Inspection on 12/11/08 for Elizabeth Lodge

This inspection was carried out on 12th November 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elizabeth Lodge 20/11/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Elizabeth Lodge Cedar Grove Trowbridge Wiltshire BA14 0HS     The quality rating for this care home is:   one star adequate 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: Alison Duffy     Date: 2 6 1 1 2 0 0 8 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 38 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 38 Information about the care home Name of care home: Address: Elizabeth Lodge Cedar Grove Trowbridge Wiltshire BA14 0HS 01225761281 01225761297 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Livability care home 8 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Additional conditions: Date of last inspection Brief description of the care home 8 8 Elizabeth Lodge is a residential care home that is registered to care for eight younger adults with a learning and/or a physical disability. The service is run by Livability. The registered manager is Mr Philip Caple. Mr Caple has approximately 17 years experience of working with older people and adults with a learning disability. Mr Caple was registered with the CSCI in May 2007. People have a single bedroom on the ground floor. Two of the bedrooms have en-suite shower rooms. Some rooms have overhead hoisting equipment. There is also a separate shower room, a further bathroom and a separate toilet. There is a large lounge/dining room. People benefit from a sensory room, which is regularly decorated with a different theme. The grounds are accessible to wheelchair users. There is a sensory garden to the rear of the property and an enclosed garden to the side. The staffing rota provides a minimum of four support workers and a senior support worker on duty during the waking day. There are two waking night staff and a member Care Homes for Adults (18-65 years) Page 4 of 38 Brief description of the care home of staff provides sleeping in provision. There is an on call management system, twenty-four hours a day. Care Homes for Adults (18-65 years) Page 5 of 38 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: one star adequate 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 key inspection took place on the 12 November 2008 between the hours of 11.40am and 4.40pm and on the 26 November 2008 between 9.45am and 6.55pm. Mr Phillip Caple, registered manager was available throughout and received feedback at the end of the visit. We met with people who use the service and staff members on duty. Due to peoples health care conditions, we were not able to receive verbal feedback about the service they received. We observed interactions between people and the staff. We observed the serving of lunch. We looked at care planning information, training records, staffing rosters and recruitment documentation. A staff member gave us a tour of the accommodation. Care Homes for Adults (18-65 years) Page 6 of 38 As part of the inspection process, we sent surveys to the home for people to complete with support, if they wanted to. We also sent surveys, to be distributed by the home to staff members, peoples GPs and other health care professionals. The feedback received, is reported upon within this report. We sent Mr Caple an Annual Quality Assurance Assessment (AQAA) to complete. This was completed on time. Information from the AQAA is detailed within this report. The last inspection took place on the 20 November 2007. There have been three complaints about the service. We undertook a random inspection in June 2008, as a result of a complaint made to us. There have been three safeguarding investigations. A joint safeguarding and complaint investigation is currently taking place. Wiltshire County Council is leading this investigation. To date, the investigation has not been concluded. As part of the investigation, the Community Team for People with Learning Disabilities (CTPLD) are reviewing peoples placements. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. What the care home does well: What has improved since the last inspection? What they could do better: Clear assessments, which have been undertaken by the home and the placing authority, must be in place before a person is admitted to the home. A review of all care plans is required without delay, to ensure each document is up to date and demonstrates the complexity of peoples needs. Where any risk to the persons health is identified, the care plan must identify how the risk is to be managed. This must include the risk of constipation or inadequate fluid intake. Protocols, which are referred to within risk assessments must be readily available to staff for reference. Staff must complete daily fluid charts for people at risk of dehydration. The charts must be evaluated daily to ensure an adequate fluid intake. Peoples goals and aspirations, should be set in relation to enhancing the individuals Care Homes for Adults (18-65 years) Page 8 of 38 quality of life rather than daily routines. All goals should state what support the person needs and be regularly monitored to review the progress being made. Consideration should be given to enable people further opportunities for social activity provision. Staff interaction with people using the service needs to be improved upon. Staff must ensure that they do not talk over people. Staff talking with each other, rather than with people using the service must be addressed and monitored. The service would benefit from some refurbishment to enable a brighter and more comfortable environment for people. All staff must receive updated training in safeguarding vulnerable people. A full review of staff training needs would enable gaps in training to be addressed. 