CARE HOME ADULTS 18-65
The Old Rectory Stubb Lane Brede East Sussex TN31 6ES Lead Inspector
Jeanette Denereaz Unannounced Inspection 14th December 2005 10:00 The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 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 Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Old Rectory Address Stubb Lane Brede East Sussex TN31 6ES 01424 882600 01424 882066 old-rectory@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes (No. 2) Limited 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) Mrs Kelly Lisa Mendis-Gunasekera Care Home 16 Category(ies) of Learning disability (16) registration, with number of places The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is three (3) in the cottage and thirteen (13) in the main house Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability only to be accommodated Date of last inspection 13th July 2005 Brief Description of the Service: The Old Rectory is registered to accommodate thirteen adults with learning disabilities in the main house, and three adults in the cottage. The property is set in extensive grounds close to the village of Brede near Rye. Whilst Brede offers some amenities the village of Westfield approximately two miles away is used for shops and post office facilities. The main property is a three-storey building and service users accommodation is now on all floors. The cottage is adjacent to the main house, is detached with all three bedrooms having ensuite facilities and a private garden area. The properties are owned by Parkcare Homes Limited, which in turn is owned by Craegmoor Healthcare Limited. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second in the year running from April 1st 2005 to March 31st 2006. The inspection took place between 10.00 and 14.00. The overall focus of the inspection was on meeting with the manager following her return form maternity leave, reviewing the progress of the requirements from the previous inspection, a full tour of the home, including the new provision in the cottage was undertaken. Time was spent meeting the manager, inspecting a number of records, policies, procedures and other documentation. Some residents were spoken to during this inspection; however, the majority of residents were out to their various day services and activities. As this report was made following the second unannounced visit, and does not cover all the standards, therefore for the reader to make a judgment about the home, it is recommended that a copy of the last inspection report of the 13th & 18th July 2005 also be obtained to have a clearer picture of the home. During this inspection areas of concern related to the outstanding Adult Protection Alerts were discussed and recruitment documentation and staff files were inspected. What the service does well: What has improved since the last inspection?
When the manager was on maternity leave the home had periods of turbulence with the staff having a lack and leadership and direction, and this did affect residents and the service. However, there was evidence at this inspection that this is now improving with the registered manager reviewing the service and recruiting new staff. The lack of handover meetings between the staff teams was an area of concern at the last inspection. This has improved and there is now a handover meeting from day and night staff. Since an incident within the home night staff now
The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 6 undertake visual hourly checks on residents, which are recorded, and these records are held by the manager. All Staff now have undertaken training in the Protection of Vulnerable Adults (POVA) since the last inspection following Adult Protection Alerts within the home. A ground floor walk in shower room has now been installed for the use of the resident that living on the ground floor and is just adjacent to her room. Also this resident’s daily activities have improved as well as her health and mobility. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 If the Craegmoor comprehensive procedures for the admittance of new residents are not followed, new residents cannot be assured that their aspirations and needs can be met. EVIDENCE: Since the last inspection there has been two new residents, coming from other Craegmoor homes. The Craegmoor organisation has a comprehensive outcome based evaluation to aid the choice of home process. However, the documents for the two new residents were seen, but the information was not thorough, and therefore could not ensure that the individual aspiration and needs could be met by the home. The two residents did visit the home, and a senior staff member met them in their previous home, before they moved, but documentation was poor. Also, the inspector had been contacted by a parent of one of the new residents, to raised concerns that she had not been informed about the move of her son, and when she requested information she was given the incorrect address. However, she has visited The Old Rectory and was made very welcome, and her son seemed happy. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The service offered to resident is now at an acceptable standard, and improvements and alteration have been made to the home to accommodate changing needs. EVIDENCE: Since the last inspection a ground floor walk in shower has been provided for the resident living on the ground floor, just adjacent to her bedroom. The registered manager is reviewing all care plans and implementing Person Centred Planning (PCP) for all residents. This process has been completed for the three residents that have moved into the Cottage. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 & 16 The home offers many opportunities for educational and leisure activities in the community and as the residents become elderly more activities are arranged within the home and within the local community. EVIDENCE: Since the last inspection daily activities of the residents have been generally reviewed and now are displayed on daily planning sheets. On the day of the inspection many residents were out and about. Many of the activities are leisure based and there are many trips to local pubs, restaurants and shops. Family contact is encouraged and residents are supported to keep in touch by telephone and visits. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards 18,19 and 20 were inspected at the last inspection on 18th July 2005. EVIDENCE: The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There as been Adult Protection Alerts raised since the last inspection, and therefore residents have not been fully protected from abuse. EVIDENCE: The home has been the subject of three Adult Protection Alerts, since the last inspection, with alleged physical abuse between residents, and a staff member to a resident. The Adult Protection Alerts are still on going and The Community Learning Disability Team are chairing the meetings. The registered manager has taken appropriate action and all staff have had training in the Protection of Vulnerable Adults and this training will be on going. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were inspected at the last inspection on the 18th July 2005. EVIDENCE: The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35 & 36 The residents would benefit from having a well supported and supervised staff team. EVIDENCE: Over the last year the has been a large turn-over of staff within the home, and from the recruitment records staff were employed without relevant experience in working with people with learning disabilities. The Craegmoor organisation has a comprehensive induction package, but the staff files inspected did not confirm that the induction had been fully undertaken. Supervision for staff has been poor, and not regular and this needs to improve. Craegmoor have introduced a new format for supervisions, but to date the manager has not had the training to compete this new system. The manager herself needs and should receive regularly supervision from senior management. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The registered manager must ensure that the resident have the opportunity to make their views known about the home, and that the staff have the competencies to ensure that the home is run well at all times. EVIDENCE: The registered manager has now returned from maternity leave and there was evidence that the home has leadership. The recruitment of staff is taking place and the home should soon be fully staff with competent and trained people. Some staff that left now have returned and the manager feels she has the potential to have a good staff team. The manager will be re-introducing house meetings to ensure that residents views are known and taken into account. The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
The Old Rectory Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000021256.V270291.R01.S.doc Version 5.0 Page 17 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 YA2 Regulation 14(1) See Sch 3(1)(a) Requirement The registered manager must ensure that new residents are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective resident and other stakeholders. The registered manager must ensure that residents are safeguarded from all forms of abuse and that the staff team are fully trained in this area. The registered manager must ensure that appropriate and competent staff are employed to work within the home. The manager should also ensure that the induction training is undertaken fully and understood by the staff, and there is evidence that this process has taken place. The registered manager must ensure the staff have regular, recorded Timescale for action 14/12/05 2 YA23 13(6) 14/12/05 3 YA35YA34 18(1)(4)(c) 19 31/03/06 4 YA36 12 18(2) 14/12/05 The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 18 5 YA39 supervision meetings at least six times a year. Also the responsible individual must ensure that the registered manager has regular recorded supervision with senior management. 24(1)(a)(b)(2)(3) The registered manager 31/03/06 must ensure that an effective quality assurance and quality monitoring systems are in place within the home to seek the views of residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old Rectory DS0000021256.V270291.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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