Inspection on 09/06/08 for The Limes

This inspection was carried out on 9th June 2008.

CSCI found this care home to be providing an Poor service.

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 29/10/08

The Limes 03/07/07

The Limes 27/04/06

The Limes 03/02/06

The Limes 03/10/05

The Limes 07/02/05

The Limes 01/09/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Limes High Street Henlow Bedfordshire SG16 6AB Lead Inspector Mrs Louise Trainor Unannounced Inspection 9th June 2008 06:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Limes DS0000014929.V366449.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 DS0000014929.V366449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address High Street Henlow Bedfordshire SG16 6AB 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) 01462 811028 01462 811028 info@limescarehome.co.uk The Limes Care Home Ltd Mrs Joan Wilkinson Care Home 23 Category(ies) of Dementia (23), Mental disorder, excluding registration, with number learning disability or dementia (23), Old age, of places not falling within any other category (23) The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users must not exceed 23. The home shall accommodate persons of either sex. No one falling into the category of MD (age range over 65 years) may be admitted into the home where there are already 3 persons of category MD (age range - over the age of 65 years) accomodated within the home. No person aged under 45 years of age who falls within the category of DE may be admitted to the home. 3rd July 2007 4. Date of last inspection Brief Description of the Service: The Limes is a privately owned residential care home, providing care for 23 residents who have physical and mental health needs. The property is situated within the village of Henlow on the High street. It was built in 1840 and has been sympathetically converted by the proprietors to retain much of its original character and charm. In 2001 a further large extension was added to increase the registered accommodation to its present occupancy. Bedrooms located on the upper floor of the original house are accessed via staircases and a chair lift; bedrooms in the extension are accessible via a shaft lift. There is a large well-maintained enclosed rear garden and car parking is available at the front of the home. The fees for this home vary from £550.00 per week, to £850.00 per week, depending on the funding source. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was a Key Inspection, and it was carried out on the 9th of June 2008 by Regulatory Inspectors Mrs Louise Trainor and Mrs Sally Snelson, between the hours of 06:30 and 13:35 hours. The home Manager and her deputy were present for the majority of the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care of three people who use the service were case tracked. This involved reading their records and comparing what was documented to the care that was provided. We also spoke to staff, Documentation relating to: staff recruitment, training and supervision, rotas, and medication administration were also examined. One of the inspectors spent the majority of the visit in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this inspection. Due to concerns regarding medication at this inspection, we requested that the Commission for Social Care Inspection (CSCI) specialist Pharmacist Inspector visited the home. This visit was carried out on the 12th of June 2008, and his findings form part of this report. We would like to thank everyone involved for their support and assistance during this visit to the home. The Limes DS0000014929.V366449.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: There is no evidence to indicate that complaints are appropriately investigated in this home, and the home does not understand the safeguarding reporting processes so that people may not be protected. No clear system for compliance with the administration, safekeeping and disposal of controlled drugs is in operation and staff are unclear of what is required. Health care is reactive rather than proactive, and reviews and record keeping is insufficient to ensure the safety of the people who live in this home. During case tracking we did not see any examples of pre-admission assessments that were thorough enough to provide the necessary evidence that the staff at the home had the necessary skills, experience and qualifications to care for the people living there. Some residents are consulted or listened to regarding the choice of daily activities, but this process could be improved. The food in this home is satisfactory, however there is no choice of menu offered routinely, so that those people who are unable to make requests verbally themselves, are not given choices. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 7 This service has a poor recruitment procedure with shortfalls in recording and processes being evident. Staff are appointed and start working without important documentation being received. Generally the home provides a physical environment that meets the specific needs of the people who live here. Toilets are sufficient and appropriately located, however not always clean and furnished to minimise risk of infection. Lack of records indicates that the manager lacks understanding, knowledge and control of some of the main components involved in the running this home and the protection of the people who live there. Staff files identified that only six staff had received any supervision since November 2007. The manager explained that informal supervision does happen however this is not recorded. There was no evidence to suggest that the regulation 37 reporting process is understood by anyone in the home. Recent staff suspensions and allegations of abuse, as well as deaths and falls in the home have failed to be reported. 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 DS0000014929.V366449.R01.S.doc Version 5.2 Page 8 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 DS0000014929.V366449.