Inspection on 09/09/09 for Nelson House

This is the latest available inspection report for this service, carried out on 9th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nelson House 05/12/06

Nelson House 23/11/05

Nelson House 12/07/05

Nelson House 24/02/05

Nelson House 04/11/04

Nelson House 08/03/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Nelson House Nelson House Brimscombe Hill Stroud Gloucestershire GL5 2QP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Paul Chapman     Date: 1 0 0 9 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 39 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 39 Information about the care home Name of care home: Address: Nelson House Nelson House Brimscombe Hill Stroud Gloucestershire GL5 2QP 01453887721 Telephone number: Fax number: Email address: Provider web address: www.nelsontrust.com Name of registered provider(s): Type of registration: Number of places registered: Nelson House Recovery Trust care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence past or present drug dependence Additional conditions: Date of last inspection Brief description of the care home Nelson House is an adapted Grade II listed building and is registered to accommodate up to 16 adults who are recovering from drug and/or alcohol addiction. Accommodation is provided over three floors with a range of communal rooms. All bedrooms are doubles as it is considered part of the rehabilitative process that residents must share to avoid isolation. The counselling programme is delivered at a nearby adapted old school building and the Trust also runs a training and education centre close by. Nelson House is part of the Nelson House Recovery Trust which comprises the residential care home and also a number of supported housing projects in Stroud and Gloucester. Residents from these houses may also attend the counselling 16 16 Over 65 0 0 Care Homes for Adults (18-65 years) Page 4 of 39 Brief description of the care home facilities and the training and education centre. Care Homes for Adults (18-65 years) Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This site visit was completed over 1.5 days on Wednesday 9th and Thursday 10th September. On the 1st day an expert by experience accompanied us, this is a person that has experience of similar treatment environments. When completing a site visit with us they will spend time speaking to people currently receiving treatment and the staff supporting them. During this site visit we completed a tour of the premises with the manager, spoke to staff, examined care packages and other documentation relating to peoples care. In addition to this we also examined records for staffing and health and safety. The registered manager was present throughout both of the visits to the service. Before completing the inspection site visit to this service we (the CQC) sent the registered manager questionnaires to distribute to people living in the home and for Care Homes for Adults (18-65 years) Page 6 of 39 staff to complete. In addition to questionnaires the registered manager also completed an AQAA (Annual Quality Assurance Assessment). This document asks a service provider/registered manager to rate the services performance against the National Minimum Standards (NMS). A service provider/registered manager will be asked to provide evidence of what the service does well, what has improved in the past 12 months and their planned improvements for the next 12 months. What the registered manager tells us in this document helps to form a hypothesis and focus on different areas depending on what the AQAA tells us. In addition to providing evidence about how the service meets the NMS it also provides us with a Dataset (information about staffing, health and safety, complaints, the environment, policies and procedures and the people living in the home). What the care home does well: What has improved since the last inspection? The service now uses a computer-based care package to records peoples needs. The centres approach to treatment has become more holistic. Staff described it as, Not just treating a persons addiction but also focusing on the other parts of peoples lives that may cause them to start using again. The centre offers people the opportunity for support with families by providing a family therapist. Care Homes for Adults (18-65 years) Page 8 of 39 The bathroom and showering facilities have been refurbished since the previous inspection was completed. The centre has employed a horticultural therapist to work with people and as a result there is an area where people are growing vegetables and flowers. A psychiatric Nurse has been employed to provide additional support for people in treatment and staff. What they could do better: The client handbook should be reviewed to see whether another format could be developed to increase the number of people that read it. The manager needs to review how they ensure people entering the centre receive all of the information they need. The centre uses a buddy system to support people when they are first admitted. Unfortunately this system is ineffective and people new to the centre receive very inconsistent support. Goals identified in peoples care packages are sometimes missed and staff must ensure that records accurately reflect whether goals have been achieved or not. Risk assessments are not being completed consistently and this is putting people at unnecessary risks. People are unclear of the reason for some meetings and this results in people not attending and voicing their opinions. Therapeutic chores do not appear to be encouraged to be completed and as a result the accommodation is untidy and dirty in places. Medication procedures/administration is poor in some areas and this is putting people at unnecessary risks. People residing in the centre at the time of this site visit were unclear of the centres complaints procedure (This is linked to the issues with the clients handbook). Not all of the staff working in the centre have completed training in safeguarding vulnerable adults and this