Inspection on 23/07/08 for Vaughan Lee House

This inspection was carried out on 23rd July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Vaughan Lee House 16/01/08

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Vaughan Lee House Orchard Vale Ilminster Somerset TA19 0EX Lead Inspector Mrs Gail Richardson Unannounced Inspection 23rd July 2008 09:30 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 Vaughan Lee House DS0000016070.V365600.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. Vaughan Lee House DS0000016070.V365600.R01.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 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.V365600.R01.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. 16th January 2008 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. 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 nonresidents each week. The current fee range is between £ 390.00 and £512.00. The fees do not include some toiletries, newspapers and magazines. Vaughan Lee House DS0000016070.V365600.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection, which took place over 1 day (7 hours) on the 23rd July 2008 by Regulation Inspector Gail Richardson. A tour of the home took place and a selection of the bedrooms and all communal areas were seen. There were 29 people currently residing at the home all of whom were receiving personal care. The homes last key inspection was conducted on the 16th January 2008. Following that inspection the registered person was required to submit an improvement plan to the Commission, which identified how they would improve the service. This was received by the Commission within agreed timescale. The company have been proactive in addressing all requirements and have demonstrated their commitment to improving the quality of the service provided. As part of this inspection the inspector surveyed the opinions of a random selection of people using the service and their representatives, GP’s, District Nurses and Care Workers. Surveys were sent to people using the service and some responses were received and that information has been incorporated within this report. The inspector spent time talking to 11 people within the home, 1 visiting health professional and 6 staff and observed that on the day of inspection, residents appeared comfortable in all areas of the home. It was evident from this observation that the people looked well cared for. All people using the service spoken to, and who were able, spoke of the staff members kindness and support. Records relating to care including 6 care plans, 2 staff files, finances and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The statement of purpose and service user guide has been updated to reflect the accommodation and services provided within the home. This enables prospective people to have a clear picture of what the service will provide. The complaints procedure has been updated to reflect that any complaints will be met within an agreed timescale, that CSCI can be contacted at any time and now includes the contact details for CSCI. All recruitment files now contain photographic evidence of identity and all required documentation to ensure that people using the service are not at risk. The staff now receive a job description. Pre admission assessments are now fully completed and have been developed to include further detail of time, place and involvement of people using the service and their relative/ representatives. This enables the home to identify all needs prior to admission. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 7 Care plans now contain a care plan for all areas of assessed and identified need. Falls and nutritional risk assessments are undertaken on admission and as necessary thereafter. Weight records are now linked to nutritional risk assessments and care planning. The care plans are detailed and include the involvement of either people using the service or their relatives/ representatives. These care plans enable staff to provide a consistent level of care. All hand transcribed medications are now signed by 2 staff to prevent the risk of inaccurate recording and the home provides people using the service with a lockable storage space in their private rooms for those people who wish to self medicate. All staff have received induction training in line with the Skills for Care Common Induction Standards. All areas of mandatory training are now covered including infection control and fire training. This training ensures that staff can provide a good standard of care. Information available to staff on adult abuse/protection reflects up to date good practice advice and includes the contact details of the local vulnerable adults lead in Social Services. All policies and procedures have been updated. What they could do better: The registered manager must ensure that systems are in place to ensure that all gaps in the Medication Administration Records are audited and a signature or appropriate coded indicator used. The manager must record how many of each medication is given to each service user who self medicates to ensure that an auditable record is maintained. The registered manager is required to ensure that all creams are named and dated when opened and in use and also to review the use of prescribed medication in the homes first aid boxes. Not all care plans or Medication Administration Records has a photograph of the person and it is recommended that records be audited and replacement photos put in place. The registered manager is required to ensure that all equipment is maintained in good condition and does not pose a risk of cross infection. This is with reference to toiletry shelving, which is damaged and rusting and one