Inspection on 29/04/09 for Buttercups & Railway Cottage

This inspection was carried out on 29th April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Buttercups & Railway Cottage 12/10/09

Buttercups & Railway Cottage 24/11/08

Buttercups & Railway Cottage 13/11/07

Buttercups & Railway Cottage 02/11/06

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Buttercups & Railway Cottage 8 Ford Road Arundel West Sussex BN18 0BH The quality rating for this care home is: zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Annette Campbell-Currie Date: 3 0 0 4 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. things that people have said are important to them: 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 They reflect the We review the quality of the service against outcomes from the National Minimum Care Homes for Adults (18-65 years) Page 2 of 33 Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for Adults (18-65) 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 mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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 33 Information about the care home Name of care home: Address: Buttercups & Railway Cottage 8 Ford Road Arundel West Sussex BN18 0BH 01903889643 01903884105 buttercups@consensussupport.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Corich Community Care Ltd Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : learning disability Additional conditions: The maximum number of service users to be accommodated is 12. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection: Brief description of the care home: Buttercups and Railway Cottage is a care home, which is registered to provide personal care for up to twelve service users in the category learning disability (LD) who are between the ages of 18 to 65 years of age. The service has been set up to provide care and accommodation for younger adults with autistic spectrum disorders and challenging behaviours. It is a detached property, which has been extended and adapted for its current use, and is located in the village of Ford. Although it is under one registration it comprises of two adjacent premises - one for three people and the other for nine. The property provides private accommodation to residents in single bedrooms located on the ground and first floors. The bedrooms include ensuite WC and bath or shower facilities. Communal accommodation is made up of a lounge and a dining room in each of the premises; they are located on the ground floor. The smaller Care Homes for Adults (18-65 years) Page 4 of 33 care home 12 Number of places (if applicable): Under 65 12 Over 65 0 2 4 1 1 2 0 0 8 house has its own private courtyard that people living there can use. An enclosed secure garden, which is available to all residents, is located to the rear of the premises. The responsible individual acting on behalf of the organisation is Mr Maarten Vegting who is responsible for supervising the management of the care home. There is currently no registered manager in post. Care Homes for Adults (18-65 years) Page 5 of 33 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: zero star poor service How we did our inspection: The previous key unannounced inspection was carried out on 24th November 2008. This key unannounced inspection was brought forward because there have been eight safeguarding referrals and investigations since the previous inspection. Consensus purchased the home in 2007 and Corich Community Care Limited are the registered providers. Some of the paperwork used in the home uses the Consensus name. The current fees are from 1370.55 to 2300 pounds per week. Care Homes for Adults (18-65 years) Page 6 of 33 Annette Campbell-Currie carried out the site visit over two days and nine hours were spent in the home. The current manager began work in December and has not applied for registration with the Commission. The manager assisted with the inspection. Mr Vegting, the registered person for the company was available for discussion. Two senior managers from Corich Community Care Ltd were also available in the home on the first day. The manager and deputy completed an annual quality assurance assessment form (AQAA) before the inspection. The AQAA provided some information however there was no comment about how the requirements from the previous inspection were being met. We (the Commission) sent out surveys to find out what people think about the home. Five staff returned surveys and eight people living in the home were assisted by staff to complete surveys. During the visit the majority of people living in the home were seen and time was spent in communal areas with some people. Direct communication was very limited due to communication difficulties. Eight members of staff were spoken with including the cook. The following documents were read: the case records for three people, the recruitment records for three staff, the complaints records, training records, quality audit documents, incident reports, samples of policy documents and medication records. The medication storage and administration was also seen. A tour of the building was carried out including the communal areas, the kitchen, five bedrooms and ensuite shower and toilet facilities. The outcomes for people living in the home have been assessed in relation to twentythree of the forty-two National Minimum Standards for Care Homes for Younger People; including those considered to be key standards to ensure the health and welfare of people living in the home. Eight requirements have been made following this inspection. What the care home does well: What has improved since the last inspection? Case records have been re-organised and some information about peoples care needs have been provided. Risk assessments have now been carried out for many aspects of peoples lives in the home. There has been an improvement in the recording of key information and a new system for documenting handover sessions has been introduced. Care Homes for