must be addressed. The manager should ensure that all staff receive regular refresher training in subjects like health and safety, fire safety, first aid, etc. A staffing review should be completed to ensure that a sufficient number of staff are employed to meet the needs and number of people who reside in the centre. Progress has been made in developing the centres quality assurance procedures but further development is required to make it effective and provide the organisation with tangible data to evidence quality outcomes for people. Care Homes for Adults (18-65 years) Page 9 of 39 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 39 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are thoroughly assessed by qualified staff before they are offered a place at the centre and this minimises the risk of people being admitted to the service whose needs cannot be met. The buddy system used at present is ineffective in providing support to people being admitted to the service. The client handbook provides people with information about the service but it is not read by the majority of people in treatment and therefore people have a limited understanding of important procedures to be followed in the centre. Evidence: The expert by experience (ex by ex) spoke to people in the centre about the client handbook provided on admission. All of the people they spoke with had received a copy of the handbook, but the majority had not read it. When asked why they had not read it a common reason was it looked bland and boring, and that people felt it was a large amount of information to digest in the first week of their stay. 1 person that had read the handbook stated, I felt quite informed and fully understood the rules that are in place, however I feel it would have been useful if member of staff had gone over the handbook in the 2nd week when it would have been easier to digest. The Care Homes for Adults (18-65 years) Page 12 of 39 Evidence: same person also made the observation, some people also have issues with reading and writing so it would be of benefit to all. This is a valid point, from the evidence it is clear that when a person reads the handbook it contains useful information they need to know, the issue is it is not being read. We recommend that the handbook is reviewed and the centre considers other methods/formats to ensure that people understand this information. As part of this inspection site visit we met with a member of the treatment team. Along with other members of the team they are responsible for completing needs assessments for people that have been referred to the Nelson Trust. We examined the completed assessments for 5 people admitted to the service over the past 6 months. The assessments we examined were detailed and provided the basis for the care plans developed if a person is admitted to the service. Where a person is funded by a local authority a community care assessment was also in place. People spoke to the ex by ex about how they had found the assessment process. Comments were mixed, but generally people said they felt it was very detailed, they felt listened too, not judged and there was good communication and understanding of the issues. People confirmed that on the day of assessment they were able to explore the centre and that this was really good. A person who had been admitted from prison felt the assessment process had been poor and they had not felt informed. Another person commented, I travelled for 3 hours to get here and stayed for 20 minutes to complete an assessment form. I wasnt shown around the treatment centre and didnt meet and residents which is what I wanted to do so I could understand what to expect and find out how rehab works. Overall people felt that the assessment process could be improved and feel that their visits were important and influenced their choice of placement and expectation of treatment. Planned improvements for the coming 12 months include reviewing the current assessment process to place a greater emphasis on assessing peoples domestic arrangements and ensuring compliance with the Hidden Harm Agenda. (see below) In the previous inspection report we commented on a practice known as the buddy system. After a person is admitted to the service they are buddied up with another person who is expected to give them support during the start of their treatment. The ex by ex said that people made the following comments about the buddy system, I feel the buddy system was hopeless, my buddy was OK, my buddy was OK but I was left to my own devices at times and he was a bit lazy, although he did share his treatment experiences, Little understanding of the system, the buddy system is not taken seriously enough by people. We discussed the buddy system with the registered manager on the 2nd day of the site visit, the way forward to try and ensure that all people receive consistent support from a buddy may be to introduce a job Care Homes for Adults (18-65 years) Page 13 of 39 Evidence: description that details the expectation of being a buddy. People speaking to the ex by ex suggested a solution to the problems may be to hold regular meetings of buddies with a member of staff so they can discuss the role and get a greater understanding of it. People currently residing in the centre were asked about their plans after discharge from the centre. For 1 person it was their last day and they stated, My discharge process started 3 months ago, I am going back to a structured routine with the possibility of education or employment, I have a lot of information on services in the community I am going back to and I also have all the information about local AA and NA meetings. I am happy with all of my needs being met. Other people who commented were at different stages of treatment, they had some awareness of a discharge plan and all agreed it was the most important part of the process. They all agreed they were confident that it would be done correctly with their input. Hidden Harm Agenda - This was an inquiry carried out by the Advisory Council on the Misuse of