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 38 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 10 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before being offered a placement at the home yet documentation to demonstrate this process is in need of improvement. Evidence: There has been one new person to the service since the last inspection. They had previously lived in another of the organisations care homes. Staff said they knew the person before their admission. They said the person had come to the home on a number of occasions, as part of the assessment process. When the person initially stayed over night, a member of staff from their previous home, accompanied them to ensure consistency. Staff said they received good information about the persons needs from this member of staff. We asked Mr Caple for the persons assessment, which had been undertaken before the person moved into the home. Mr Caple said they had not as yet received the placing authorities documented assessment and care plan. This should happen before the person is admitted. Staff received a large amount of documentation about the Care Homes for Adults (18-65 years) Page 11 of 38 Evidence: person including their previous care plan and health care records. Staff could not find a copy of the assessment the home had undertaken before admission. We said this should be readily accessible for reference and to demonstrate that the persons needs could be met within the home. Care Homes for Adults (18-65 years) Page 12 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans do not demonstrate the complexity of peoples needs and are insufficiently reviewed to ensure accurate information. Decision-making is encouraged in relation to peoples ability. The risk assessment process is being further developed to ensure potential risks are addressed. Evidence: We saw that each person had a care plan in place. The plan covered aspects of personal and health care, as well as communication and daily activity. We saw that one plan in particular had not been reviewed and was very out of date. Within the AQAA however, it was stated we visit the care plan each month to see if the plan needs changing in the light of the service users changing needs. We saw that people had very complex needs yet the care plans did not reflect this. For example, under night care it was documented I need staff to help me get my nightie/pyjamas on and help me clean my teeth. The same statement was repeated in Care Homes for Adults (18-65 years) Page 13 of 38 Evidence: another persons care plan. Due to the use of nightie and pyjamas, we said the form was standard and not person centred. The information did not tell the reader how the person liked to be supported or the complexity of aspects such as undressing, transferring and being made comfortable. It said the person was active during the night yet there was no information about what this meant, whether it caused a risk or the person needed support. Within another plan, it was recorded staff to be assertive with me in order to help me clean my teeth twice daily. We said greater clarity was needed with this statement and a protocol was required. The plan continued to state staff always to ask my permission before washing intimate areas. Due to the persons learning disability, we said ways in which staff should do this, should be stated. A protocol should also be in place regarding the provision of intimate care from a member of staff of the opposite gender. Staff told us that male staff do not provide intimate personal care to female people using the service, unless in an emergency. We spoke to staff about peoples personal and health care needs. In some instances, the information within the care plan was different from what we had been told. For example, we saw one person being fully assisted to eat at lunchtime. They had sandwiches but the member of staff was placing small amounts of food on the fork and then placing it in the persons mouth. The care plan stated that the person was able to use the hand over hand method to eat. They could also manage finger foods. When asked about this, staff told us that the person could no longer eat independently. They said they needed assistance to ensure they ate a sufficient amount. This must be updated in the care plan. Within the plan it was stated I would like patient staff, who are educated about nutritional food types. We did not see any evidence that attention had been given to this, although Mr Caple told us staff training in nutrition, had been arranged. We saw that there were guidelines in place regarding the management of behaviours. One intervention plan was not dated. There was no evidence that it was being followed in practice. There were transferring and the use of lap strap guidelines yet these were in need of updating. We saw within one care plan that it stated guidelines must be followed when walking XX. We did not see any evidence of the guidelines identified. Staff told us that they no longer undertook this practice, as the risk had been assessed as too high. Mr Caple told us that staff had recently rationalised the files and had probably removed too much information. He said this would be addressed. Peoples goals and aspirations were identified with the persons individual plan. We advised greater clarity within some information. For example, one goal identified I would like to live a full and active life. The information did not state specific activities, Care Homes for Adults (18-65 years) Page 14 of 38 Evidence: the support needed, who would be responsible or clear timescales. We said the outcome should also be evaluated