Inspection on 16/01/08 for Vaughan Lee House

This inspection was carried out on 16th January 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

Vaughan Lee House 23/07/08

Vaughan Lee House 04/12/06

Vaughan Lee House 09/02/06

Vaughan Lee House 08/08/05

Vaughan Lee House 04/02/05

Vaughan Lee House 16/09/04

Vaughan Lee House 25/03/04

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 Vaughan Lee House Orchard Vale Ilminster Somerset TA19 0EX Lead Inspector Ms Sue Hale Key Unannounced Inspection 16th January 2008 09:00 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 Vaughan Lee House DS0000016070.V357807.R02.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. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vaughan Lee House Address Orchard Vale Ilminster Somerset TA19 0EX 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) 01460 52077 vaughanleehouse@tiscali.co.uk ILMINSTER AND DISTRICT (O P W ) HOUSING SOCIETY Limited Mrs Rosalind Anne Woolmington Yvonne Foulsham Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 30. 4th December 2006 Date of last inspection Brief Description of the Service: Vaughan Lee House is a care home providing care and support for up to 30 older people. The home is located in a residential area of Ilminster. Local services including shops, pubs and public transport are nearby. The home is owned and managed by a local charitable organisation. The home was purpose built in 1970 with the specific aim of providing support for local people. Consequently the majority of residents are from Ilminster and the surrounding villages. Locally based staff are also attracted to working in the home. Consequently the home has strong links with the local community that benefits the residents. All accommodation is on the ground floor and bedrooms are for single occupancy. The home offers a limited amount of day care for non-residents each week. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this key inspection was to inspect relevant key standards under the Commission for Social Care Inspection ‘Inspecting for Better Lives 2 Framework’. This focuses on outcomes for residents and measures the quality the service under for general headings. These are; excellent, good, adequate and poor. These judgment descriptors for the seven chapter outcomes are given in the report. One Inspector undertook the inspection over the course of one day in January 2008. There were 28 people living in the home on the day the inspection, one resident was in hospital and there was one vacancy. The inspector undertook a tour of the home, and looked at records and other documentation relevant to the running of the care home. Records relating to four residents and three new members of staff were looked at. The inspector spoke to 12 residents, 1 visitor, 4 members of staff and the registered manager, Mrs Foulsham. The home completed an Annual Quality Assurance Assessment (AQAA) and surveys were sent out to residents, relatives, staff, GPs and health and social care professionals. 18 relatives returned surveys, 13 staff and 14 residents. This is a very good response and the results of the surveys are incorporated into this report. The current fees range from £373 to £490. As a result of these inspection 10 requirements have been made, 3 of which are outstanding from the last inspection and 18 recommendations of good practice. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: All residents are given a statement of the terms and conditions of residency when they move into the home. Prospective residents and their families are Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 6 encouraged to visit the home and spend time there before they make a decision about whether to move in. A relative commented that the homes ‘ethos is one of humanity and good humour, the atmosphere is calm and relaxed, yet efficient, the staff are kind, patient and dedicated’. Staff were observed to be professional, respectful and had positive interactions with residents. Visitors are made welcome to the home and one relative said that they felt ‘greeted in a friendly and pleasant way’. Staff support and encourage residents to access all necessary health and medical care. One resident surveyed said that they had ‘always been happy at Vaughan Lee House’ and another commented that they had had ‘no regrets about moving into the home’. Residents enjoy the monthly trips out of the home to local places of interest. Residents were aware of their right to raise any concerns or complaints and were confident these will be listened to and dealt with appropriately. Residents confirmed they were treated with respect by staff and their right to privacy and dignity was acknowledged and respected. The food served at the home is home made and provides a good standard of nutrition for residents. Staff were familiar with individuals likes and dislikes and make good efforts to suit peoples preferences. The majority of care staff are qualified to NVQ level 2 or above. All the residents spoken to and surveyed were very satisfied with the standard of care they receive at the home. People spoke warmly about the staff and comments included that they were ‘friendly’, ‘caring’ and ‘look after people very well’. Residents are encouraged to bring into the home their personal possessions and to personalise their private room. The home was clean, tidy and free from odours on the day the inspection. Residents are satisfied with the laundry service the home provides. All accidents are recorded and records were scored securely. Equipment and facilities at the home were well maintained and serviced to make sure that people living and working in the home are safe. Residents and staff are very positive about the manager, Mrs Foulsham and the management team and their approachability. The home has internal quality assurance systems in place to check on the quality of the service provided. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Up to date copies of the statement of purpose and service user guide that includes all the relevant information must be readily available in the home to make sure that prospective residents and their relatives are able to make an informed decision about residency. The terms and conditions of residency needs minor amendment to meet the national minimum standards. People should not be admitted to the home unless a thorough assessment has been undertaken to make sure that their health, social and care needs can be Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 8 met. All care planning documentation should be fully completed, dated and signed. Care plans should cover all the recommended topics and be reviewed monthly and updated as necessary. Nutritional risk assessments should be undertaken for all residents and reviewed and updated as necessary. Closer attention should be paid to monitoring resident’s weights and care plans and risk assessments should be updated when a weight loss that gives cause for concern is identified. The complaints procedure should include a timescale within which complaints will be dealt with and the procedure and policy should make clear that complainants are able to contact Commission for Social Care Inspection at any stage of the complaint. The way in which complaints are recorded and investigated must be more robust to make sure that concerns and complaints are taken seriously and people have confidence that they will be investigated. The management of aggression/violence by resident’s policy should be reviewed and updated to reflect current good practice advice and guidance. Consideration should be given to providing residents with a lockable storage space in their private rooms so they can keep money and valuables safely. The staff application form should be revised to make sure that it complies with current good practice and employment legislation. All prospective staff should complete an application form. All staff should be given a job description, terms and conditions of employment. References should be obtained from an applicants last employer. The induction programme is poorly managed with little evidence that new staff are undertaking a thorough induction to both the home and their role. The staff training programme should be revised to make sure that it includes topics relevant to current residents including dementia and challenging behaviour. All staff must receive regular formal supervision to make sure their care practice is in line with the homes expectations of them. The supervision policy should be reviewed to reflect the national minimum standards. All policies and procedures should be reviewed and updated to make sure that they reflect current good practice advice, the national minimum standards and give relevant information and guidance to staff and the management team. Consideration should be given to streamlining the way that information is held and stored at the home to make sure that information is readily available and consistent. The fire risk assessment should be updated to include evacuation procedures. COSHH risk assessments should be reviewed and updated if necessary. Vaughan Lee House DS0000016070.V357807.R02.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. Vaughan Lee House DS0000016070.V357807.R02.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 Vaughan Lee House DS0000016070.V357807.R02.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): 1,2 and 3. Standard six is not applicable to this service Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. An up to date statement of purpose and resident guide was not available. People who move into the home are given a statement of the terms and conditions of residency. Pre admission assessment procedures are inconsistent and not always undertaken. EVIDENCE: The statement of purpose available to staff in the policies and procedures file was dated May 2003 and the terms and conditions of residency January 2002.A statement of purpose and service user guide has been sent to the Commission for Social Care Inspection with the response to the draft report Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 12 but this did not include all the required information. Of the residents surveyed 13 said that they had received a contract. 9 relatives said that they had always received enough information about the home, 6 said that they had usually had enough information and 3 said that they only sometimes had had enough information. One relative commented that ‘I have never received any written information or brochures about the home even before my relative went there’. However, they went on to state that they had visited the home and that any questions they had, had been answered by staff. Mrs Foulsham forwarded a statement of terms and conditions of residency dated March 2007. This includes what is included in the fee, the notice period, who is responsible for the fees and what residents are responsible for purchasing themselves. It does not include the number of the room to be occupied and who is responsible if there is a breach of contract. We (the Commission for Social Care Inspection) looked at the care files of two people who had moved into the home since the last inspection. One file had a pre admission assessment that was signed by the registered manager but not dated. The pre admission assessment form covers all the topics recommended in the national minimum standards. However on this file six sections were blank. The other file checked did not have a pre admission assessment form on file, but some information had been sent from the home the person had previously lived in. There was no evidence that there had been a thorough pre admission assessment undertaken to make sure that the home could meet the persons needs before they moved in. Vaughan Lee House DS0000016070.V357807.R02.