Drugs, focusing on children in the UK with a parent, parents or other guardian whose drug use has serious negative consequences for themselves and those around them. Care Homes for Adults (18-65 years) Page 14 of 39 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The sample examined by us showed that peoples care plans are based on the assessments completed before admission to the centre. Care plans are agreed with each individual and they sign the document confirming this. People are asked to identify goals they want to achieve but records make it impossible to confirm that each of these goals are achieved. People are consulted about their views but confusion about the meetings terms of reference hamper the outcomes. Not all staff are following the centres risk assessment procedures and this is raising potential risks where it happens. Evidence: As we have mentioned in the previous outcome section the care plans created for each person are initially based on the assessment completed before a person is admitted to the service. The care plans we sampled covered the following areas: - Drug/alcohol history, Housing, financial, ETE (Education, Training, Experience), family, physical/mental health, criminal/legal issues, cultural needs, spiritual and unmet needs. Care Homes for Adults (18-65 years) Page 15 of 39 Evidence: During the first 2 weeks of residence staff will support a person to settle in and care plans will start to be developed. Since the previous inspection was completed the centre has made 2 significant changes to how care is provided. Firstly, the centre now uses a computer-based care package for care planning, copies of care plans are then printed for each of the clients. The second change has been with the approach to providing care. The model used is now a more holistic approach, this was described to us as not just treating a persons addiction but also focusing on the other parts of peoples lives that may cause them to start using again. This may mean supporting people to address legal, financial and family issues. We examined the care packages for 3 people currently residing in the centre. This showed in the first 2 weeks staff support each person to settle in. During this period a care plan with goals will be developed with a counsellor. Once completed the person is asked to sign it confirming their agreement with the information. All of the care plans we examined provided us with a good level of detail about the individuals needs. There is a 3 week cycle for reviewing peoples care plan/goals. It is dependent on when the person enters the centre (where they are in this cycle) as to how quickly peoples goals are set. We examined peoples goals to assess whether they were being achieved. There was some evidence of this happening, but we found a number of examples where a person had identified a goal and at there next review there was no mention of the goal. We brought this to the attention of the staff we were with. We explained that there should be an audit trail showing that where a person identifies a goal they either do, or do not achieve it. This was brought to the attention of the manager. It becomes a recommendation of this inspection report that this is addressed. Whilst completing our tour of the premises we saw that peoples goals/contracts are on a noticeboard in the kitchen. Other people in the home are able to comment on an individuals progress towards meeting the goals. Comments from people in treatment to the ex by ex included confirming they were involved throughout the process (first stage, review and updates). They confirmed that they have access to a copy of the care plans, they felt they are a useful tool in helping to identify goals and gain a sense of achievement. All of the people commented that they were very happy with their involvement in developing care plans. 1 person commented, My care plan was developed to meet my needs and I Care Homes for Adults (18-65 years) Page 16 of 39 Evidence: like being involved and not forced to do anything. As part of the centres treatment programme people are expected to attend the addictions focus group. Whilst they are attending the group they will complete 3 assignments. The 1st assignment asks they to explain why they are in treatment, the 2nd asks the person to identify the consequences of using, the 3rd asks them to reflect and write a detailed account of what they have learned. Whilst people are residing in Nelson House their choices are limited as day time activities are very structured. But, as part of treatment there is a philosophy of starting to give people responsibilities, and choices. An example of this is as a group they are expected to agree a menu for the following week, shop for the ingredients (with a limited amount of money)and take it in turns to cook meals for the group. In addition to this other activities are available and people are given the choice about completing them (sports at a local sports centre). There are 3 forums/meetings held regularly. There is a meeting called a community meeting held every Monday where all staff and clients attend to discuss issues. Every week there is a house meeting, this is just for the staff and people residing in Nelson house. In this meeting they will discuss issues around the home and decide on the menu for the coming week. People spoke to the ex by ex about a these meetings and agreed that they were good and enabled them to bring up issues. There was some confusion about a 3rd meeting named the service user meeting that was held every 2 weeks. When speaking to the ex by ex some people said they did not really understand what the purpose of this meeting was, and as a result have not attended. 