to identify whether the goal had been reached. Within some areas, we said the goals could be more creative to enable the persons quality of life to be enhanced. For example, one goal was to continue enjoying my shower. We said this was an aspect of daily routine rather than an aspiration. We saw that the care plan stated I usually enjoy a shower but have been known to enjoy a bath in the evening, if theres time and enough staff who know me well. We said the opportunity of the person having a bath should be further explored. People are unable to fully communicate their needs through speech. Staff told us that they aim to encourage decision-making, as much as possible. They recognised that at times, this was difficult. They said in one instance a yes might mean no. They explained how a process of elimination may be used regarding something a person may need. Staff told us how some people communicate through eye contact or body language. Such aspects were identified on the persons care plan. We saw one person self harm by biting their arm. They were showing they were uncomfortable and needed support with personal care. An agency member of staff did not recognise this although a permanent staff member provided the support required. There was little within the care plan about how staff should minimise the risk of the person self-harming. At lunchtime we saw a member of staff ask a person if they wanted soup or sandwiches. They were then able to select a choice of filling. We saw another person being shown two tins of soup of different varieties. They were able to point to the one they wanted. We saw one person being asked if they wanted orange or blackcurrant squash. Within a survey however, a care manager told us I noted that XX was not asked if s/he would like a choice at mealtime. A member of staff said Come on. Ill get you some macaroni cheese. The care manager said this was a training issue. Within the AQAA it was stated risk assessments are maintained and reviewed on a regular basis. We saw that there were a number of individual risk assessments in place. Some were currently in the process of being reviewed. Others had been updated in January 2008. We saw that work was being undertaken with the Community Team for People with Learning Disabilities (CTPLD) regarding the development of health care risk assessments. Matters such as infection control had recently been addressed. As stated above, we saw that some guidelines such as transferring were in need of updating. Documentation stated that people should always be supported when having a bath. The risk assessment referred to a bathing protocol yet this was not evident within the care plan. Care Homes for Adults (18-65 years) Page 15 of 38 Care Homes for Adults (18-65 years) Page 16 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People undertake social activity provision yet greater engagement with staff would enhance the time spent within the home. Meal provision is undertaken in relation to individual need and preference. Evidence: Three people were at home during the inspection. Two were at their day service. We saw that one person spent time watching the music channel and films on the television in the lounge. A member of staff said they love films. When one finishes, they will let you know so another can be put on. The person later went to their room and listened to music. One person sat with their books and puzzles. They later went out for a walk with another person who uses the service and staff. In the afternoon, one person spent time in the kitchen with a member of staff. They were making cakes yet the person did not show any interest in the activity. The staff member continued with the Care Homes for Adults (18-65 years) Page 17 of 38 Evidence: task while talking to the person. We did not see any other organised social activity provision taking place. Some staff sat with people in the lounge but did not engage well with them. Staff spent time talking with each other rather than interacting with people who used the service. Staff told us that they tried to enable people to go out, as much as possible. They said they had a driver who was contracted for fifteen hours a week. The driver was flexible and supported people with evening trips. One member of staff told us that there were sometimes difficulties regarding the amount of staff who could drive the homes vehicle. They said staffing levels were also a challenge, due to people needing one or two staff to support them when out. One staff member said they would like to enable people to go out more. Another member of staff told us that they were in the process of arranging for some people to attend a local amateur dramatic performance. They were also bringing in a musical for people to watch the following evening. Staff said they would arrange snacks and drinks, to make it a social evening. Staff told us about shopping, meals out and a tribute band concert, which people had enjoyed. They said people had also enjoyed trips to the beach and to the cinema. They said the ministers from the local church and chapel visit on a regular basis. Within a survey, a staff member told us provide more opportunities to take residents out on trips etc. Another comment was getting funding for staff for activities or days out can sometimes be difficult. As a means to improve the service, they said allow for staffing and staffing levels to be increased for trips out and do more activities. This member of staff said that sometimes there was not enough staff to meet the individual needs of the service. Two other members of staff told us very well staffed at all times. The AQAA confirmed, there is a regular evening entertainment be it films, bingo, quiz and