Adults (18-65 years) Page 7 of 33 There is now a system for recording complaints made about the service to show that these are investigated in line with the homes complaints policy. The manager has introduced a system for supervision of staff so that they have the support they need. What they could do better: The home must display an up to date registration certificate. It is an offence under the Care Standards Act 2000 not to do so. Requirements have also been made regarding the following matters. The manager must submit an application for registration to the Commission in order to comply with legislation. The care plans should be clear and person centred providing detailed guidance to staff about all aspects of each persons health, personal care and emotional and spiritual needs so that staff fully understand the care that people need. Care plans should be person centred and involve each individual and the people who know them well, so that a clear and structured progamme of care can be provided. The care plans should be kept under review and any changes in need noted with updated guidance as necessary. The storage and recording of controlled medication must meet with current legislation in order to protect people in the home. The policies and procedures regarding the covert administration of medication should be followed in order to keep people safe. Documentation must show that a multi disciplinary decision was made that included the general practitioner (GP) and that the decision was made in the best interests of the individual concerned. The home must provide a policy regarding medication procedures when people are not in the home. Any change in dosage of medication must be clearly authorised by the person who prescribed the medication. Systems must be set up to ensure the home is kept safe and clean at all times. The registered providers must ensure that there is a robust recruitment procedure in place and that all the required checks are carried out before someone begins work. The registered providers must ensure that requirements and recommendations made at multi-disciplinary safeguarding meetings are followed up in order to protect people living in the home. The registered providers must ensure that the quality assurance systems are effective in identifying where improvements to the service should be made and making sure these shortfalls are addressed. Care Homes for Adults (18-65 years) Page 8 of 33 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 websitewww.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 9 of 33 Details of our findings Contents Choice of home (standards 1 – 5)........................................................................ 11 Individual needs and choices (standards 6 – 10) ................................................... 12 Lifestyle (standards 11 – 17) .............................................................................. 16 Personal and healthcare support (standards 18 – 21) ............................................. 19 Concerns, complaints and protection (standards 22 – 23) ....................................... 22 Environment (standards 24 – 30) ........................................................................ 23 Staffing (standards 31 – 36)............................................................................... 25 Conduct and management of the home (standards 37 – 43) ................................... 27 Outstanding statutory requirements..................................................................... 29 Requirements and recommendations from this inspection ....................................... 30 Care Homes for Adults (18-65 years) Page 10 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs and aspirations assessed before a decision is made about them moving to the home, however the home is not always able to meet the assessed needs of people living there. Evidence: There is a policy and procedure regarding the assessment process to be carried out before a decision is made about someone moving to the home. It was found at the previous inspection that assessments had been carried out with the people who now live in the home. One person was moved from the home recently following a safeguarding investigation concerning the persons safety after he had been hit by another person living in the home. There is currently a vacancy in the home. West Sussex Adult Services suspended new contracts in November and the home have voluntarily agreed that there will be no new admissions at present. These measures and the twelve safeguarding investigations that have been carried out since August 2008 show that while pre-assessments were carried out before people moved to Buttercups and Railway Cottage, the home is not currently meeting each persons assessed needs. Care Homes for Adults (18-65 years) Page 11 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples assessed needs are not documented in an up to date and holistic plan of their care that can be kept under review. People are assisted to make some decisions about their lives where they are able to. People are not always supported to be independent within a clear risk assessment framework with risks being kept under review. Evidence: At the previous inspection in November it was found that care plans were not holistic or person-centred and it was not clear in all cases that peoples care needs had been reviewed and care plans updated. A requirement was made following the inspection. Corich Community Care Ltd provided an action plan for improvement of the service following three safeguarding investigation carried out by West Sussex Adult Services in October 2008 which states that a full care plan document, with associated guidelines, support plans and activity timetables to be prepared. Care planning training was to take place in November. We have been told that this training did take place. A follow up visit was carried out by Mr Vegting, the area manager on November 10th and a report of the visit