1 person had said they had been involved in the meetings and said, its good to see my suggestions are being taken on board and the maintenance work is done. We spoke to the manager about this on the 2nd day of our site visit and discussed the purpose of the meeting and its value. The manager stated that it may not be held in the future. We suggested that if it was then maybe there should be terms of reference in place for it. If people do not wish to discuss issues in public they are able to speak individually to their named counsellor. People were in agreement that issues brought to the attention of their counsellors were addressed. A requirement of the previous report related to the risk assessments. It was a requirement that assessments should be completed for each of the people living in the centre. Each of the people whose documents we sampled had risk assessments completed by staff as part of the assessment process. We saw assessments covering topics including; physical threats to others, prescribed medication, self-harm, suicide attempts and sexual offences. We identified a shortfall with this process. As part of the Care Homes for Adults (18-65 years) Page 17 of 39 Evidence: initial assessment process the assessing staff complete a basic risk assessment, they are then expected to complete a more detailed assessment. At the time of this inspection we were only able to find 1 example of this being completed in the 4 we examined. The manager must ensure that all people are thoroughly risk assessed to ensure that people are not put at unnecessary risks. The AQAA completed by the manager highlights that the figures for client retention in the quarter up to June 30th 2009 have improved slightly to 80.8 and this may be due to the change of emphasis in the care programme. It is planned that over the coming 12 months the organisation will will work towards achieving EATA (European Association for the Treatment of Addiction)accreditation making them an accredited provider. Care Homes for Adults (18-65 years) Page 18 of 39 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The centre provides people with activities that meet their needs whilst they are in treatment. People are expected to complete theraputic chores as part of their treatment but there appears to be little encouragement to take responsibility to do this. The food provided at the centre is chosen by the people living there who are responsible for preparing it. Evidence: Standards 12, 13 and 15 are not specifically relevant to this client group. The centre provides people with a structured timetable of activities that are mainly based within the centres properties. As part of the centre there is a day service, called the Star centre. The day service provides people with the opportunity to take part in activities such as bicycle maintenance, football, IT (information technology), woodwork, music, art, aromatherapy and pottery. People who spoke to the ex by ex Care Homes for Adults (18-65 years) Page 19 of 39 Evidence: commented that overall the activities provided to them are a key factor in their rehabilitation. Every Friday afternoon sports sessions are organised at a local sports centre, speaking to staff about this they felt it worked really well and they explained they provide people with support sometimes. People are given the opportunity to take part in games of football, squash, badminton and use the gym. During the summer months staff organise outward bound days. Activities people have been able to complete include canoeing, rock climbing, caving, abseiling, archery, assault courses and kayaking. People feel these activities help to build relationships within the community, as well as improve their confidence and trust in each other. People who spoke to the ex by ex stated,I really enjoy outward bounds, Ive never done canoeing, rock climbing or archery before and it would be better if it was done twice a month instead of once. Since the previous inspection the centre has employed a qualified a horticultural therapist. As a result of this there is a small area in the rear yard of the centre where people are growing flowers and vegetables. In addition to the various activities available across the centres sites people are able to take part in voluntary work in the local community, and will be supported to find and complete external educational courses. The centre uses Narcotics and Alcoholics Anonymous fellowships. Staff stated that since the previous inspection they had also started to use fellowships outside the local area (Swindon for example). Speaking with staff they felt this was a good idea as some people may leave the centre and settle in the surrounding area and this gives them more access to support. Staff support people to attend these groups by providing transport. There is an expectation that people will attend twice a week, many people attend more frequently than twice a week. The centre offers an in-house family service which is led by a qualified family therapist. People residing in the centre have the opportunity to attend weekend seminars where they can invite family members if they wish. People who spoke to the ex by ex stated that they are enabled to see family and stay in contact with them whilst they are at the centre. If people do not wish to discuss issues in public they are able to speak individually to their named counsellor. People were in agreement that issues brought to the attention Care Homes for Adults (18-65 years) Page 20 of 39 Evidence: of their counsellors were addressed. As part of the centres treatment programme people are expected to complete theraputic chores around the service. People are expected to take responsibility for cleaning different areas of the home. At the time of this site visit we found the communal areas of the home to be untidy and unclean in some instances. The ex by ex completing the site visit with us felt people were not being encouraged to complete these tasks, and that when tasks were not completed there were no sanctions and therefore this promoted a chaotic environment. 