relatives and friends are welcome to join in. Staff told us that people are supported to maintain contact with their families. Visitors are welcomed at any time. People are also supported to send cards to their family members on special celebratory occasions. One member of staff told us that plans were being made to support people with their Christmas shopping. Staff told us that positive relationships had been established with peoples relatives. They said some people regularly go to their parental home for the weekend. Due to regular contact, staff told us that there is good communication about the persons needs. Within a survey, a staff member told us good contact with families, is an element of what the home does well. Care Homes for Adults (18-65 years) Page 18 of 38 Evidence: Within surveys, in response to what the home does well, a member of staff told us some staff willing to go out of their way to make clients life easier. Taking clients out to concerts, cinema, meals out. As a means to improve the service, they said more activities outside of the home. Holidays for clients. A care manager, within their survey told us XXs spiritual needs have been encouraged and church visitors s/he knows welcomed. There is a sensory room within the home. This is due to be refurbished. A member of staff told us that it is very well used and one person in particular, will take him/herself off to the area, independently. As stated earlier in this report, people are encouraged to make decisions in relation to their ability. Staff told us that people are encouraged to be involved in housekeeping tasks but they are not really interested. Staff said people are generally not involved in the homes weekly food shop. They said this was mainly due to the level of crowds and the need to push the trolley and support the person. Staff said that people are sometimes supported to go down to the local shop to buy smaller items. Staff told us there is an ongoing menu, which is changed as required, in relation to seasons or produce available. We saw the menu included a range of traditional food. Staff said that meal provision is arranged in terms of peoples preferences, their needs and healthy eating. They said they have learnt what people like over the years. People are encouraged to have fresh fruit. We saw that the main meal is taken in the evening. During the day people have a hot snack or sandwiches. As stated earlier in this report, some people need assistance to eat. This was undertaken in an unrushed manner yet there was little engagement with people, while they were being supported. Care Homes for Adults (18-65 years) Page 19 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clear management strategies must be in place to ensure peoples health care needs are met. Evidence: One member of staff told us about the personal and health care needs of people. This information was not always evident within the persons support plan. As stated earlier, the care plans did not support the complexity of peoples needs. For example, a member of staff told us about how mouth care is given to one person by using swabs. The care plan indicated the use of a mouthwash yet there was no information, as to how this was to be used. We saw within one care plan that the person does not always drink sufficiently. We saw a fluid chart was in place but it had not been fully completed. There was no recorded evaluation at the end of the day, to ensure the person had had sufficient fluid intake. We saw that this person was asked if they wanted a drink. They chose what they wanted and their choice was given to them. However, we saw that the drink remained untouched. They had minimal fluid intake during the day. We advised Mr Care Homes for Adults (18-65 years) Page 20 of 38 Evidence: Caple to monitor this, as the lack of evidence within fluid charts could be poor fluid intake rather than poor recording. The risk of dehydration must be addressed within the risk assessment process and be documented within the care plan. We saw another person being supported to have a drink. Staff supported them by holding a glass with a straw. This was unsuccessful so the staff member then tried a beaker with a lid. The person managed this well. Within another plan, it was stated it is important that I do not become constipated. There was no evidence, as to how this risk was minimised. The care plan stated that the person was on supplement drinks to reduce weight loss. Staff told us that the drinks were no longer given, as the persons weight was now stable. There was limited evidence within the care plan in relation to how this persons weight was being monitored. Within documentation demonstrating a recent regulation 26 visit, we saw that some protocols and procedures had been discussed. The report stated protocols and guidelines to be obtained from relevant professionals that includes eating, drinking, moving and handling and epilepsy. Mr Caple told us that representatives from the Community Team for People with Learning Disabilities were in the process of updating all Epilepsy Management Plans. We did not look at these during the inspection. Within training records we saw that staff had received training in the administration of emergency epilepsy rescue medication. As stated earlier within this report, CTPLD was supporting the service with developing protocols, in terms of infection control. Within a survey, a care manager told us that the persons health care needs were being properly monitored and attended to by the service. They said I have been involved in changes to GP, placement becoming more permanent, GP visits and recommended treatments. His/her family have also been notified and involved in choices etc. During the