stated: The manager and key workers must ensure that all residents have Consensus care plan folders in place using Consensus documentation.... risk assessments and care plans must be evaluated on a monthly basis by their key worker and involve the resident if possible. The timescale for implementation was four weeks. Care Homes for Adults (18-65 years) Page 12 of 33 A requirement was made following the previous inspection regarding the need for the provider to ensure that care plans provide clear information about peoples needs and that these must be kept under review. An improvement plan was requested. The manager designate stated in the improvement plan that: all care plans to be individualised, clear, concise, factual and to reflect how each service user wants to be supported. Further improvement includes involving family and circle of support. During this site visit the documentation regarding the care of three people living in the home was looked at in detail. The care needs of these people were discussed with the manager and staff on duty at the time. A team leader has set up a personal profile for the eight people living in the main house. These documents are entitled: All about me and provide a brief summary of peoples needs and wishes, the information is presented in a person-centred way and is clear. Examples of comments include: I will need support in washing. You can put your hand on my hand to guide me where to soap my body. There is a section at the beginning of each profile that states the level of the persons understanding, for example: I can understand most things but I would need help making decisions such as choosing my clothes, how to get about in the environment and consenting to legal matters. The personal profiles are kept in the staff office downstairs so they are available for ease of access, however two of the care staff said they were not aware of them. While the information provides some guidance it was not detailed and did not provide guidance about all aspects of each persons care needs. The care folders for three people were seen; these documents are kept in the main office on the second floor. The folders have been re-organised and put into a clearer order. There was no evidence to show that all those living in the home have had a reassessment of their needs with updated holistic care plans drawn up as agreed following the previous inspection and safeguarding meetings. An assessment package document was in place for two people. These were not detailed and did not reflect each persons needs for example in the section: Psychological support and mental health needs it stated this was not applicable, although it was clear that both people are in need of psychological support regarding behavioural issues. It was noted that both people are Christians however there was no comment about how they should be supported with their spirituality. It was noted for one person that : I can display challenging behaviours however there was no comment about triggers or actions to be taken in the event of an incident. There was evidence to show that the care plans previously drawn up were still in place; in one case since 2006 and for another person since 2007. These care plans did not cover all aspects of each persons care needs and there was no evidence to show that they had been reviewed and updated to reflect changes of need. The requirement regarding care plans that was made at the previous inspection has been partially met and a further requirement regarding the need to provide updated holistic care plans that cover all aspects of each persons needs has been made. The people living in the main house have complex needs and need a high level of staff Care Homes for Adults (18-65 years) Page 13 of 33 support in their daily lives including one to one support at times. Some people need two staff to one person for support in the community. There was no indication in the case records to show when people need additional levels of support or to show in the daily planning how this should happen. One person has a contract for 49 hours per week of one to one time with staff. There was no indication in a care plan as to how this time should be spent and there was no member of staff assigned to be with this person during the first day of the inspection. It was observed that this person spent a significant part of the day with no staff support. There have been concerns that key information is not passed between staff or to senior staff regarding changes of care needs or behavioural issues. A requirement was made at the previous inspection that staff must be provided with guidance about recording key information. The daily recording sheets for three people were seen. These had been completed and signed by the senior member of staff on duty. There was some information about the activities that people had taken part in and key behaviours during the day. There was a comment about one persons behaviour: agitated pm, screaming, kicking other members of staff, residents, however there was no comment about actions taken or the outcome of the incident. A handover sheet has been set up so that key information is passed between senior staff at the beginning of each shift. There is a check list to ensure that all the required documentation is completed. Care staff during the shift are expected to pass relevant information to the shift leader who should then document this and pass the information on to the next shift leader. A handover meeting was observed and key information was passed on. Feedback from care staff spoken with indicated that they know that they should pass on information to shift leaders but they are not clear what happens to the information and feel they cannot always be sure that information is acted upon. An example was given of a situation with a service user who needs to have a member of staff sit with him while he is eating to make sure he eats slowly, otherwise he can make himself sick. An incident had occurred on