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5, 6 People who use this service experience poor quality outcomes in this area. With the exception of people who are admitted to the home following a period of day care at the home. There was no evidence that prospective residents are assessed prior to admission. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During case tracking we did not see any examples of pre-admission assessments that were thorough enough to provide the necessary evidence that the staff at the home had the necessary skills, understanding, experience and qualifications to care for the people living there and fully meet their needs. During this inspection we found several examples of where people’s needs were not being either addressed or met. It was not clear if this was because The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 10 these needs were not recognised, or because staff lacked the skills to meet them. Records from a visiting district nurse indicated that one person had a pressure area that required treatment. Staff who had assisted this person with personal care on the morning of the inspection stated that these areas were healed. When we checked, this was not the case, and these areas had not been treated and dressed correctly. The records of another person read that they had been restrained on two occasions. The manager stated this was not accurate and that staff were using incorrect vocabulary in their reports. We were unable to confirm this; however training in control and restraint techniques is not something that the staff in this home attend routinely. Another person had a repetitive behaviour that we observed during this visit. It was likely that this was indicative of ‘a need’, however staff did not communicate with this person or attempt to pursue what this need might be, and their behaviour was ignored, therefore the need was not being addressed. Evidence indicated that some people in this home were pursuing independent activities during the day, however they still had their toast buttered for them at breakfast, and there was no evidence to suggest that they were being actively encouraged to further this personal independence in other areas of daily living. Another person continually put themselves on the floor, however there was no evidence to suggest that staff were managing this problem, or investigating why it may be happening. There was a general acceptance of all of these behaviours, rather than an investigatory approach, which may have resulted in an improved quality of life for some of these people. We did however see an example of an assessment that had been started on a person that was currently attending day care in the home, with a view to taking up a permanent placement in the future, indicating that some people were encouraged to visit the home prior to permanent admissions being arranged. The manager told us that this was how they would like to do all preadmissions assessments as they got a clear picture of the person’s needs, abilities and the level of care and support they would require. In two of the files sampled there were letters addressed to family members stating the need to move the individuals from one room to another, either for their own benefit or to benefit someone else. The letter stated that the move had been planned with the agreement of the service user. Letters in the files also suggested that, in some cases, family members were invoiced for the extras that were not included in the contracted price, such as aromatherapy and hair washes and cuts. The home did not offer intermediate care, but did offer day care. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 11 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 People who use this service experience poor quality outcomes in this area. No clear system for compliance with the administration, safekeeping and disposal of controlled drugs is in operation and staff are unclear of what is required. Health care is reactive rather than proactive, and reviews and record keeping are insufficient to ensure the safety of the people who live in this home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During the inspection we looked in detail at the care records of three service users, including one who had passed away. There were care plans available for each individual, but they had not always been written in sufficient detail or for all aspects of care. For example one person had a catheter, there was no mention of this in his care plan. Whilst we The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 12 accept that the community nurses were responsible for changing the catheter, the care staff had responsibility for the daily catheter care. It was apparent that the registered manager was not auditing care records, including the daily logs. For example more than once we noted a comment about a person living at the home needing to be restrained. When we asked for the restraint policy and training record we were told there was not one, as restraint was not used. The manager stated that it was the wrong use of vocabulary. We also read for the same person ‘sometimes finds himself on the floor’. The accident record and the person’s personal risk assessment did not support this. The manager explained that this person would spend time on the floor, but as the reader of the plans we had not picked this up as part of this persons behaviour. One care plan was so confusing, that we were unsure as to whether the person still had a pressure area requiring care. We had to request permission to check this person’s pressure areas. Before we did this, the deputy manager and the member of staff who had provided the personal care that morning, told us that the area had healed, and there was no care plan to suggest otherwise. However there was an