rusting toilet rail. Toilet floor coverings in two areas identified and windows and wall in toilet identified as in need of repair. The registered manager is recommended to ensure that all bins are foot operated to prevent the risk of cross infection and to review the practice of storing communal toiletries in bathrooms. It was observed that whilst the home has changed the style of application form there is no space to record the applicants employment history with dates of Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 8 jobs started and left. This is required to ensure that people using the service are not placed at risk. The manager is required to update the form to include these details and ensure that any gaps in employment history are identified and documented. The management of supervision no less than 6 times per year must be developed to ensure staff are supported to provide a good standard of care. The registered manager should ensure that two staff signatures are recorded for all residents’ personal financial transactions to ensure a clear and consistent audit trail of all monetary transactions. The manager is recommended to audit accidents monthly to observe for trends and incidences to promote accident prevention. The registered manager is also recommended to ensure that all personal documentation is stored in line with the Data Protection Act. 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.V365600.R01.S.doc Version 5.2 Page 9 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.V365600.R01.S.doc Version 5.2 Page 10 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 3 4 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that people who are thinking about using the service, and/or their representatives, have the information they need to enable them to make an informed decision about moving to the home. The home has procedures in place to ensure that it only offers a service to people whose needs can be met by the home. People are given the opportunity to test-drive the home prior to admission. EVIDENCE: Since the last inspection the home have updated the Statement of Purpose and Service User Guide to include all information recommended in the National Minimum Standards. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 11 3 Residents surveys received stated that all 3 had received a contract and all 3 felt they had received enough information prior to admission, to make an informed decision. We examined 2 pre admission assessments at this inspection and both contained evidence that people thinking about using the service had been appropriately assessed by the home before a placement was offered. The pre admission assessment forms have been developed to include were they have taken place and who was involved. We were also able to see that the home had obtained additional assessments from appropriate healthcare professionals where available. People are able to test-run the home and the manager explained that they would usually come for the day and spend time with other people using the service. Once admission has taken place there is a two-week trail period in place to ensure that people are happy at the home and that all needs can be met. Contracts were examined and were seen to contain sufficient detail of the terms and conditions of residency; it is recommended that the room number be added to the contract to ensure clarity of fees if room changes should occur. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed needs and preferences of individuals’ are clearly set out in their plan of care. The home ensures that people have access to a range of appropriate healthcare professionals. The home’s procedures for the management and administration of peoples’ medication require some improvements to ensure the safety of people using the service. People are treated with dignity and respect by the staff at the home. EVIDENCE: Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 13 When asked do you receive the care and support you need, all 3 surveys said always, all 3 responded that staff listen and act on what the residents say and all 3 felt they received the medical support they needed. During this inspection we examined four care plans in detail and followed the care of these people through examination of other records such as accidents, medication and contacts with healthcare professionals. We found that care plan contain information which reflected the individuals’ assessed needs. Care plans had been devised from the pre admission assessments and further completed assessments, which included moving and handling needs, nutritional and environmental risk assessments. There were care plans in place for short term care needs and one care plan review showed a clear audit trail over a period of several months of a problem identified, several options tried and eventual solution to the problem. There was evidence that some individuals and/or their representatives had been involved in the care planning and review process. Involvement of people using the service in the monthly reviews is recommended to develop a person centred approach to care planning. Not all care plans or Medication Administration Records has a photograph of the person and it is recommended that records be audited and replacement photos put in place. Care plans contained evidence that people have access to appropriate healthcare professionals. Each person is registered with local GP’s. The home maintains detailed records relating to the persons contact with healthcare professionals. On the day of inspection a visiting health professional told us ‘ We have a good working relationship with the home, we liaise well and work together’. Other visiting health professional’s surveys commented; ‘This service manages people with psychiatric health problems well with a variety of approaches according to need.’ ‘Staff always attempt to support clients in the home and are willing to engage with the MDT to try interventions’ ‘Admission to hospital only occurs when ones approaches have failed’ ‘The home does well almost everything to my knowledge and experience of the residents’ ‘A very compassionate, well run and happy home’. The home has equipment were an assessed need has been identified, this included equipment for pressure relief, bathing and moving and handling. Care plans also contained information as to the individuals’ preferences with regard to preferred times for waking, retiring to bed, dietary preferences and bathing. People who had specific needs relating to wound care had the regular input of the visiting District Nurse and records were maintained at the home. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 14 Throughout the day we were able to observe staff interactions with the people living at the home. These were noted to be kind and respectful. People looked clean and well attired. Surveys received comments included; ‘Home provides a welcome atmosphere, clean environment and caring staff’ ‘I believe that my relative is allowed to do as they wish’. ‘The home has good food and friendly caring staff’. ‘I think the care home is fine as it is’. The medication systems appeared to be mostly managed to a good standard, some areas require further review to ensure that systems safely support people using the service. The home uses a pre packed blister pack system and has written protocols in place on the Medication Administration Records for the administration of most medications. There were several gaps evident in the Medication Administration Records and the home is required to review the Medication Administration Records and audit the records and action any gaps noted. There was evidence of variable doses being recorded and hand transcribed entries being signed by 2 staff. People using the service have the option to self medicate should they want to and risk assessments are in place to ensure safe practice is maintained. Lockable storage is available as required. The manager is recommended to record how many of each medication is given to each person who self medicates to ensure that an auditable record is maintained. A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. Feedback to the manager included advice that all creams should be named and dated when opened to ensure that out of date creams are not used. The homes first aid box contained a prescribed solution, which was named for a specific person. This is not good practice as named prescribed solutions are for that persons use only and this practice must be reviewed. All medications were stored safely and securely with systems in place for ordering and disposal. The room used for the storage of medications is well organised and environmentally suitable for its purpose but the temperature requires further review. On the day of inspection the temperature was 26 degrees with two fans running. The raised temperature may have an adverse effect on the storage of some medications and suitable temperature control should be reviewed. Vaughan Lee House DS0000016070.V365600.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that people are given the opportunity for social stimulation and community contact. People are offered a wholesome and varied diet and the home has created a pleasant dining environment. EVIDENCE: Resident’s surveys asked are there activities arranged by the home that you can take part in, 1-always, 2-usually. Care plans contained good information about the social history and hobbies/preferences of people living at the home. Staff maintain a record of all activities offered and undertaken in each persons plan of care. The home employs activity staff whom co ordinate in house activities and trips out. Records of activities include visiting musicians, dominos, theatre trips, outing for cream teas and visits from the donkey sanctuary. The home has access to large print library books. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 16 A residents meeting in February 2008 suggestions were made by residents for more activities. Records would support that these suggestions were actioned. During this inspection we spoke to people living at home who confirmed that activities take place mid week in the mornings only and that they have a choice if they wish to participate. They told us that they enjoyed the activities available. One person using the service commented ‘Activities- I choose not to use them’. On the day of inspection there was a planned game of Bingo in the dining room, people had daily newspapers and one person was playing the piano. Some people chose to spend time in the privacy of their own rooms and others were seen in the various lounge areas, all communal areas of the home were seen to be used for social activity. The home has a hairdressing salon available and visiting hairdressers have access to this facility enabling people to continue using the hairdresser of their choice. The people using the service explained that they are supported to access the local shops and the home has regular visits from clergy of various denominations. Visitors were seen throughout the day of inspection and people using the service confirmed that they are always made welcome. The home has a pleasant garden area, which includes an inner courtyard, which has been made wheelchair accessible and has seating and tables. People using the service told the inspector that they enjoy this area and it is often used. All rooms are single occupancy and were seen