2 people who spoke to the ex by ex said, there is a lack of motivation and responsibility when it comes to the house. We discussed this with the manager to clarify whether this was the homes approach having understood from previous inspections that people are expected to complete chores as part of their treatment. During this discussion the issue of staffing the home was brought up (see standard 33). Feedback from all of the people spoken with was positive about the food at the home. As highlighted earlier in this report people choose the menus and they are also responsible for preparing them. The menus seen during the site visit showed a good variation in the meals prepared. Care Homes for Adults (18-65 years) Page 21 of 39 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have access to the appropriate physical and emotional support as required and this ensures that these areas of their health are maintained. Medication administration procedures are putting people in the centre at unnecessary risk. Evidence: Standard 21 is not specifically relevant to this setting. None of the people living in the centre receive any personal care from staff. Records in peoples files show that the appropriate health professionals meet physical needs whilst the counselling team addresses emotional needs. All people admitted to the centre are registered with a local GP, we received comments from the GP about the centre, when asked what they thought the centre did well they stated support, challenge and guide people. Speaking with the manager they explained a qualified psychiatric nurse has been employed to offer additional support when working with people dual diagnosis. This is a good practice and will enhance the service offered to people in the centre. The AQAA supplied by the manager highlights that over the past Care Homes for Adults (18-65 years) Page 22 of 39 Evidence: 12 months arranging dental work for people has improved. As part of this site visit we spent time with staff responsible for managing the centres medication. The previous report made a requirement that homely remedies must be stored securely, this is now being done. Since the previous site visit was completed a monitored doseage system (MDS) has been introduced. We discussed this with the staff who explained that they have used 2 systems due to problems with ensuring peoples medication needs were met. We examined the medication sheets prepared by staff. These were hand written and the member of staff who stated that they have contacted the pharmacist who will be providing printed sheets/labels in the future. This will help to minimise potential risks to people in the future. If medication changes do need to be made it should be recorded who has authorised this change, and if it involves staff hand writing a medication sheet they must sign it and the change should be checked by another staff member to minimise the risk of a mistake being made. These issues become a requirement of this inspection report. Staff stated that when medication enters the centre they check it to ensure that it is the correct doseage and quantity. Unfortunately this has not been recorded and it becomes a requirement of this report that staff keep a record of these checks. Staff stated that medication administration was mainly the responsibility of the night staff. When staff give people their medication they initial the medication sheet to conifirm they have done this. It is good practice to have a record of sample staff initals to enable the reader to see who has administered the medication. It becomes a recommendation of this report that this is available in the future. We examined a sample of previous administration sheets and found there were some gaps where staff had not initialed or used a letter from the key to explain whether the person had received their medication or not. 1 gap was from 7 days before this site visit and it was unclear whether the person had received their medication. It is unacceptable practice that after a period of 7 days no explanation is available. It becomes a requirement of this report that a procedure is implemented to ensure gaps are identified promptly and the reason is detailed in the medication sheet. Failure to do this puts people at unnecessary risks. The above findings from medication sheets raised concerns about staff medication training. It was explained to us by the manager that all staff received training in house before they are allowed to administer medication. Considering the findings of this site visit it becomes a recommendation of this report that this system of training is reviewed to ensure that all staff administering medication have a clear understanding of their responsibilities. Records were seen identifying what medication has been returned to the pharmacy for disposal. The pharmacist had signed this document confirming what they have Care Homes for Adults (18-65 years) Page 23 of 39 Evidence: received. After the site visit was completed the manager supplied us with evidence confirming that these shortfalls are in the process of being addressed. Based on this information the potential risks identified should be minimised. As part of the next inspection we will assess this standard in full and require evidence that these shortfalls have been addressed. The requirements and recommendations of this report will remain until the next inspection. Care Homes for Adults (18-65 years) Page 24 of 39 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The centre provides people with a number of opportunities/methods to comment on the service they are receiving. Not all of the people living in the centre have a good understanding of the complaints procedure and this may be putting people at a disadvantage/risk. The majority of the staff team have completed training in safeguarding vulnerable adults and this helps to minimise potential risks to peoples safety. Evidence: Since the previous inspection was completed the manager has introduced a form named Tell us about it. The aim is that people can use the form to easily make a complaint, a comment or a compliment about the service. These forms are available around the centre. The ex by ex spoke to people about making a complaint. Most of the people they spoke to had little or no understanding of the Nelson Trust complaints procedure and in the main this was due to not reading the the client handbook. People said if they were unhappy and wished to complain they would speak to their head counsellor. All of the people said they were confident about how to make a complaint, but 1 person commented, Ive never been told about the actual procedure, I am confident in making a complaint, I wanted to make a complaint last week but was unsure how too. I feel it should be discussed as it is relevant. Other people commented that they were unsure if it was talked about as they received a lot of information on entry to the Care Homes for Adults (18-65 years) Page 25 of 39 Evidence: centre. 