inspection, two people using the service were supported to get ready to go out. People were ready to go yet staff were discussing the staffing rosters. One person became agitated. A member of staff said they would go outside with the person until the other staff member was ready. They walked around the car park. The person remained agitated. There was no urgency of the staff to go out immediately after people were ready. The person remained agitated during their return. They quickly returned to their books and puzzles and appeared relaxed. We said the reasons for the persons distress must be investigated. Factors, which may be contributory factors such as having to wait before going out, must be addressed. The persons care plan must identify the support the person needs when going out. We saw that the person went out with a bib style apron on. They did not wear this inside the home. We said Care Homes for Adults (18-65 years) Page 21 of 38 Evidence: this did not promote the persons dignity. The home has systems in place for the handling of medicines, and people receive their medicines as their doctor has prescribed, in a safe way. There are some improvements needed in the storage arrangements for controlled drugs to ensure their safekeeping and to comply with legislation. We spoke to the manager and staff involved with handling medicines in the home. We looked at records of medication kept and given to people. We looked at some care plans to see what information is recorded about how people should receive their medicines. We also looked at policies and procedures that are available for staff, and we discussed arrangements for training and assessing staff who are involved with giving medicines. There are no people living in the home at present who look after their own medicines. Medicines are supplied in blister packs. Most medicines are stored safely for the protection of people who live in the home. There needs to be improvements to the storing and recording of controlled drugs. Controlled drugs must be stored in a suitable cupboard that meets the Misuse of Drugs (Safe Custody) Regulations 1973 as amended. Records are kept in a bound notebook, but this is not page numbered. It is a requirement that the home addresses these issues. This is to ensure that controlled drugs are safely stored and recorded, to comply with current legislation. There are clear records of medicines received into the home, those given to people and those returned to the pharmacy. In the care plans that we looked at, there were details on how and when to give medicines prescribed when required, although it was sometimes difficult to find, as the care plans had so much information in them. Within one care plan, we saw a number of topical creams and some as required medication. Staff told us about the medications and when they were used. We advised that this information should be recorded within the care plan. We also said that the persons pain management should be more clearly defined. There are also risk assessments for medicines. These records help to show that people are given their medicines safely and as their doctor has prescribed for them. The home often gives medicines with food to make it easier for people to swallow them. This is done after getting permission from the doctor. These permissions are currently being updated and it is recommended to check that up-to-date permissions are available for all people in their care plans. Care Homes for Adults (18-65 years) Page 22 of 38 Care Homes for Adults (18-65 years) Page 23 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to manage complaints. Ensuring all staff have up to date adult protection training would further protect people from abuse. Evidence: The organisation has a formalised system of managing complaints. A record of complaints is maintained. A copy of the complaints procedure is given to people and their relatives on admission. Copies are also located in the front entrance area of the home. Within the homes recent annual Quality Survey report we saw that 100 of peoples families who responded, were aware of the complaint procedure. We saw that within a regulation 26 visit, it had been identified that the complaint procedure could be placed on a CD. Due to their complex health care conditions, people rely on others to recognise any form of discontentment. Mr Caple told us that he believed relatives were confident in raising any concern and were strong advocates for people. Mr Caple said that any concerns were always taken seriously and addressed and resolved, as quickly as possible. Within surveys, all staff told us that they were aware of what to do if they received a complaint about the service. A care manager told us any concerns have been addressed quickly and appropriately. Care Homes for Adults (18-65 years) Page 24 of 38 Evidence: Since the last inspection, there have been three complaints about the service. We undertook a random inspection in June 2008 in response to the one complaint. We initiated a joint investigation into another complaint with Wiltshire County Council. As part of this, peoples placements were to be reviewed. The investigation is continuing with Wiltshire County Council, as the lead organisation. There have been three alerts made to the local safeguarding unit since the last inspection. Two incidents have instigated investigations, which to date have not been concluded. We saw that a copy of the document Keeping Vulnerable People Safe in Wiltshire was displayed within the entrance area of the home. Staff told us that they would immediately report any allegation of abuse to Mr Caple. They said in his absence, a senior manager within the organisation would be contacted. We saw that