the previous day when no staff had been with him at breakfast time and he was sick. This had been recorded in the daily sheet but no incident report had been completed or a reminder to staff on the next and subsequent shifts to make sure someone sits with this person at meal times. The manager said that he has been trying to improve communication in the home and encourages staff to pass on key information. The manager is advised to ensure that communication in the home is further improved to make sure that peoples daily care needs are closely monitored and necessary actions taken to reflect any change in need or behaviour and that care staff are involved at all points in this process. The use of language in written and verbal communication from staff was discussed with the manager. Some written comments included words not appropriate for use when working with adults, for example: I can put my toys in the box and went to the garden playing with toys. During the day comments were made describing behaviour as good or naughty. The manager was advised to ensure that staff understand the need to treat people with respect as adults although their level of understanding may be limited. There is a key worker system that the manager says helps to ensure that people are Care Homes for Adults (18-65 years) Page 14 of 33 supported to make choices in their lives. Key workers have been involved in providing information for the personal profiles and assessment package documents which include some information about peoples likes and dislikes. The range of daily activities provided is limited and therefore people have limited choice of lifestyle. A requirement was made at the previous inspection regarding risk assessments. Risk assessments have now been reviewed and updated and a number of new risk assessments have been carried out. Guidance is provided about ways to prevent risks and there are support plans in place for each person in the main house. Samples of risk assessments were seen and various aspects of risk identified. A risk was identified for one person who needed one to one support from staff at times however there was no care plan to show how this should happen. For one person there was no risk assessment following a recent safeguarding incident when he had been hit by another person living in the home. An updated risk assessment should have been completed and new guidance provided to staff. This was discussed with the manager who agreed to put this in place. The requirement is therefore partially met. The manager in the AQAA stated that he is involving parents in the care of their relatives. There were records of the meetings he has had over the past three months with the parents of most people living in the home. The information was clearly recorded and showed that most aspects of peoples care had been discussed. The manager was advised that care plans must be in place so that reviews or meetings of each persons care can be held regularly in order to show that their care is being monitored and any necessary changes are noted and guidance passed on to staff. Care Homes for Adults (18-65 years) Page 15 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not always supported to take part in meaningful and leisure activities of their choice or to be integrating into community life. People are supported to maintain contact with their families. People do not always receive the support they need with their sexuality. The home provides a healthy and nutritious diet. Evidence: There was some information in the case records that were seen to indicate some of the activities that people enjoy. Some people have the opportunity to go to college for courses adapted to their needs and the organisation has an activities centre that is also used. During the first day of the site visit three people were taken to Longleat for a day out, one person went to college, three people were taken out for a drive during the morning and one in the afternoon. There was a hand written task list showing which members of staff would be taking people out. On the second day of the site visit there was no task list to show the activity plan for the day. The case records that were seen had a brief activity programme for each morning and afternoon. For one person the choice of activities for the week were: a drive twice in the week, three walks, two sessions of watching videos, playing in the garden once, swimming or hydro one afternoon and time in their room on another afternoon. Activities for Saturday and Sunday were flexible. There was no guidance about the activities on offer in the home. The case records that were seen did not provide Care Homes for Adults (18-65 years) Page 16 of 33 guidance to staff about the choices available for people in the home each day or detailed information about the activities that people enjoy or that may support them with a care programme. The people who were at home during did not appear to have a programme of stimulating or relaxing activities planned with them. It was observed that staff were sitting with people in the lounge but there was little interaction and staff were not being proactive in setting up activities. The guidance on one persons case record stated: for him to be pre-occupied with different activities as much as possible. There was no guidance or planning about how this should happen. Another person had a goal listed as: I want to have structured activities however there was no record of how this should be provided. No structured activities were being provided for this person during the site visit and there was no documentation to show that structured activities had been provided on a daily basis. As mentioned in the previous outcome area one person who is funded for one-to-one support was spending the majority of his day unfocussed and on his own either in communal areas or in his room. He was in the kitchen for a short period of time being supported to have a coffee. It was evident that this person was able to follow