to be personalized with peoples own décor choices and some small pieces of furniture. Resident meeting minutes record people using the service being involved in choosing room colors and naming newly built parts of the home. Resident’s surveys asked if residents like the meals at the home, 2 said always, one was blank. Copies of menus were made available at this inspection and people using the service confirmed that people are encouraged to influence what food/meals are offered. People spoken with were very positive about the standard of the food at the home. Each person has a nutritional assessment, which is reviewed monthly. Choices and preferences are recorded. Coffee was seen to be served in the lounges and to peoples rooms. Biscuits and fresh fruit were noted to be served at this time. On the day of this inspection the lunch consisted of roast beef, Yorkshire pudding, roast potatoes, vegetables and the alternative was omelette and cold Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 17 meats, desert was a choice of cheesecake or fruit and cream. Meals are served in 2 dining rooms, one room served the food from a hatch from the kitchen and the second dining room was served from a trolley. Both rooms are pleasantly decorated and the tables are laid with linen and condiments. People using the service confirmed that the lunchtime meal was appetising and plentiful; they said the meals were always served hot and were of a consistently good standard. The atmosphere was calm and sociable, people told the inspector that all meals are available in the dining room but should you request it your meal could be served in your bedroom. The menu for the evening meal was assorted sandwiches, bread butter, jam and cakes. Supper was served around 7pm and included milky drinks, cheese and biscuits and crisps. Vaughan Lee House DS0000016070.V365600.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate systems in place to enable people to raise concerns. People using the service and staff are confident in the management of the home to address any concerns The home takes appropriate steps to reduce the risk of harm or abuse to people living at the home. EVIDENCE: The home displays a complaints procedure within the home, a copy is available in the Statement of Purpose /Service User Guide. We were advised that the home had not received any complaints since the last inspection and CSCI has not received any complaints about this service. Staff and people living at the home confirmed that they would feel confident in raising concerns, if they had any, with the manager or staff on duty. One person told the inspector ‘I am happy and have no complaints, but if I had I would speak to Yvonne’. The home has a range of policies and procedures available to staff to ensure that people are protected from the risk of harm or abuse. The home has a copy of Somerset’s revised Safeguarding Adults procedure and training records indicated that all staff have received appropriate training in abuse awareness. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 19 Staff spoken with also confirmed that they were aware of the ‘whistle blowing’ policy and that they knew how to raise concerns. Some policies were seen to contain previous contact details for CSCI, an updated policy is also available. It was discussed with the manager that the old policies should be replaced to provide clear directions. The home’s staff recruitment procedures reduce the risk of harm or abuse to the people living there. Vaughan Lee House DS0000016070.V365600.R01.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): 19 20 21 22 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person has their own bedroom which they can personalise and choices of several communal areas. People have access to pleasant and secure garden areas. The home has appropriate procedures in place to reduce the risk of the spread of infection. The standard of cleanliness is good. EVIDENCE: A wide selection of bedrooms and all communal areas were viewed during this inspection. The home has undergone a recent development program to provide further bedrooms rooms and a large communal lounge. This communal area Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 21 contains a seating area and a dining area. The room is used for social activities and is light and airy and decorated to a very good standard. One person told the inspector that ‘ There is nothing bad about living here, I have a nice room and no complaints’. It was apparent that people are encouraged to personalise their rooms and small pieces of personal furniture were evident. Most rooms have en-suite facilities and no rooms are shared. The standard of furnishings, fixtures and décor in bedrooms and en-suites were of a very good standard. One person explained that their room was to be refurbished and they would be temporarily using a different new room, which they then had an option to remain in. They had been involved in the choice of colour of the redecoration. It was observed that three freestanding wardrobes had not been secured to the wall, this was discussed with the manager who organised the maintenance staff to attend and secure them immediately. The home has an ongoing maintenance program and on the day of inspection painters were decorating the outside of the home. There is a range of bathrooms and toilet facilities with equipment for bathing either assisted or unassisted is available to support people with personal hygiene. Hot water outlets are fitted with thermostats to ensure that they do not exceed the Health & Safety Executive recommended upper limits. Outlets checked at this inspection were within recommended limits. Some bathrooms were seen to have a choice of