1 person that had read the client handbook commented, the complaints procedure is in the handbook, I feel comfortable using the procedure should I need to complain. Other people also commented that they did not want a complaint to impact on their treatment in anyway. It becomes a requirement of this report that a method of ensuring people clearly understand the complaints procedure and that it will not negatively effect their treatment if they make a complaint is implemented. Since the previous inspection was completed the CQC has not received any complaints about the service. Speaking to the manager they stated that they have received 1 complaint since the previous inspection was completed. The centre has a whistle-blowing policy for its staff. It is important that staff complete training in safeguarding vulnerable adults. The previous report made a requirement that all people working with people in the centre complete safeguarding adults training. The manager supplied us with staff training records after the inspection site visit. Records showed that there is a total of 13 staff employed in house and night support, of that number 5 have completed this training in 2008, while another 3 completed it in 2007. 5 staff have not completed any safeguarding adults training. It becomes a requirement that staff who have not completed training are enrolled on a course, and it is a good practice recommendation that people who have not completed training in the past 2 years are also enrolled on a course. Speaking with the manager and from information supplied in the AQAA the safeguarding training provided in house has changed over recent months. It now looks in greater depth at the subtle ways in which staff/client boundaries are breached which may lead to protection issues. Care Homes for Adults (18-65 years) Page 26 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides people with a homely, comfortable environment that helps to maintain their safety. At the time of this site visit we found the centre to be a little untidy and dirty in places and this poses unnecessary risks to people residing in the centre. Evidence: On arrival at the centre with the manager we completed a tour of the premises. To the front of the property is a parking area with a garden beyond that. The garden has a range of flower beds and a good-sized lawn that are all well maintained. A covered smoking area has been built in the garden. The manager stated they have arranged a maintenance contract where they have a person on-site for a minimum of 2 days a week. The manager has also produced a schedule for re-decoration around the centre. We examined a record of maintenance requested and completed kept by the staff. We entered the home though a door into the dining area. The manager explained that this area had just been painted and that new carpets were due to be fitted. We then went through to the rear yard where, as mentioned earlier in this report people are growing vegetables and flowers. Entering the kitchen the manager explained they are Care Homes for Adults (18-65 years) Page 27 of 39 Evidence: arranging for it to be replaced in the near future, at the time of our second site visit we met the craftsman employed to complete this. It is planned that where possible people residing in the centre will be involved in building the kitchen in woodwork sessions (the craftsman is also employed by the centre to support people with woodwork sessions). There are 2 lounges in the centre; 1 is a large lounge with a range of sofas and chairs, while the other is a smaller room with a TV and DVD player. A requirement of the previous report was for a new carpet to be fitted in the large lounge, this has been done. Looking at the large lounge we recommend that re-decoration should be completed as it is looking a little tired. We visited all of the bedrooms and this showed that they were all decorated to a good standard and personalised by the people currently residing in them. Since the previous inspection the main toilet, bathroom and secondary shower rooms have all been renovated to a high standard. A shortfall identified during our time in the centre was that the toilet on the ground floor had no paper, soap or towels. It is a recommendation that the staff ensure that this is addressed in the future. At the time of this site visit it was our opinion that the building was generally clean, but quite untidy as a result of people residing in the centre not completing their chores. This was discussed with the manager of the service. The organisations website clearly states there is an expectation that people residing in the centre complete day to day chores, if this approach is no longer being followed then the manager must ensure that other methods are implemented to ensure that the home remains clean and tidy. This becomes a recommendation of this report. Care Homes for Adults (18-65 years) Page 28 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team is made up of people with extensive experience of working in this environment and this enables them to provide a consistent approach. Staff training records were in place and this showed that refresher training is required in a number of health and safety topics to ensure that people are not put at unnecessary risks. Evidence: People commented to the ex by ex that they felt staff were quite good at what they do, they are approachable, respectful, non-judgemental. 