simple instructions and has potential for developing some independence skills with the one to one time with staff that has been contracted for him. The daily record sheets for one person showed that over the course of a week he had been for a drive on ten morning and afternoon sessions although the purpose of these outings or the planned destination was not clear. One morning had been spent at the activity centre, one morning was spent in the house and there was a music session one afternoon with a note to say that he had not enjoyed this session. The record sheets for another person showed a similar pattern with the person being taken for a drive on seven mornings and afternoons over five days and the only other activities were walking in the garden three times, watching videos twice and one morning spent at the activity centre. The range of activities that these people had taken part in were limited with no apparent structure planned to meet their individual needs. The communal areas in the home are limited and therefore restrict the opportunities for individual or small group activities. There is a room in the grounds that could be used for activities and there was an assurance at the previous inspection that there were plans to make better use of this facility. There has been no progress in making this space available for people living in the home and there is no planned timescale for this to be done. The manager said in the AQAA that there has been more community involvement recently. There was no evidence to show that people are involved in community activities although two people were taken to a local swimming pool on the evening of the site visit. The manager said that he is encouraging staff to help people to choose suitable places for holiday visits. People are supported to maintain contact with family members and the manager has made progress in involving relatives in the care of each person living in the home. He has had meetings with some relatives and said he plans to have further meetings every six to eight weeks. The manager said that relatives have said that they Care Homes for Adults (18-65 years) Page 17 of 33 appreciate the contact with the home and that they are kept informed of key events. The organisation has a policy about sexuality and relationships. The recommendation following a safeguarding investigation in November 2008 was that one of the people living in the home should be referred for specialist support with their sexuality; the manager said that this has not yet been done although he agreed it was an urgent matter. He agreed that he would make a referral without delay. The people who live in the main house require close supervision or constant one to one attention for their safety and the safety of people around them. Peoples rooms are kept locked during the day in case other people go into their room and cause damage. People have freedom of access when they communicate to staff that they wish to go to their rooms. Access to other areas of the home including the kitchen, is restricted for peoples safety. The manager said that he is aware of the Deprivation of Liberties Safeguarding legislation that was introduced on April 1st and is reviewing these measures in light of the guidance. There is a full time cook who provides a cooked meal at lunch times and prepares food for meals on Saturday before she finishes work on Friday. Fresh fruit and vegetables are used and food is home cooked. Meals are planned by the cook who takes into account peoples likes and dislikes. The cook knows the people living in the home well and understands their preferred choices of food. There is information about special dietary needs in the kitchen. The dining room is small and several people need support with eating which means that staff should be able to sit with them. This means that the dining room is crowded and noisy at meal times which some people living in the home find difficult. There have been recommendations following safeguarding investigations that mealtimes should be staggered. Staff said that this has been tried but people living in the home do not understand the concept of having to wait for their food. Mr Vegting said there are plans for the dining room and communal areas to be extended however there is no agreed timescale for this work to begin. Care Homes for Adults (18-65 years) Page 18 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People may not always receive personal care in the way they prefer or require. Peoples healthcare needs are not clearly documented to make sure they always receive the healthcare that they require. The policies and procedures regarding the administration of medication do not fully protect people Evidence: The people living at Buttercups and Railway Cottage need help and support with personal care. All rooms in the main house have en-suite facilities so that people have privacy with showering and personal care. Staff are provided with guidance about the way to provide personal care as part of their induction. Care plans have not been updated or reviewed to provide guidance to staff about the way people prefer or need their personal care to be provided. One persons personal profile included some guidance about personal care: I will need support in washing. You can put your hand on my hand to guide me where to soap my body. This kind of guidance was not available in all cases. A holistic care plan must be in place for each person so that staff have clear guidance about the way people prefer or need their personal care to be provided. The written information about peoples healthcare needs was patchy. The assessment package documents seen on two peoples case records had a section about health needs, however this only included medication taken with no medical history or current health needs noted. There was no updated care plan to include healthcare needs and required actions. People do not have a Health Action Plan although the manager said that he is thinking of putting