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst all residents have a care plan the quality and detail of these are inconsistent and residents have no involvement in care planning. Residents have ready access to healthcare and medical professionals as required. Medication is well managed by trained staff. People who live at the home are treated with respect and their right to privacy and dignity acknowledged. EVIDENCE: We looked at four residents’ files in detail and found that whilst all residents had a care plan these lacked detail, did not cover all the recommended topics Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 14 and did not always reflect individuals current needs. Files all included a set of the homes care planning documentation that included moving and handling assessment, weight records, nutritional risk assessment, short term care plan, medication record, contact with medical and healthcare professionals and key worker contact. On one file records included details of the medication taken, a life history, moving and handling assessment, a copy of the funding authorities assessment, contact with professionals, a short-term care plan and a daily record. There were also a lot of records about contact and consultation with medical professionals about the residents deteriorating health. Relevant risk assessments were in place that included how to manage challenging behaviour and personal care but these had not been updated since September 2007 although it was evident that the person’s mental health had been deteriorating. Although the resident had dementia there was no nutritional risk assessment in place and no advice for staff on how to reduce the risk of weight loss. On the second record a healthcare professional had noted a weight loss in November 2007 but there was no evidence that this had been noted by the home or any action taken. As noted in outcome group 1, 6 of the assessment sections were blank which gave no information or guidance to staff on the residents needs. On the third record there were details of the persons next of kin and relatives, a short-term care plan, moving and handling assessment, medication record, a record of any contact with medical and health care professionals, the terms and conditions of residency and a copy of the funding authorities assessment. The nutritional assessment was blank and the daily record was lacking in detail. The fourth record contained a copy of the terms and conditions of residency, copies of reviews undertaken by the funding authority, and very good records of contact with the speech therapist and specialist nurse. However, although the person had a medical condition which restricted their mobility and had a significant effect on their physical health the manual handling assessment had not been reviewed since August 2007. The nutritional assessment was blank. The amount of detail in the daily record varied significantly with very little detail for more able residents with comments such as ‘slept well’ and ‘good morning’. However, the records of residents with significant needs contained information about what care had been given and how the person was at that particular time. Some care records were kept in the residents’ private rooms. However, there was no evidence that residents or their relatives were involved in assessments, care planning or reviews. None of the residents spoken to were familiar with their care plans or could remember being consulted about the care they Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 15 receive. They seemed unaware that the paperwork in their rooms related to them. The care plans dont cover all the recommended topics and therefore don’t give sufficient information and guidance to staff on how to meet resident’s needs. Weight records were not up to date and there was no evidence that the records were linked to nutritional assessments or used to up date care plans and risk assessments where there had been a weight loss recorded either by the home or medical and health care professionals. However, all the people spoken to felt that their care needs were being met by the staff with 12 people surveyed saying that their needs were always met and 2 saying that they were usually met.12 people surveyed said that staff always listened and acted on what they said. Residents have access to GPs, district nurses, and other related medical and health care professionals including dentists, and opticians as necessary. Pressure relieving equipment was provided according to indidvual need. Although it was evident in discussion with staff that one resident had significant needs due to a medical condition only two members of staff have completed training in relation to this. Staff were observed to knock on the door of residents private rooms before they entered and people spoken to confirmed that staff respected their right to privacy and dignity. One relative survey said that they thought that the home treated ‘residents individually’. Staff were observed to have a good relationship with residents that was friendly and respectful. One resident told us that they would like to have the opportunity to have more than one bath a week and that sometimes this was offered, but was dependent on staffing levels. We looked at medication practice in the home and found that the policies and procedures manual contained eight separate policies the majority of which were undated and not signed. However, the deputy manager had obtained upto-date guidelines on managing medicines in care homes and these were kept with the medication. Medication is administered by a small number of staff, all of whom have undertaken training. There were photographs of the majority of residents with the medication records, there were no gaps on the medical administration records (MAR), controlled drugs were stored correctly and when checked found to be correct, fridge temperatures were recorded, returns were recorded and patient information records were retained for reference. Some handwritten entries on MAR sheets had only one signature. Vaughan Lee House DS0000016070.V357807.R02.