1 person commented, The staff here are very helpful and caring, they are making the effort to help me gain a lot from treatment. All of the people spoken with felt that the staff meet their needs in most aspects of their treatment. During the site visit we spoke to both of the staff on duty. Both people had worked at the centre for a number of years and has extensive experience of working with this client group. The centres staff team are divided into 2 groups with 1 part of the team working during the day from 8am to 6pm, with the 2nd part of the team working nights between 6pm and 8am. During the day there are normally 2 staff on duty, and from 6pm there is 1 member of staff on duty. As identified earlier in this report we found shortfalls in the medication recording of night staff which led us to discuss staff training with the manager. The manager stated that the night staff position Care Homes for Adults (18-65 years) Page 29 of 39 Evidence: needs to become more professionalised, they stated that night staff will be completing a range of training seen as mandatory (first aid, food hygiene, etc) and that future contracts of employment will specify that staff have to undertake training to become/remain a night support worker. We have made a requirement that medication training is completed by all night staff. These standards state (33.3/33.11) that staff should be available in sufficient numbers and that the staff ratio should be reviewed regularly. From conversations with the manager a staffing review has not been completed in a significant amount of time. As a result we recommend that a review of staffing is completed. This is seen as a good practice recommendation. We examined the recruitment records for staff employed since the previous inspection was completed and found that the information gathered met the criteria of these regulations. After completion of the site visit the manager sent us a copy of the staff training records; this provided evidence of staff completing training to minimise potential risks to people including; fire safety, first aid and food hygiene. Looking at the dates of when this training was completed we recommend that the manager books refresher training where staff have not completed training in over 2 years to minimise potential risks to people they support. Speaking with the manager they explained they have identified that line managers need training in supervision and management and this will be arranged for the coming months. Speaking to staff, the manager and looking at records showed that the manager completes supervisions, but these need to be recorded more frequently. This becomes a recommendation of this report. Care Homes for Adults (18-65 years) Page 30 of 39 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The centre is well-managed providing people with a safe-environment to complete their treatment. Some progress has been made towards developing a quality assurance process but it fails to deliver quantitative/qualitative information about what the service does well, or what it needs to do better. Health and safety is managed effectively on the whole but some practices need to be reviewed to minimise potential risks further. Evidence: The registered manager has been in post for a considerable length of time and oversees the day-to-day running of the home and its compliance with the standards and regulations. In addition to the registered manager there are also therapeutic and clinical managers. A copy of the homes employment liability insurance certificate was displayed. Regulation 26 visits are completed monthly by one of the Trustees. When completing them they will speak with people living in the home or their representatives, speak with staff, inspect the premises inside and out, examine records for medication, fire Care Homes for Adults (18-65 years) Page 31 of 39 Evidence: equipment tests and medication administration. We sampled a selection of the reports completed since the previous inspection and found no shortfalls. The AQAA highlights the centres effectiveness stating that they have a planned completion of treatment rate of 77 , the National Treatment Agency (NTA) set a target of 70 . The average stay in the centre is 13.5 weeks, the NTA set a target of 12 weeks, there is also an occupancy rate of 80.7 . We spoke to the manager about quality assurance. As discussed earlier in this report a number of meetings have been introduced to enable people in treatment to comment on the service they receive. In addition to this the manager introduced a form named tell us about it that asks for peoples opinions of the service. Since the previous inspection the manager has introduced an evaluation form for people to complete when they leave treatment. This has not been very successful with only 6 completed questionnaires being returned. We discussed the possible reasons for this and it was agreed that the form should be reviewed. This becomes a recommendation of this report. In the inspection report completed in 2007 we suggested that as well as people living in the home taking part in the quality assurance process the centre could also ask funding authorities/care managers for their opinions. A format for this could be a tick sheet, or yes/no answer sheet that also gives people the option to write comments if they wish. This becomes a recommendation of this inspection report. The manager stated that they are in the process of reviewing all of the centres policies and procedures. Health and safety audits are completed monthly to check cleanliness, fire safety, house keeping and first aid. Hot water outlet temperatures are checked monthly by staff and the centre are currently with a qualified engineer to ensure there are no present risks from legionella. Fridge and freezer temperatures are recorded daily. Looking in the kitchen fridge we found it was dirty, and some food had been left uncovered. The homes freezer is situated in another room, when looking at it we found uncovered food loose in the base of it. We brought this to the attention of staff on duty. It becomes a recommendation of this inspection report that the fridge is cleaned regularly, it is also a recommendation that