Mr Caple has reported incidents, which affects the persons well being to us, under regulation 37. As stated above, Mr Caple also informs the local safeguarding unit, as required. Within the training records, we saw that the majority of staff have not received recent training in safeguarding vulnerable adults. Mr Caple was aware of this. It had also been raised in a recent regulation 26 visit. Mr Caple said a training package, which involved adult protection training, had been purchased. Mr Caple had also applied for staff to participate within the local council, safeguarding training. We saw that listening devices were being used. We heard a member of staff communicate with a person in their room, by voices coming from a device, in the dining room. This did not promote the persons privacy. Staff told us that the devices assisted with alerting staff of a person having a seizure, when unattended. We saw that the listening device was identified within the care plan. We advised that documentation be reviewed. Guidelines of when the device should be used should also be in place. Care Homes for Adults (18-65 years) Page 25 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is clean and safe yet the refurbishment of certain areas would enhance peoples comfort. Evidence: People have a single room on the ground floor. Two rooms have an en-suite facility. We saw that all rooms were personalised with various pictures, photographs and other personal possessions. Some rooms had sensory equipment. There was a lounge, a dining area, a sensory room and a separate quiet area. The quiet area, which was next to the kitchen, contained a computer. Mr Caple and staff told us that a grant had been secured to refurbish the sensory room. Staff told us that this would be very beneficial, as the room is very well used. They said the bathroom was also due to be refurbished. It was anticipated that the room would be much more comfortable and inviting, following refurbishment. While the environment was clean, tidy and safe, we saw that some areas would benefit from brightening up. The lounge, dining area and the quiet area appeared tired and Care Homes for Adults (18-65 years) Page 26 of 38 Evidence: were in need of updating. Mr Caple agreed with this and said discussions had been held with senior managers in relation to making the environment more comfortable for people. Within a record of a regulation 26 visit, we saw that Mr Caple had given a list of works regarding bedroom redecoration to senior management. We saw in the entrance area that there were two bicycles. Mr Caple said these belonged to staff on duty. He said the bicycles were brought inside, as there was no secure storage outside. We advised that this be further addressed, as it was not welcoming to have these within full view. Within a survey, a care manager told us the environment lacks something - it is adequate but not homely and stimulating. It looks tired and unwelcoming. It needs fresh ideas and enthusiasm. Some staff do not seem to be aware of the holistic aspect required, not just about care. A member of staff told us that there had been no changes to the laundry systems since the last inspection. They explained the facilities continue to meet the needs of the service. They said that staff are responsible, for the laundering of all peoples clothing and bedding. The night staff complete the ironing. Staff told us that they have access to disposable protective clothing, as required. Care Homes for Adults (18-65 years) Page 27 of 38 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. The use of agency staff, although short term, is impacting upon service provision and shows the need for greater induction. People are not at the centre of staff interactions and greater engagement is needed. People are protected by a robust recruitment procedure. Evidence: We looked at the staffing rosters. We saw that there are generally five staff on duty throughout the day when people are at home. One person who uses the service receives full one-to-one support. When they are not in the home, staffing levels reduce. At night there are two waking night staff. A senior support worker undertakes sleeping in provision. The roster identifies the member of staff who is responsible for running the shift. There is an on call management system. Staff told us that they are responsible for all housekeeping tasks, as well as supporting people with their daily routines. This includes cooking, cleaning and the laundry. We saw that a high level of agency staff have been used to maintain satisfactory staffing levels. Mr Caple said the service is fully staffed yet agency staff are used to cover annual leave and sickness. He said he aims to have a team of agency staff, who get to know people using the service. Mr Caple told us however, that this is not always Care Homes for Adults (18-65 years) Page 28 of 38 Evidence: possible. During our inspection we saw that there were two agency staff on duty in the morning. One agency staff told us that they had not been at the home before, so were not familiar with people or their routines. They said they were waiting for a permanent member of staff so that they could offer a person support with their personal care. As stated earlier in this report, we saw one person biting their arm. An agency staff did not recognise or deal with this distress. A permanent member of staff was able to support them and enable greater relaxation. A member of staff told us very difficult if they [agency] have not been here before but some are very good. We advised that greater focus is given to the induction of agency staff. We talked to staff about peoples needs. They told us about how people needed to be supported and their