entry from the community nurses, made the week before, that referred to a ‘grade three pressure sore’ and the need to change this person’s position regularly. There was no turn chart in place. When we checked, the area in question was broken, and had had no dressing or treatment applied that day. All of the care plans that we looked at had been reviewed the previous month, but not for more than three months prior to that. There was some evidence that care plans were updated as needs changed, but as these changes were not dated, it was not clear when this had taken place. Risk assessments were in place, but many suggested that the individuals needed constant monitoring. There was no evidence to indicate that this was happening on the day of this inspection. During this visit we witnessed one lady stand up and fall to the ground. Despite the fact that no staff were present to witness this fall, they still failed record it because they were sure that it was a controlled fall. We witnessed people being moved and handled appropriately with the exception of the use of footplates on some wheelchairs. Pressure relieving equipment, such as specialist mattresses was being used. Although no controlled drugs were being administered at the time of the inspection we did find controlled drugs in the home. The manager told us these were waiting to be returned to the pharmacy. We also found medication, which was the property of a person who had passed away in March 2008, waiting to be returned. As a consequence we attempted to audit the controlled drugs held in the home. The book used to record the use of the Controlled The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 13 Drugs, did not meet requirements, and entries were not always concurrent. Also in the cupboard was a supply of Oramorph and Morphine Sulphate tablets that had been obtained by a family member, on behalf of a resident, received into the controlled drug cupboard by the staff, but not documented. Due to our concerns regarding medication in this home, we requested the CSCI specialist pharmacist inspector to visit and look at medication handling procedures, medication storage, medication records, and associated care records, as part of this key inspection. This Visit took place on the 12th June 2008. Findings from the Pharmacist Inspectors visit on the 12th of June 2008. Written medicine handling procedures were available to the care staff but these are not always followed. Clear records were kept of all medicines coming into and leaving the home. Records were kept when medication was given to residents. However, there were a lot of problems with these records. Some medication was recorded as given to residents but the corresponding dose remained in the blister pack of medicines. If medicines were not given to residents, the reason why was not being clearly recorded. One staff member initials the form to indicate medication is given, with the initial “O” which is the same as a code to indicate the medication has been omitted and more details are needed to explain the reason why. So it is sometimes confusing to know whether medication has been omitted or given by this member of staff. There were a lot of gaps in the records of when medicines are given, giving no clear indication if they have been administered to residents or not although the corresponding dose had sometimes gone from the blister pack. A medicine for one resident which is prescribed to be taken at 6pm was recorded as being given at 4pm although a staff member reported that it was given “nearer to 6pm”. The record for another resident whose medication should be given at least half an hour before food, drink or other medicines, showed that the particular medicine was given at the same time as other medicines although a member of the care staff said it was given separately. Where medication is given on a variable dose basis e.g. “one or two tablets” the actual dose given is not always recorded so this could result in residents receiving too much or too little medication. A practice has developed whereby pharmacy provided dispensing labels are used on the medication record forms. Although this might reduce transcribing errors, such labels easily become detached or cover relevant other information on the forms. This practice should be re-considered. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 14 To protect residents, an immediate requirement was made to improve the accuracy of the medication administration records and to ensure medication is only given in accordance with the prescriber’s instructions. Some of the hand-written medication record forms did not clearly indicate the date on which medication is given. When handwritten additions or alterations were made to the computer printed medication administration record charts, supplied by the pharmacy, these were not signed and checked for accuracy. The areas used to store medication were secure but the temperatures of these areas are not monitored or recorded. The temperatures were at the upper limit of acceptable levels and staff were unaware of what the correct temperature should be. The failure to store medicines at the proper temperature could result in residents receiving a treatment that is ineffective. No controlled Drugs were in use at the time of this inspection. Previously they were being stored in a locked cupboard but this does meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 (as amended). The usage of Controlled Drugs had being recorded in a separate book but this was not a register as stated in the regulations. However, a new register has been obtained. Not all staff had received robust training on the safe use and handling of medicines but a program of training is being planned by the manager. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience adequate quality outcomes in this area. Some residents are consulted or listened to regarding the choice of daily activities, but this process could be improved. The food in this home is satisfactory, however there is no choice of menu offered routinely, so that those people who are unable to make requests verbally themselves, are not given choices. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During the inspection we did not see any group activities, but we did see some people being supported to pursue hobbies. One person who lived in this home was a keen gardener and was instrumental in keeping the garden immaculate. He also had an interest in fishing, and part of his morning routine included feeding the Koi Carp in the garden pond. He clearly enjoyed this task and was very informative about these creatures and keen to chat with us and share his The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 16 knowledge. He told us that he had just been on a two-day fishing trip, however also said. “I don’t get out as much as I’d like”. During the morning, he and another resident went out with a member of staff to buy fish food, and another service user was escorted to a doctor’s appointment by staff. However there was little else in the way of activities for the majority of the people in this home on the day of this inspection. The care plans did not provide much information about people’s previous interests and pastimes or how these were being pursued in the home environment. One person told us that he worked in a charity shop during the day. One or two people living in the home also spoke of playing bingo sometimes, and the prizes that they won. When we arrived at the home at 06.30hrs the dining tables were ready for breakfast and the porridge had been made and was waiting to be reheated in the microwave. The weekly menu, which was displayed on a whiteboard in both dining areas, was for the week commencing 5th May, which was a month earlier. We therefore deduced that the residents had not been made aware of what meals they were to have for the last month. During the inspection the board was updated. As people got up, or were got up, they were taken to one of the dining areas for breakfast. At 07.30 hours, there were 11 residents eating breakfast. We noted that few people were given a choice. Staff appeared to know what they wanted, and even the resident’s who were able to, were not given the option of putting spread on their toast. This was done by staff from a large tub of margarine before it was distributed to individuals. This theme was repeated at lunchtime. The menu did not include any choices, however the cook confirmed she could prepare an alternative if she knew someone disliked the planned meal. On the day of the inspection the lunch was recorded as ham, eggs and chips, in reality it was fried bacon, eggs and chips. We were surprised to notice that the place mats at every place had a Christmas decoration on them. A member of staff told us, “that’s what the residents choose, they eat better if the table looks bright.” We were concerned that as a number of the people in the home had dementia, and a Christmas picture could be confusing. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience poor quality outcomes in this area. There is no evidence to indicate that complaints are appropriately investigated in this home, and the lacks understanding of the safeguarding reporting processes so that people living in this home may not be protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: A number of thank you letters were displayed in the home, however when we asked to see the complaints file, the manager was unable to locate it. She did look for one, which suggested that she was aware one should have been used. The visitor’s book at the entrance to the home was being used appropriately, and the entrance also housed information for families and friends, including the most recent adult protection leaflet to be produced by the Local Authority. Unfortunately despite this leaflet being displayed, management were not aware of its’ contents or how to safeguard the people living at the home. Just prior to this inspection CSCI had received a call from the family of a resident from this home. The resident had made allegations regarding the treatment she had received from some staff in this home. The home had not reported this matter either to CSCI or the Safeguarding team, and when this was discussed with the manager, she was unable to demonstrate any The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 18 understanding of the local protocols and procedures that are in place to protect people in care homes. The manager informed us that she had taken advice from her ‘consultancy company’. We suggested that she make contact with the local Safeguarding teams as a matter of urgency, to obtain the appropriate protocol documents. We were shown a file, which contained violent incident forms. One suggested that a person took a knife out of the cutlery drawer and went to use it on a fellow resident. The incident report went on to indicate that staff had been able to take the knife away. A second form stated ‘ a member of staff was slapped around the face’ and a third recorded one resident slapping another around the face. None of these incidents had been reported either to CSCI, as an incident affecting the well being of a service user, or to the local Safeguarding Co-ordinator. An Immediate Requirement was made regarding Safeguarding reporting. As detailed elsewhere in this report, we noted that in one persons daily records staff referred to restraining them. The manager believed that this was the wrong use of vocabulary, as staff were not trained to use restraint. When we questioned one member of staff about her understanding of restraining two service users if they had an altercation. She replied by stating “ I would make safe, but not stop them, as you are not allowed to these days.” The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 26. People who use this service experience adequate quality outcomes in this area. Generally the home provides a physical environment that meets the specific needs of the people who live here. Toilets are sufficient and appropriately located, however not always clean and furnished to minimise risk of infection. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home was generally clean, tidy and free of any offensive odours. We did however note that the tiles in one toilet/ bathroom were dirty and that outside coats were being stored on the back of the bathroom door. This bathroom was The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 20 operational as the bin contained a number of used disposable gloves, however the bin was not lined. The staff toilet did not have any means for us, or staff to dry our hands after washing them. The large freezers in the kitchen had broken down two weeks earlier and the part needed for the repair was on order. The cook was shopping more frequently and having regular deliveries from a local supermarket. The hall and main stairway was being redecorated. This was being done in small stages with the minimum of disruption to the people living and working in the home. There had been concerns raised at the previous inspection regarding the risks surrounding the ‘open’ door to the laundry room in the basement. A new coded door has been fitted so that residents cannot access this area. In one bedroom that we visited, the drawers and cupboards were labelled suggesting what should be put where. For example socks, vests. The person in the room had been confined to bed for sometime and would not be capable of finding or putting away his clothes, so this labelling was of no benefit to the resident and did not give the room a ‘homely’ feel. The gardens attached to this home are beautifully kept, and there are ramps and slopes enabling wheelchair users to access all areas of the garden. There is a large ornamental pond full of gold fish and koi carp. This is surrounded by safe fencing and decking which provides a pleasant relaxation area for residents to enjoy weather permitting. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience poor quality outcomes in this area. This service has a poor recruitment procedure with shortfalls in recording and processes being evident. Staff are appointed and start working without important documentation being received. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The personal files of four staff were examined during this inspection. The recruitment processes in this home were ‘disjointed’ and the manager was unaware of processes she should be following to protect her residents and also to protect herself from hefty fines for employing staff without the appropriate Home Office documentation. All staff had fully completed application forms that included their employment history, and contracts were signed, however one person had signed and dated their contract, and therefore commenced employment, prior to receipt of an Enhanced Criminal Records Bureau (CRB) check. Two of the files only contained one reference, one of which was from a friend and had nothing from the previous employer, however this was obtained during the inspection. One person had an overseas passport, but no evidence from the Home Office to indicate that they had permission to work in this country. The manager was The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 22 unaware that the home had to apply for a work permit for this individual. She thought work permits were transferable from job to job. As it transpired, this individual had unlimited leave to remain, but the manager had not obtained any evidence of this before offering work. Training records indicated that mandatory training is carried out on a regular basis, and generally the staff attend updates, as they are due. In the last nine months records showed that twelve staff had attended Moving and Handling training, fourteen staff had completed their food hygiene training and twelve had completed their safeguarding training. However despite staff having this training, there had recently been serious allegations made by a resident, and staff did not respond or report this matter appropriately. Some specialist training had been available to some staff, however evidence indicated limited attendance in subjects such as Mental Health and dementia. Although the home is registered to care for people with mental health problems, one of the senior staff when discussing training said. “I am looking forward to having some training on mental health to understand it better”. This home presently has three staff on duty during the day and two staff plus one ‘sleeping in’ at night. However the rotas identify that some staff have been working excessive hours. Between the 26/05/08 and the 22/06/08, one member of staff had only had four days off, and each of these days off followed a night shift. During this twenty-eight day period this person worked, 16 night shifts, 5 x 14 hour day shifts and 3 x 7 hour day shifts. Although we appreciate that some staff are happy to do extra shifts, these were excessive hours and the health and safety of the both the staff and residents could be put at risk. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 37, 38 People who use this service experience poor quality outcomes in this area. Lack of records indicates that the manager lacks understanding, knowledge and control of some of the main components involved in the running this home and the protection of the people who live there. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager of this home has a mental health nursing background and many years experience in the care profession, however it was very evident during this visit that, she is out of touch with some of the core processes and procedures which are required to meet with the National Minimum Standards The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 24 for Care Homes. She was not able to demonstrate any understanding of Safeguarding reporting procedures, and subsequently a recent case of allegations in this home has been seriously mismanaged. Recruitment processes were poor, and her personal knowledge regarding Home Office documentation such as work permits was very limited. Serious concerns were identified relating to medication records and vocabulary used in report writing. This indicated that there is no auditing process in place by the manager. There was no evidence to suggest that the regulation 37 reporting process is understood by anyone in the home. Recent staff suspensions and allegations of abuse, as well as deaths and falls in the home have failed to be reported. A ‘violent incident book’, detailed several incidents that had occurred over recent weeks. None of these incidents had been reported to CSCI. An immediate requirement was left relating to regulation 37 reporting. Staff files identified that only six staff had received any supervision since November 2007. The manager explained that informal supervision does happen however this is not recorded. Records of complaints and investigations, and staff disciplinary matters are poorly documented. The manager was unable to locate the complaints file. We were shown a quality assessment file. The file included questionnaires that had been completed by people who live in this home and relatives during April 2008. There were very few negative comments in the ones completed by service users, other than comments such as ‘sometimes have to wait, but then it happens’. However the weighting given to these questionnaires would be very low, as they had all been completed by a member of staff on behalf of these individuals. There was one very negative form from a relative. As a result the manager and the deputy had met with this person and discussed the issues and kept a record of the meeting. The home only holds personal funds for five residents in this home. These were all checked and records were accurate. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 1 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 3 3 3 2 X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 1 1 The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement No residents should be admitted to this home unless a suitably qualified person has carried out a full assessment of needs. People who use this service must have an individual care plan that is reviewed regularly to reflect changing needs. Previous requirement 31/08/07 partially met Complete and accurate records must be kept of all medication administered, or not, together with a reason why the medicine was not given, in order to demonstrate that residents receive the medicines prescribed for them. An immediate requirement notice was served. This is a repeat requirement, previous timescale of 31/07/07 not met. Resident must be protected by being given medication only in accordance with the prescriber’s instructions. An immediate requirement The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 27 Timescale for action 30/06/08 2. OP7 15(2)(b) 31/07/08 3. OP9 13(2) 17(1)(a) 14/06/08 4. OP9 12(1) 13(2) 14/06/08 notice was served. 5. OP9 13(2) Medicines, including controlled drugs, must be stored properly, securely, and in appropriate environmental conditions. This will protect residents from harm and their medication from diversion. Staff authorised to administer medicines must be trained and assessed as competent to do so. This will protect residents by ensuring medication is only handled by competent trained staff. 31/07/08 6. OP9 13(6) 18(1) 30/08/08 7. OP16 22 8. OP18 13(6) 37 9. OP29 19(1)(b) People who use this service must 30/06/08 be protected by the homes complaints procedure, and all records relating to investigations must be maintained in the home. People who live in this home 20/06/08 must be protected by appropriate referrals being made to the safeguarding team. An immediate requirement notice was served. This is a repeat requirement, previous timescale of 31/07/07 not met The manager for this home must 20/06/08 be in receipt of all the appropriate documents specified in paragraphs 1 to 7 of schedule 2, for each employee prior to them commencing work. People who live in this home 31/07/08 must be care for by staff that are appropriately trained to meet their needs. This must include Mental Health and Dementia training. The care of the people in this 31/07/08 home must be managed by an individual who can demonstrate DS0000014929.V366449.R01.S.doc Version 5.2 Page 28 10. OP30 19(5)(b) 11 OP31 9 The Limes a clear understanding of their responsibilities and control of all systems in the home that protect the people who live here. 12. OP33 24(2) A report reviewing the quality of care in this home must be submitted to CSCI to ensure that the people who use this service are being listened too, and their opinions considered. Previous requirement 31/08/07 partially met People who live in this home must be cared for by staff that are appropriately supervised People who live in this home must be protected by accurate record keeping. People who live in this home must be protected by appropriate reporting systems being applied to accidents and incidents including any injuries with unknown origins/ causes. An immediate requirement notice was served 31/07/08 13. 14 15. OP36 OP37 OP38 18(2) 17 37 31/07/08 31/07/08 30/06/08 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 OP9 Good Practice Recommendations Reconsider the practice of using pharmacy provided dispensing labels fixed to medication record forms, as these do not provide a clear or permanent record of medication prescribed. The Limes DS0000014929.V366449.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 DS0000014929.V366449.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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