shampoo, talcum powder and bars of soap. This practice of communal toiletries is to be avoided to reduce the risk of cross infection. Specialist equipment was seen where there was an assessed need and this was reflected within each persons care plan. The home takes appropriate steps to reduce the risk of the spread of infection. Liquid soap and paper towels are appropriately sited and staff have access to a good supply of disposable gloves and aprons. It was observed that not all bathroom bins were foot operated, this is recommended to reduce the risk of cross infection. Some areas require further attention, the toiletry baskets in several rooms are rusting and require replacement to prevent the risk of cross infection. Some bathrooms/toilets require attention. The base of toilet frames and flooring in 2 toilets requires replacement and the wall and window frame of one toilet require decorating. The home employs 4 domestic staff each day and the home appeared to have a very good standard of hygiene and was fresh smelling. People using the service told the inspector that the home is always clean and that the cleaning staff are very helpful. 3 residents surveys confirmed that the home is always clean and fresh. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 22 Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by adequate numbers of staff who have been appropriately trained. The home follows robust staff recruitment procedures, which reduce the risk of harm or abuse to the people living there. EVIDENCE: Resident’s surveys asked if staff were available when you need them said, 3always. On the day of inspection there were 4 care staff on duty (one senior carer and 3 care staff) with the registered manager. Further staff included 1 administrative staff, 5 domestic staff,1 handy man and 1 activity staff. There are 4 care staff on duty in the afternoon and 2 waking staff and one on call sleep in staff on duty overnight. At inspection, people indicated that their needs were met and staff stated that they experienced no problems in meeting peoples assessed needs with the number of staff on duty. One person told the inspector that you can ring anytime and they will come, another said that they often brought her a cup of tea in the night. Staff confirmed that a recent increase in afternoon staff had improved the time being able to be spent with people using the service. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 24 Relative’s surveys asked, do staff have skills and experience to care properly? Responses are 2-Always,2 Staff commented that ‘The homes looks after and cares for its Service users providing a comfortable caring and safe environment’. We were informed that over 50 of staff has achieved a minimum of an NVQ Level 2 in Care. This exceeds the recommendation of the National Minimum Standards. Records confirmed that mandatory training is maintained for all staff and that further training is encouraged. All staff have completed training in abuse awareness and the home has a qualified first aid staff member on each shift. We were able to see that staff follow an appropriate induction programme on commencement of employment. The manager stated that newly appointed staff are provided with an induction workbook, which is in line with the Skills for Care 12 week Common Induction Standards. One staff confirmed that they were currently within their induction period and felt well supported in all areas of induction. We examined the home’s procedures for the recruitment of staff. Two staff have been employed since the last inspection and both staff recruitment files were examined. These were found to contain all required information. We were able to see evidence that staff did not commence employment until the home was in receipt of an enhanced criminal record check (CRB) and protection of vulnerable adults check (POVA). Staff files also contained signed contracts and job description. It was observed that whilst the home has changed the style of application form there is no space to record the applicant’s employment history with dates of jobs started and left. This is required to ensure that people using the service are not placed at risk. The manager is required to update the form to include these details and ensure that any gaps in employment history are identified and documented. Vaughan Lee House DS0000016070.V365600.R01.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 32 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from effective management systems where an open and inclusive style of management is promoted. No quality assurance has been undertaken since the last inspection to assess the views of people using the service and is recommended to be undertaken Supervision of staff is variable and is recommended to be reviewed to ensure that all staff receive supervision no less than 6 times per year. The home follows correct procedures to ensure the health and safety of persons at the home EVIDENCE: Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 26 There have been no changes to the management structure since the last inspection. The registered manager Yvonne Foulsham is an experienced and appropriately trained manager who promotes an open, positive and inclusive style of management. Both staff and people using the service told us that she was very supportive and approachable. Annual Quality Assurance questionnaires had not been sent since the last inspection and the views of the people using the service and their relative/representatives had not been sought. The registered manager is recommended to undertake this audit to establish that people using the service are happy with the care they receive. Staff meetings and residents meetings are