health care. They explained how people communicated. Some staff have worked at the home for a number of years and know people well. As stated earlier within this report, we saw that there were occasions when staff communicated with each other, over people using the service. One member of staff said Ill take his/her coat off in a minute. There was no acknowledgment of talking to the person. Another example was when an agency member of staff said shall I put him/her here? We saw that some staff sat with people in the lounge but there was little engagement. Some staff spent time at the dining room table talking to each other rather than interacting with people using the service. We saw one member of staff come in. They sat down with staff and then said I will go and check the laundry. People using the service were not given priority at this time. We discussed these interactions within feedback. Mr Caple told us he would monitor the situation. He said he would raise issues with the staff team at the staff meeting, which was to be held the following day. We looked at the recruitment documentation of the three most recently employed members of staff. The files generally contained the required information. There was a photograph, an application form and two written references. Each staff member had been checked against the Protection of Vulnerable Adults register before commencing employment. Criminal Record Bureau (CRB) certificates were in place. Mr Caple told us that the organisation sends out a health declaration, as part of the recruitment process. They are returned to the personnel section of the organisation. Mr Caple told us that the organisation would inform him if there were any issues highlighted on the declaration. Mr Caple told us that he does not see the actual documentation. Staff told us that they received regular supervision and they attended various training courses. They said they had recently completed manual handling and epilepsy training. One staff member told us that they had started a distance learning food hygiene course. They said that all staff were completing the course. We looked at staff training records. We saw that some people had completed epilepsy awareness training in October 2008. This included the administration of emergency rescue medication. Care Homes for Adults (18-65 years) Page 29 of 38 Evidence: Another person had completed the Certificate in Care Planning and Documentation. We did not see any recent training in safeguarding vulnerable people, infection control, communication or individual health care needs of people such as learning disability. Mr Caple was aware that training opportunities had reduced. He said they had recently changed training providers and focus was now being given to these areas. He said staff had applied to participate on the local county councils vulnerable adults course, but it was always full. He said other external courses only appeared to accept one or two participants so training the whole staff team externally, was a challenge. Mr Caple told us that training sessions on nutrition, coping with challenging behaviour, dying and bereavement and adult protection had been arranged. A member of staff was also planning to attend the Train the Trainers training, so that they could cascade information to the staff team. Within a survey, a staff member told us that they regularly met with their manager for support. They said they received regular supervision and had training relevant to their role. Other members of staff said always have regular supervision and always keen to do extra courses. Within their survey, a care manager told us I think the staff lack the motivation and training however, they do ask for outside help, perhaps not soon enough. Care Homes for Adults (18-65 years) Page 30 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff commented positively about the management style of the home although greater monitoring is required to address the shortfalls identified within this report. While a quality assurance system is now in place, a clear action plan to address identified areas would enhance service provision. Evidence: Mr Caple was registered with us in May 2007. He came to the home originally, to cover the post, on an agency basis. Mr Caple has worked in various care settings, for approximately 17 years. He has the Registered Managers Award RMA and the City and Guilds Advanced Management for Care qualification. Staff told us that Mr Caple was very approachable and his availability was good. They said he was involved with peoples support and sometimes worked a shift, as part of the working roster. They said he was very informative and aware of peoples needs. They said he joins in with staff handovers, if he is available. Care Homes for Adults (18-65 years) Page 31 of 38 Evidence: Within a survey, a staff member told us Phil Caple is always happy to discuss anything I need to. I always have lots of supervision with Phil. A care manager within their survey said I have found the manager to be responsive and caring. Since the last inspection, a formal quality assurance system has been devised. We saw an Annual Quality Survey report, which had been undertaken by the organisations interim Quality and Policy Manager. The report included feedback from surveys, which had been sent to peoples family members and health care professionals. The report highlighted a number of views such as not enough activities and stimulation. We saw that the action plan did not highlight how these issues were to be addressed or who would be responsible. There were no timescales within the action plan. Mr Caple told us that a report with identified timescales had been sent to the organisation. The copy