these in place. There was evidence to show that some Care Homes for Adults (18-65 years) Page 19 of 33 people receive support from the speech and language therapist although any guidance provided had not been included in a holistic plan of care. Contact with dentists, chiropodists and opticians had been noted but records were not up to date. One person had a dental check up in October 2007 with a note to say a check up would be needed in 6 months. There was no record to show that this had happened. Weight charts that were seen were not up to date. Clear and detailed guidance had been provided for people who experience epileptic seizures so that staff are clear about how to monitor and support them. There was an emergency during the first day of the site visit following staff monitoring the number and frequency of seizures that one person was experiencing. An ambulance was called and the incident was handled well by staff who were on duty and a senior member of staff who had come to the home on her day off. There was no clear protocol for ensuring that all the relevant information is sent with a person admitted to hospital, although a member of staff travelled with the person and a record of the medication taken was photocopied. Grab sheets were seen in the case files of two people, these were incomplete but could provide useful guidance in the event of someone being admitted to hospital. The manager said in the AQAA that a local pharmacy provides support and training for medication issues and all staff who administer medication have recently updated training. The pharmacy also carries out annual audits. The medication storage and samples of records were seen. There is a new protocol for administering medication that is prescribed to be used as required (PRN). The member of staff with delegated responsibility for medication was advised to ensure that the recording of controlled medication meets good practice guidelines. The storage facilities for controlled medication does not meet with current legislation. A requirement has been made regarding this matter. A requirement was made at the previous inspection regarding the need for the home to follow their policy regarding the covert administration. The manager said in the improvement plan that medication would be monitored regularly however the homes policy regarding the covert administration has not been followed. There was no documentation to show that a multi disciplinary decision had been taken that included the general practitioner (GP) and that the decision was made in the best interests of the individual. The records seen showed that the dosage for one persons medication had been changed recently. The member of staff said that the psychiatrist had been consulted about this issue however there was no written agreement to the prescribed dosage being changed or documentation of a telephone discussion with the consultant. There is no written guidance or policy regarding the procedure for people having their medication when they are out of the building or how administration in these circumstances should be recorded. A requirement has been made regarding the medication policies and practice in the home. Care Homes for Adults (18-65 years) Page 20 of 33 Care Homes for Adults (18-65 years) Page 21 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are now recorded to show that they are appropriately investigated and the necessary action is taken to address them. The procedures within the home do not fully protect people. Evidence: There is a complaints policy and procedure that is given to relatives of people living in the home who are not able to make complaints for themselves. There is a procedure for recording complaints. A requirement was made at the previous inspection regarding the need to keep a record of complaints. Three complaints had been recorded and investigated since the previous inspection so this requirement has now been met. The home follows the West Sussex multi agency policy and procedure regarding safeguarding vulnerable adults. There have been twelve safeguarding incidents and investigations since August 2008. The allegation of physical abuse was substantiated in eight cases and neglect by the home in three cases. Neglect by staff who did not report an incident that they observed while on duty was also substantiated in one case. A number of requirements and recommendations were made following these investigations and all staff have attended updated safeguarding training. Not all the recommendations have been implemented and there was no clear plan stating how and when they would be met. It is of concern that staff spoken with were not aware of the outcome of the investigations. For people to live and work safely in the home requirements and recommendations made at multi disciplinary meetings must be met within agreed timescales. A requirement has been made regarding this matter. Care Homes for Adults (18-65 years) Page 22 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in an environment that is not kept safe at all times. The home is not kept clean and hygienic at all times. Evidence: There was no evidence of a written plan regarding the maintenance and development programme for the home with agreed timescales. Mr Vegting said that there are a number of improvements planned. The communal areas including the kitchen, the dining room and lounge in the cottage and main house and five bedrooms were seen. A number of safety issues were brought to the attention of the manager and two senior staff from the organisation who were visiting the home. This included the banisters on the stairway that were loose and one was exposed with nails protruding from the top, a loose light switch fitting in the hallway, broken radiator thermostats and window restrictors that were not being used with no risk assessment in place. The banister was taped up at the time and was repaired on the second day of the visit. The flooring in bathrooms seen was worn, broken and was not