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 good. This judgement has been made using available evidence including a visit to this service. The routines of the home are flexible to suit individual’s choices and preferences. Visitors to the home are encouraged and made welcome. Activities and trips are available for people who live at home. Residents are satisfying with the standard variety of food served at the home. EVIDENCE: A poster giving details of planned outings was in the entrance hall and these included trips to the seaside, garden centres, Christmas lights and visits for cream teas. 13 residents returned surveys eight of which said that there were always activities available, four said they usually was and one said that there was sometimes suitable activities available. The comments received from relatives included ‘activities are regularly run’, ‘keeps residents active’, ‘they Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 17 put on a couple of trips now and then’. Residents spoken to on the day the inspection confirmed that there were activities available if they wanted to join in and that staff would help them do this if necessary. Activities are not available at weekends and are undertaken in the morning by a member of the care team. A relative commented that the home ‘allowed freedom of choice as to how people spent their time’. The routines of the home are as flexible as possible to meet resident’s individual needs and preferences. Residents spoken to confirmed that they were able to get up and go to bed at times to suit themselves. This was also confirmed in the minutes of staff meetings where the manager had emphasised to staff that they must respect resident’s choice with rising and retiring times. Local clergy from various denominations visit the home and residents are able to continue their religious practice if they want. All the people spoken to on the day of the inspection confirmed that visitors would be made welcome at any time. One relative surveyed said that the staff ‘are always cheerful and friendly towards residents and visitors alike’. Another relative said that residents were made to feel that Vaughan Lee was their home and that there ‘friends were welcome guests’. The home uses a 12 week rotating menu that this changed to reflect summer and winter choices. There isnt a planned choice at lunchtime although residents are able to have an alternative if they dont like the main course. We observed lunch being served, it was well presented and there was an alternative to the main meal available. Tables were laid with clothes with cloth napkins and condiments available. Water was provided at lunchtime in jugs that have been bought since the last inspection. All food at the home is home cooked, and the cook is familiar with resident’s likes and dislikes. All residents spoken to enjoyed the food and were clear that choices were always available if they didnt like something. The main meal of the day is served at lunchtime but the teatime meal includes lots of variety including hot and cold food. 14 residents responded to the survey about food with 6 people saying they always liked the meals and 8 said that they usually did. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Complaints policies and procedures are unclear and complaints are not recorded properly. Policies and procedures for safeguarding adults do not give clear relevant information to staff. The whistle blowing and advocacy policies have been updated to give clear information to residents and staff. EVIDENCE: The complaints policy in the policies and procedures manual had not been updated as recommended in the last report. Mrs Foulsham forwarded a revised complaints policy that says complaints will be dealt with within 28 days of receipt but this does not make clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. The complaints procedure also does not include a timescale or make it clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 19 One complaint had been received since the last inspection but the record keeping was inadequate. It did not record who had made the complaint, what date it had occurred, any discussion with the resident concerned or the outcome. All the residents surveyed knew how to make a complaint and 6 always and 8 usually knew who to speak to about any concerns. The majority of relatives surveyed also knew how to make a complaint. The information about adult protection in the policies and procedures manual does not reflect current good practice, did not refer to the Somerset wide locally agreed procedures or to the Department of Health No Secrets guidance. However, the manager told the inspector that they had a copy of the CSCI protocol and guidance relating to adult protection and also a copy of the Somerset safeguarding vulnerable adults procedure. The manager was advised that this guidance had now been revised and where this could be obtained. The training matrix supplied by the home showed that three members of staff undertook training in adult protection in 2007, 14 members of staff had undertook training in 2005 with 17 staff not completed any training on this at all. However, 12 staff who completed surveys said that they had been given information about adult protection and how to report any concerns or allegations. The whistle blowing policy had been revised and now includes the contact details of Public Concern at Work. The management of violence by resident’s policy had not been reviewed and updated to reflect current good practice advice and guidance as recommended in the last report. The advocacy policy has been revised and now makes clear that residents can access external advocacy services, it also includes the details of local agencies. The home has a policy that makes it clear to staff that they should not accept gifts from residents but this does not include advice for staff that they should not assist with or benefit from residents wills. The manager later forwarded information that indicated that advice on this was given to staff but this was not on the staff files checked. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy with no unpleasant odours. Residents have some choices about what their room looks like. Progress needs to continue on updating and refurbishing the home. Residents are satisfied with the laundry service provided. Infection control policies and procedures need updating and to be linked with staff training. EVIDENCE: We looked around the home and viewed some of the residents’ private rooms. All rooms were well looked after, clean and tidy. Residents are able to Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 21 personalise their rooms according to their room taste and bringing small items of furniture within space constraints. Residents do not have access to a lockable space to store their valuables within their room although they are able to have a key to their door and keep it locked if they want to. The home has an ongoing refurbishment programme to replace and update furniture and carpeting worn through wear and tear. The small lounge/dining room has been redecorated and refurbished, after consultation with residents it was decided that this should be used as a quiet room without a television. The door to the sluice has been fitted with a keypad system and is now secure. The home did not have any unpleasant odours on the day the inspection. One relative commented that there is ‘never a smell when you enter the home’ although another relative commented that sometimes their relatives room was ‘not as clean as it could be’. 14 residents replied to the survey, 11 of whom said the home was always fresh and clean while 3 said the home usually was. Since the last inspection 4 additional ensuite rooms have been built and these were all occupied on the day the inspection. One relative commented that they were surprised that people living in the home were ‘not given any priority in the improved rooms’. The residents spoken to were satisfied with the standard of the laundry service and said their clothes were well cared for by staff and returned in good time. The laundry has hand washing facilities for staff, and the floor was non permeable. Protective clothing and gloves were readily available for staff. On the day of the inspection one washing machine had been taken away for repair. Some but not all staff have undertaken training in infection control. One new member of staff told us that they had received no training since starting work at the home and were unaware of infection control issues. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 22 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. The home’s recruitment procedure has shortfalls in recording and processes. People have confidence in the staff and care for them and an increase in staffing numbers has led to greater satisfaction and better outcomes for residents. The majority of the care staff are qualified to NVQ 2 or above. There is inconsistent supervision of staff and little evidence of structured formal support and induction given to new members of staff. EVIDENCE: Staff rotas were seen that demonstrated that staffing numbers have increased since the last inspection. There are now two staff awake at night with one on call. Mrs Foulsham told the inspector that this had improved the service for residents and that the on-call person was rarely disturbed. An extra member of staff has been employed in the morning and staff spoken to told the inspector that this meant that they now had time to talk to residents and felt they were able to offer a better standard of care. However, one resident spoken to said Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 23 that ‘staff rarely have time to sit and talk to me’. Ms Foulsham stated that the home had advertised for an extra member of staff in the late afternoon/teatime that would further improve staffing levels and the quality of service. All the residents spoken to on the day of the inspection were very pleased with the standard of care they receive from staff, one resident said that ‘staff always spoke kindly to residents and never raised their voice’. The relatives surveyed said that staff of friendly, helpful and caring at all times. Other comments included that staff were ‘excellent’, ‘always responsive to individual needs’ and that staff were ‘always cheerful’. However, comments from relatives also included ‘I think they should have more staff’ and ‘I know the cleaners have a lot to do in very little time’. One member of staff said that they felt ‘that at times there isn’t enough staff on duty’. This was confirmed by a resident surveyed who said ‘there seems to be a shortage of staff’. All members of staff spoken to were very positive about working at the home and two new members of staff spoken to confirmed that they were enjoying working at the home. The staff application form has not been revised as recommended in the last report. It is out of date and is unlikely to comply with current employment legislation. The manager stated that prospective applicants are now asked to provide a CV but this would mean that those people would not be making either a health or rehabilitation of offender’s declaration as required in the Care Home Regulations. We looked at the records of three new members of staff. All files contained a record of interview, an application form or CV, a copy of the job offer letter, a satisfactory CRB and POVA First check and some evidence of identity. Staff do not start work at the home until both the POVA and CRB checks have been received. There was no evidence on staff files that employees had been given a copy of the General Social Care Council code of conduct, although the registered provider told us that all staff had been given their own copy. Two files did not contain a job description, none of the files contained a terms and conditions of employment, there was no record that any mandatory training had been undertaken, including fire safety. This was confirmed by two members of staff that the inspector spoke to who both said that they had not undertaken any training since starting work at the home. Two files did not have references from the person’s last employer. One file did not contain photographic evidence of identity. One file did not contain a health or rehabilitation of offender’s declaration. There was no evidence that any of the staff had had formal supervision since they started working at the home. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 24 Information supplied by the home on the AQAA stated that they were 14 care staff 8 of whom are qualified to NVQ level 2 or above. All three files checked had an induction booklet in which a member of the management team ticked the topics that needed to be covered by the member of staff. In all booklets checked key areas such as where fire extinguishers are, fire safety and the complaints procedure were not ticked as relevant. There was no indication how the induction was being undertaken or how new staff were being supported by the management team. The training matrix supplied by the home showed that staff undertook training in manual handling, health and safety, infection control, fire safety, abuse, diabetes, first aid, food hygiene, bereavement and medication. However, only two staff had undertaken training in diabetes, two in food hygiene, and two in bereavement. The range of training offered is limited and does not include relevant topics such as dementia, challenging behaviour or person centred care. Kitchen records were well maintained with checks made of fridge and freezer temperatures. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 25 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems need to be further developed. Improvements have been made in the way residents finances are managed by the home. Policies and procedures are out of date and don’t provide up to date information and guidance to staff. Information systems in the home are poorly organised. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 26 EVIDENCE: The manager, Mrs Foulsham is qualified and experienced to run the home. The home works in partnership with residents and their families.14 relatives surveyed said that the home always kept them up to date and 2 said that the home usually did. The time allocated for Ms Foulsham to undertake management duties has significantly improved since the last inspection. Mrs Foulsham has recently started working as supernumerary to the care staff, this is meant that she has been able to make some progress on the outstanding recommendations and requirements. However, there remains a lack of systems in the home to monitor such things as how complaints are dealt with, staff recruitment files, that adult protection information is up to date and robust and the lack of up to date policies and procedures to give clear advice and guidance to the staff team. All residents spoken to were very positive about Mrs Foulsham and the deputy heads of home saying that they were approachable and always available. Staff surveyed said there was always a senior member of staff to confer with and staff spoken to on the day the inspection said that they felt Mrs Foulsham and other senior members of staff were always available for support and advice. Mrs Foulsham has achieved NVQ level 4 in care and the NVQ level 4 registered managers award. There have been 4 staff meetings, one for night staff, one for domestic staff and two for carers, since the last inspection with minutes available. Mrs Foulsham stated that residents meetings are not held due to lack of interest but a suggestion box has been set up and the management team and the committee discuss the suggestions. The home has developed resident, staff, food and relatives surveys to find out what people think of the home. Mrs Foulsham forwarded the results of two resident surveys neither of which were dated so it was not possible to know when the survey had been undertaken. The outcome of the surveys were mainly positive with issues identified as needing improvement including the home to be cleaner, more carers and more than one bath to be available. The home undertakes monthly internal quality assurance checks of the environment. The way in which residents finances are kept has been changed following the recommendations made in the last report. All residents’ monies are now kept separately, with receipts and are audited by one of the deputy managers. All monies checked were correct. The records were signed by one member of Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 27 staff. However, the finance policy has not been updated and does not reflect current practice at the home. The home has a staff development training and supervision policy that is undated with no evidence of review. The information about supervision does not meet the national minimum standards in relation to how often supervision should be undertaken or what topics it should cover. There was no evidence of supervision on any staff files checked. However, 12 staff surveyed said that they received regular supervision. The majority of the policies and procedures were out of date, unsigned and showed no evidence of regular review. The information provided by the home noted three policies and procedures that the home did not have in place. However, these were all seen in the policies and procedures manual albeit out of date. This confirmed that the policies and procedures are not used by the management team or staff as a working tool. Recommendations made in the last report in relation to specific policies and procedures identified as needing review and update had not been addressed. The equal opportunities policies related only to staff, not residents and did not reflect current good practice or legislation. The infection control policy was dated August 2005 and did not reflect current good practice and advice for staff. A member of staff was observed contravening infection control practice but they told us that they had not received any training in relation to this. A training matrix supplied by the home showed that 50 of staff had not undertaken any training in infection control or health and safety. There was no evidence on the staff files checked that they had undertaken mandatory training or training relevant to their role such as infection control, health and safety and COSHH. The majority of staff has undertaken training in first aid although it was unclear from the training matrix if all the qualifications were current. The training matrix showed that all members of staff except 1 had completed fire safety training. An accident book is completed when necessary in a letter sent to individuals GPs if the fall occurs or are they sustaining injury. The accident book was cross checked with residents care files on all accidents had been recorded in the daily record. There was a high number of unobserved falls since the last inspection and the manager agreed that these would be looked at to see if there were any common factors that could be addressed. Records were seen that confirmed that equipment and facilities at the home such as the heating system, emergency lighting, fire alarm and hoists were appropriately maintained and serviced. Record showed that the fire system and emergency lighting are checked on a regular basis. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 28 A fire risk assessment was in place but needed reviewing to include evacuation procedures. COSHH risk assessments were in place but had not been reviewed since 2006. Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 29 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 2 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 3 2 1 2 2 Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 30 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 OP1 Regulation Schedule 1, 4 (1) I Requirement The statement of purpose must be reviewed and updated to include all the information required in the Care Home Regulations 2001. (This refers to the relevant qualifications and experience of the registered provider, the age of people who can be accommodated at the home, the size of rooms in the care home and the arrangements made for consulting with service user about the operation of the home. (Previous timescale of 30/04/07 not met). 2 OP3 14(1) (a) (c) (d) The registered person must ensure that people are not admitted to the home unless a preadmission assessment has been fully completed. Prospective residents must be involved in this process. 01/03/08 Timescale for action 31/03/08 Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 31 3 OP7 15(2) (c)(d) The registered person must ensure that people who live at the home are involved in care planning and review as far as practicable. 31/03/08 4 OP16 22 (4) The registered person must 31/03/08 make sure that the complaints procedure includes a timescale of 28 day within which complaints will be investigated. (Previous timescale of 30/04/07 not met). 5 OP29 Schedule 2(1) 10(1)(b)(i ) The registered person must ensure that photographic evidence of identity is sought and retained on staff files. (Previous timescale of 30/3/07 not met). 01/03/08 6 OP29 Schedule 2 (6) (7) The registered person must ensure that all documentation required in the Care Home Regulations is obtained before new staff start working at the home. The registered person must ensure that all staff receives induction training. The registered person must ensure that all members of staff are appropriately supervised. The registered person must ensure that all members of staff are familiar with and trained in infection control procedures. The registered person must ensure that all people working at the home are trained in fire safety. DS0000016070.V357807.R02.S.doc 01/03/08 7 OP30 18(1) (i) 31/03/08 8 OP36 18 (2) 31/03/08 9 OP38 13 (3), 18(1) (i) 23(4)(d) 31/03/08 10 OP38 01/03/08 Vaughan Lee House Version 5.2 Page 32 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 OP2 Good Practice Recommendations The statement of terms and conditions should be revised and include the room to be occupied and who is liable if there is a breach of contract. Care plans should cover all the topics recommended in national minimum standard 3.3. Weight records should be linked to nutritional risk assessments and care planning. Care plans should be reviewed monthly with the resident and updated as necessary. Falls and nutritional risk assessments should be undertaken on admission and as necessary thereafter. Two members of staff should sign handwritten entries on MAR sheets. The complaints policy should be reviewed to made clear the complainant’s of able to contact the CSCI at any stage for complaint. This should be reviewed in the statement of purpose, service user guide and statement of terms and conditions. The management of violence policy should be reviewed and updated to reflect current good practice advice and guidance. Information available to staff on adult abuse/protection should be consistent and reflect up to date good practice advice. It should include the contact details of the local vulnerable adults lead in Social Services. 2 3 4 5 6 7 OP7 OP7 OP7 OP8 OP9 OP16 8 OP18 9 OP18 Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 33 10 11 12 13 14 OP24 OP29 OP29 Serious consideration should be given to providing residents with a lockable storage space in their private rooms. The registered person should ensure that the staff application form complies with employment legislation. A reference should be obtained from applicant’s last employer. All staff should be given a job description and terms and conditions of employment. Serious consideration should be given to considering if the range of training offered is sufficient to give staff the information and skills they need to meet resident’s needs. The registered manager should ensure that two staff signatures are recorded for all residents’ personal financial transactions. The supervision policy should be reviewed and updated to reflect the national minimum standards. All staff should be supervised at least 6 times a year. All polices and procedures should be reviewed and updated to reflect current good practice and the national minimum standards. They should be dated and signed and reviewed yearly. COSHH risk assessments should be reviewed and updated. OP29 OP30 15 16 OP35 OP36 17 OP33 18 OP38 Vaughan Lee House DS0000016070.V357807.R02.S.doc Version 5.2 Page 34 Commission for Social Care Inspection South West Region Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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