held regularly and minutes are maintained. Most documents within the home are stored securely and maintain the confidentiality of people using the service. It was noted that a unit of drawers stored in a bathroom contained letters belonging to a named person using the service. The manager is recommended to ensure that all documents are stored correctly in line with the Data Protection Act. The supervision policy has been reviewed and updated to reflect the national minimum standards. The registered manager confirmed that further work is needed to ensure that supervision of all staff takes place regularly. All staff should be supervised at least 6 times a year. The home maintains records for all accidents. Records were examined and were found to contain appropriate action including a follow up report for each accident to the persons GP. As required in the Care Homes Regulations, the manager informs the Commission of any death or significant event at the home. The manager is recommended to audit accidents monthly to observe for trends and incidences to promote accident prevention. Systems for managing personal monies were examined and found to be satisfactory , however, the registered manager should ensure that two staff signatures are recorded consistently for all residents’ personal financial transactions to ensure a clear audit trail of all monetary transactions. FIRE SAFETY – We were able to see evidence of weekly in-house checks on the home’s fire alarms. The systems were serviced in 11/04/08 and included checks on the emergency lighting system. The fire officer last visited on 25/04/08. Staff training records indicated that staff had received up to date training. A fire risk assessment is in place but not examined at this inspection. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 27 ELECTRICAL SAFETY – Hardwiring certificate is to be forwarded to CSCI and Periodic Appliance testing was undertaken on 22/07/08. GAS SAFETY - A gas certificate was last undertaken 08/10/08. EQUIPMENT SERVICING – We were able to see servicing records for the home’s bath hoists and mobile hoist dated 18/12/07. Hot Water Temperatures To reduce the risk of scalding, hot water outlets are required to be checked monthly to ensure that they do not exceed the Health & Safety Executive’s safe upper limits. This is not currently taking place and the manager is required to ensure that monthly checks of all hot water outlets are recorded and any associated action taken to reduce any risks of burns and scalds. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 3 17 3 18 3 1 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 2 2 3 3 Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? no 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that systems are in place to ensure that all gaps in the Medication Administration Records are audited and a signature or appropriate coded indicator used. The registered manager is required to ensure that all creams are named and dated when opened and in use. The manager must record how many of each medication is given to each service user who self medicates to ensure that an auditable record is maintained. 2. OP19 12(1)(a) 16(2)(c) 16(2)(j) The registered manager is required to ensure that all equipment is maintained in good condition and does not pose a risk of cross infection. This is with reference to; Toiletry shelving, which is damaged and rusting and rusting toilet rails. Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 30 Timescale for action 30/08/08 30/08/08 Toilet floor coverings in areas identified. Windows and wall in toilet identified in need of repair. 3. OP29 12(1)(a) The manager is required to update the application form currently in use to include space to record employment history and ensure that any gaps in employment history are identified and documented. The registered manager must ensure that hot water temperatures are monitored, recorded monthly and any appropriate action taken. 30/08/08 4. OP38 12(1) 30/08/08 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. 2. Refer to Standard OP2 OP7 Good Practice Recommendations The statement of terms and conditions should be revised and include the room to be occupied . Not all care plans or Medication Administration Records has a photograph of the person and it is recommended that records be audited and replacement photos put in place. The registered manager is recommended to review the use of prescribed medication in the homes first aid boxes. The registered manager is recommended to review the practice of storing communal toiletries in the bathrooms. The registered manager is recommended to ensure that all bins are foot operated to prevent the risk of cross DS0000016070.V365600.R01.S.doc Version 5.2 Page 31 3. 4. 5. OP9 OP19 OP19 Vaughan Lee House infection. 6. OP33 The registered manager is recommended to undertake a quality assurance audit to establish that people using the service are happy with the care they receive. The registered manager should ensure that two staff signatures are recorded for all residents’ personal financial transactions. The manager is recommended to ensure that all documents are stored correctly. The manager is recommended to audit accidents monthly to observe for trends and incidences to promote accident prevention. 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. 7. OP35 8. 9. OP37 OP38 10. OP36 Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South West 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. Extracts may not be used or reproduced without the express permission of CSCI Vaughan Lee House DS0000016070.V365600.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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