clean. Two showers were not working efficiently and were in need of repair. A gas ring in the kitchen was broken and had been for some time. The manager said that an engineer had visited the home on 6th April and said it was safe, however there were no clear plans to say when this would be repaired. There were screws protruding from several drawers and wardrobe and doors in peoples rooms. This was pointed out to the manager and senior staff who said the matter would be addressed. The paintwork in the communal areas and in some bedrooms is scuffed and damaged. One person did not have a blind in his room and his privacy is not protected as his window has a view onto the main road. The furniture in the lounge is in need of repair Care Homes for Adults (18-65 years) Page 23 of 33 and cleaning or replacement. The home must be kept in a good state of repair and systems put in place to ensure that there are regular safety checks and any risks or safety issues are addressed as a matter of urgency. There is a cleaner for the home who also works as a carer. On the first day of the visit he was out with people living in the home and no arrangements had been made for the home to be cleaned by someone else. There was no cleaning schedule in the home with a plan for deep cleaning of certain areas including the kitchen floor, the dining room, communal bathrooms and other communal areas. There were dirt smears on walls and radiators in some rooms and one persons toilet had not been flushed or cleaned. The window ledge in one persons room had not been cleaned and an ornament was stuck to the paintwork. The manager must ensure that staff who are responsible for cleaning should be supported and guidance provided so that the home is kept clean to prevent the risk of cross infection. A requirement has been made regarding the health and safety and hygiene procedures in the home. Care Homes for Adults (18-65 years) Page 24 of 33 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by staff who are trained for their job. The recruitment procedure does not fully protect people. Staff are provided with supervision meetings. Evidence: Six of the twenty three care staff have achieved the National Vocational Qualification (NVQ) at level two or above. Eleven new staff have been appointed recently and not all of them have experience of working with people who have complex needs and a learning disability. The manager said that new staff are going through an induction programme to provide them with the knowledge and skills that they need. Samples of the induction programme were seen however one recently appointed member of staff said that he or she did not have an induction and learnt about the home by shadowing another member of staff. The number of staff on duty have been reduced. The manager said that there are now six staff on duty in the main house each morning and afternoon, providing care for eight people. A senior carer acts as a shift runner for each shift. There are two members of staff in Railway Cottage providing care for three people who are able to be more independent. The manager has reorganised the staffing for people living in the cottage so that there is a more consistent approach to their care. At night there are two waking staff on duty in the main house and one in the cottage. It was agreed at a safeguarding case conference in November that the manager would carry out spot checks at night to make sure that staff understand what is required of them and that they are carrying out their duties. The manager said that to date no unannounced checks have been carried out at night. Care Homes for Adults (18-65 years) Page 25 of 33 A number of people living in the home need a high level of staff support especially when out in the community. The exact staffing needs of people are not identified in a plan of care therefore it is difficult to ensure that staffing levels in the home are sufficient to meet the needs of the people living there. It was not clear how the staffing for the person who is funded for one to one care was to be allocated and as already mentioned he was spending a significant amount of time on his own. There has been a recruitment drive and eleven new staff have been appointed in recent months. The use of agency staff has greatly reduced because there is now a more consistent staff team. There is a recruitment procedure that includes prospective staff completing an application form, an interview then takes place and the required checks should be carried out before the person begins work. The recruitment records for three recently appointed staff were seen. One person was interviewed in December. There were no dates on their employment history and the interview notes were partially completed so it was not clear whether or not gaps in employment had been explored. An Enhanced Criminal Record Bureau (CRB) check had been received before the person began work. The records for the other two people did not include a record of the interview. There was no curriculum vitae (CV) for one person to show any gaps in employment and the references given could not be matched with the persons work history. The records for another person showed that the references did not match the names given. There were also gaps in employment and it was not clear whether or not these had been followed up. There was no evidence to show that a CRB had been obtained before the person began work. The home must ensure that there is a robust recruitment procedure in place to ensure that people living in the home are protected. A requirement has been made regarding this matter. There is a training programme in place and the organisation has appointed a training manager. The records for fifteen staff showed that everyone had attended training in mandatory topics although some were due to attend updated training. Staff have also attended training in conflict management. The manager said that he has not yet carried out appraisals with staff to identify their training needs. The