people using the service are safe, comfortable and their dignity maintained. The registered manager is recommended to display the homes complaints policy within the home. The management of the home are recommended to access the Safeguarding Vulnerable Adults Policy for Somerset and the Mental Capacity Act to ensure that the people using the service are supported by current legislation. The whistle-blowing policy is recommended to contain the contact details for CSCI. The registered manager is recommended to review staff deployment to ensure that people using the service who spend their day in the downstairs lounge are supervised and have access to staff. The registered manager is recommended to develop a system to record how staff are supervised in the period of time between the POVA and the Criminal Record Bureau Check had been received. The manager is recommended to review the induction process to include all areas indicated in the skills for care Common Induction Standards. The manager is also recommended to ensure that 50 of staff have successfully completed an NVQ in health and social care. The registered person should ensure that monies held at home on behalf of service users does not exceed £50. It is strongly recommended that records and balances are audited at least monthly. The registered person should maintain appropriate records relating to staff supervision which is to take place a minimum of 6 times per year and is to include all areas outlined within the National minimum Standards. The registered manager is recommended to audit all accidents monthly to look for trends and repeated incidences to help prevent accidents. DS0000015987.V347294.R01.S.doc Version 5.2 Page 37 4. 5. OP16 OP17 6. 7. OP18 OP27 8. OP29 9. OP29 10. OP35 11. OP36 12. OP37 The Limes The Limes DS0000015987.V347294.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Limes DS0000015987.V347294.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. 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