within the file had been used, as a starting point, before further discussions with staff and senior management. We saw that people using the service were not involved in completing surveys. Mr Caple identified that this was because of peoples heath care conditions and their limited communication skills. There is a range of health and safety policies in place. We did not view these on this occasion. At the last inspection, we made a recommendation that hot water temperatures are monitored due to unpredictable temperatures. This has been addressed. Staff also showed us records where they document the temperature of the water, when assisting a person to have a bath. We saw that external contractors undertake the servicing of all equipment. A current gas safety certificate was in place. An audit regarding asbestos had been undertaken. We saw that the fire risk assessment was in need of review. Mr Caple told us that the Fire and Rescue service were being contacted to offer specialised expertise in this area. There had been an Environmental Health inspection in September 2008. The comments stated on the report were generally well maintained. However, you must implement a food safety management system to your business operation to comply with Article 5 of 852 2004. Mr Caple told us this had been addressed. We saw that there was a daily record of the refrigerator and freezer temperatures. Records also showed the temperature of hot food immediately before it was served. As stated earlier in this report, risk assessments are in the process of being further developed and updated. As previously reported, when a risk assessment identifies the need to refer to a protocol, this must be readily accessible. Care Homes for Adults (18-65 years) Page 32 of 38 Are there any outstanding requirements from the last inspection? Yes R 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 1 6 15(1) and 2(b) The registered person must 28/02/2009 ensure that care plans fully reflect peoples needs and how they are to be met. Each care plan must be regularly reviewed and kept up to date, as needs change. This requirement was made at the last inspection but remains outstanding. Care Homes for Adults (18-65 years) Page 33 of 38 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 2 14 The registered person must ensure that a robust assessment process, which confirms that the persons needs can be met within the home, is evidenced. So that people can be assured that their needs will be met. 23/12/2008 2 6 15 The registered person must 31/12/2008 ensure that each care plan is up to date and is regularly reviewed to reflect peoples changing needs. To ensure the persons changing needs are identified and addressed. 3 6 15 The registered person must 28/02/2009 ensure that each person has a care plan, which is accurate and fully reflects the complexity of his or her needs. To ensure the persons needs are met. Care Homes for Adults (18-65 years) Page 34 of 38 4 18 12 The registered person must ensure that the identified persons agitation when going out is investigated. Measures to minimise any distress must be addressed and be clearly identified within the persons care plan. To ensure the persons well being. 31/12/2008 5 18 12 The registered person must ensure that protocols in relation to peoples health care needs are clearly accessible within peoples care plans. This must include the management of constipation and poor fluid intake. To ensure peoples health care needs are met. 31/01/2009 6 20 13 Controlled drugs must be stored in a controlled drugs cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 as amended, and records must be held in a suitable register. This is to ensure that they are safely stored and to comply with current legislation. 31/03/2009 7 23 13 The registered person must ensure that staff undertake training in safeguarding vulnerable people. 28/02/2009 Care Homes for Adults (18-65 years) Page 35 of 38 To ensure staff are able to recognise any potential abuse and therefore safeguard people. 8 42 13 The registered person must ensure that an up to date fire risk assessment is in place. To ensure peoples safety. 30/01/2009 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 1 2 The registered person should ensure that the assessment processes, which include visits to the home, are fully documented. The registered person should ensure that peoples goals and aspirations enhance their quality of life. The support people need to reach their goals should identified within the care plan and be regularly monitored and evaluated. The registered person should consider ways in which opportunities for social activity provision can be enhanced. The registered person should ensure that daily fluid charts are fully completed and evaluated on a daily basis. The registered person should ensure that documentation about listening devices is reviewed. Times, in which the devices should be used, should be clearly identified. The registered person should give consideration to how the environment can be made more homely and welcoming. The registered person should ensure that the issue of staff talking over people and not fully engaging with them, is addressed and regularly monitored. The registered person should undertake a full review of staff training needs in order to identify and plan further training provision. The registered person should ensure that the homes quality action plan has measured outcomes, to identify when issues have been addressed. Page 36 of 38 2 6 3 4 5 12 19 23 6 7 24 32 8 35 9 39 Care Homes for Adults (18-65 years) Care Homes for Adults (18-65 years) Page 37 of 38 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. 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