manager has set up a system for staff supervision and samples of supervision records were seen. The requirement regarding supervision that was made at the previous inspection has been met. Care Homes for Adults (18-65 years) Page 26 of 33 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not currently managed by someone registered with the Commission. The quality assurance systems are not effective in ensuring a good quality of service in the home. The health, safety and welfare of people living in the home and of staff are not fully protected. Evidence: The current manager has been in post since December. It was agreed by Mr Vegting at a safeguarding meeting in November that an application for registration would be made without delay. An application has not yet been submitted and an assurance was given that this would be received within two weeks of the inspection. It is a legal requirement that a care home must be managed by a person registered with the Commission. Some of the recommendations or requirements made at safeguarding meetings have been put in place however a number are still outstanding and are a matter of priority. It is of concern that staff spoken with were not aware of the previous inspection report or the requirements that were made. The staff spoken with said they had not been given feedback about the outcome of the safeguarding meetings. A coordinated approach must be taken to ensuring that requirements and recommendations are prioritised and that staff are provided with the guidance they need to make sure that care practices in the home are improved. Senior managers from the organisation visit the home on a regular basis. There is currently no administrative support for the manager. The registered providers must Care Homes for Adults (18-65 years) Page 27 of 33 ensure that the manager is given the support that he needs to ensure the home is run efficiently and effectively and meets with the regulations. A requirement has been made regarding this matter. Quality audit reports have been provided by senior managers in the organisation and Regulation 26 visits take place, however there are a number of agreed actions that have not yet been implemented. The manager has involved family members in the care of their relatives living at Buttercups and Railway Cottage. This is having positive outcomes for people living in the home as their needs and wishes will be better understood by staff providing care and support for them. There is no system in place yet for seeking feedback about the home from people living in the home and people involved in their care. A requirement has been made regarding the quality assurance processes in the home. The manager said in the AQAA that the equipment in the home is serviced as required. The fire procedures are being revised and senior staff were visiting the home to make an assessment and draw up a new procedure that will be circulated to staff. The manager said that a fire risk assessment has been drawn up. Incidents are recorded and samples of incident reports were seen. The manager said that he monitors the reports. There has been concern in the past about the appropriate reporting of incidents to the West Sussex Adult Services and to the Commission. There has been an improvement in reporting procedures. The incident reports for two people were looked at and for one person there had been no reports since March although previously there had been several each month. Care Homes for Adults (18-65 years) Page 28 of 33 Are there any outstanding requirements from the last inspection? Yes No 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 29 of 33 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 6 15 The registered provider 30/05/2009 must ensure that care plans are person centred and provide clear and detailed information about all aspects of each persons health, personal care and emotional and spiritual needs with detailed guidance to staff about how peoples needs should be met. Care plans must be kept under review and changes made when peoples needs change to make sure that people are receiving the care that they need. 2 20 13 The registered providers must ensure that the storage facilities for controlled medication meets current legislation in order to keep people safe. 30/05/2009 3 20 13 The registered providers must ensure that medication 30/05/2009 Care Homes for Adults (18-65 years) Page 30 of 33 policies and procedures are provided and followed, including the use of covert methods of administration, procedures to be followed when people are out of the home and any changes in guidance regarding prescribed medication is documented to make sure that people are kept safe. 4 23 13 The registered providers must ensure that requirements or recommendations made at safeguarding meetings are followed up and put in place to ensure that people living and working in the home are kept safe. 5 24 13 The registered providers must ensure that the home is kept safe and hygienic in order to protect the health and wellbeing of people living there and of staff. 6 34 19 The registered providers 30/05/2009 must ensure that there is a robust recruitment procedure in place in order to protect people living in the home. The registered providers must ensure that the manager of the home submits an application for registration to meet the legal requirement for the registration of a person managing a care home. 8 39 24 The registered providers 30/05/2009 Page 31 of 33 30/05/2009 30/05/2009 7 37 8 30/05/2009 Care Homes for Adults (18-65 years) must ensure that the quality assurance systems are effective in identifying where improvements to the service should be made and making sure that these shortfalls are addressed in order to keep people safe and provide a good quality of care. 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 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 33 of 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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