food is stored safely. As identified in the environment section of this report earlier the centre has a covered smoking area in the garden. People currently living in the home choose not to smoke in this area and stand on the drive outside the kitchen door. Staff commented to the ex by ex supporting us that they had asked people to smoke in the garden, but they continued to smoke on the Care Homes for Adults (18-65 years) Page 32 of 39 Evidence: driveway. People smoking by the kitchen door is health and safety risk. It is recommended that if people are going to continue smoking in this area then a risk assessment should be completed. This becomes a recommendation of this report. The centre has a fire risk assessment in place, this has been reviewed by an appropriately qualified engineer. We examined the records for checks of fire safety equipment being completed by both staff and qualified engineers and no issues were identified. Care Homes for Adults (18-65 years) Page 33 of 39 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 34 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The manager must ensure that each person residing in the centre has detailed risk assessments completed that identify and minimise potential risks. Failure to complete thorough risk assessments puts people at unnecessary risks. 13/11/2009 2 20 13 The manager must ensure that all staff administering medication receive accredited training to minimise the potential risks to people requiring medication to be administered by staff. Failure to do this may put people at risk of medication errors that are detrimental to their health. 30/10/2009 3 22 22 The manager must ensure that they all people understand the complaints procedure. People must also 13/11/2009 Care Homes for Adults (18-65 years) Page 35 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action understand that making a complaint will not negatively impact on their treatment. Failure to achieve this may lead to people who are unhappy with the service they are receiving not making a complaint or raising concerns. 4 23 13 The manager must ensure that all staff working in the centre have completed training in safeguarding vulnerable adults. Failure to provide this training to staff may mean that people in the centre are being put at unnecessary risks. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 13/11/2009 1 1 The manager should review the client handbook to ensure that the information is presented to people in an appropriate format that enables them to understand procedures and the service offered. Failure to do this may put people at unnecessary if they are unclear about the procedures that should be followed. 2 2 The buddy system should be reviewed to ensure that people asked to be a buddy have a clear understanding of their responsibility as a buddy. Care Homes for Adults (18-65 years) Page 36 of 39 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Failure to do this could mean that people entering the centre will not receive the best available support in the first few days after admission. 3 6 Peoples care plans and goals should provide an audit trail to show that peoples needs are being met. If a person identifies a goal they wish to achieve there should be a record of whether it was achieved or not. To help minimise confusion about the purpose of meetings the manager should provide people with terms of reference that clearly identify the purpose of the meeting. If people are expected to complete therapeutic chores as part of their treatment there should be more encouragement by staff for them to complete them. Staff training in medication should be reviewed to ensure that staff responsible for administering medication have a clear understanding of the procedures and safe/good practices. Staff must keep a record of checking medication dosage and quantity when it enters the centre. There should be a sample list of staff initials to enable other people examining medication sheets to see who was responsible for administration. Staff that have not completed safeguarding adults training in the past 2 years should be enrolled on a future course. Failure to do this may mean that staff practices do not reflect current practices. The main lounge in the home looks a little tired and in need of decoration. The manager should review the schedule of re-decoration to ensure that the lounge is re-decorated in the near future. The staff should ensure that there is always toilet paper, soap and hand towels available in toilets. The cleanliness and tidyness of the centre needs to be maintained to a higher standard either by improving current practices or implementing new practices to ensure this. The manager should complete a review of the staffing for the centre to ensure that there are sufficient numbers employed to meet peoples needs. Page 37 of 39 4 8 5 16 6 20 7 8 20 20 9 23 10 24 11 12 27 30 13 33 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 14 35 The manager should ensure that staff complete refresher training of courses relating to health and sfety to ensure that people are not put at unnecessary risks. The manager should ensure that staff receive regular supervision and that the outcomes from these sessions are recorded. The manager should contact funding authorities/care managers and ask them for their opinion of the service provided. This information will help to inform the quality assurance process. The manager should review the feedback questionnaires given to people when discharged from the service as the current format has been unsuccessful in delivering the information required to support quality assurance. Food stored in the fridge and freezer should be covered and dated. The manager should complete a risk assessment about people smoking outside of the kitchen door on the driveway. The fridge in the centres kitchen should be cleaned at regular intervals. 15 36 16 39 17 39 18 19 42 42 20 42 Care Homes for Adults (18-65 years) Page 38 of 39 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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