Inspection on 03/09/07 for Greathouse Home - Leonard Cheshire Disability

This inspection was carried out on 3rd September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greathouse Home - Leonard... 13/06/06

Greathouse Home - Leonard... 04/01/06

Greathouse Home - Leonard... 12/07/05

Greathouse Home - Leonard... 24/02/05

Greathouse Home - Leonard... 22/09/04

Greathouse Home - Leonard... 12/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Greathouse Cheshire Home Kington Langley Chippenham Wiltshire SN15 5NA Lead Inspector Tim Goadby Key Unannounced Inspection 3rd & 4th September 2007 10:25 Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greathouse Cheshire Home Address Kington Langley Chippenham Wiltshire SN15 5NA 01249 750235 01249 758826 greathouse@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Joyce Amor Care Home 25 Category(ies) of Physical disability (25), Physical disability over registration, with number 65 years of age (25) of places Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated in the home at any one time is 25. The maximum number of service users in receipt of nursing care who may be accommodated in the home at any one time is 21. The maximum number of service users in receipt of personal care who may be accommodated in the home at any one time is 6. 13th June 2006 Date of last inspection Brief Description of the Service: Greathouse provides accommodation and care with nursing for up to 25 adults with physical impairments. The homes care planning and review systems show whether an individual is receiving nursing or personal care. Three rooms are used for short-term care. Some people attend for day care. The service is operated by the Leonard Cheshire Foundation, a voluntary organisation. Greathouse is in Kington Langley, on the outskirts of Chippenham, which offers a range of amenities. The village is also close to major road and rail links. The building has been used as a care home for around 50 years. A significant ground floor extension was added in the 1970s. There is a large garden with views over neighbouring countryside. Parking is available for visitors. Service users can access the ground and first floors. There is a lift between these. All service users have single bedrooms. One room used for short-term care has an en-suite facility. There are four bathrooms for general use and a number of additional toilets. The home has a range of equipment and adaptations, designed to suit the needs of its service users. Due to the age of the property and its location, there are future plans for reprovision of this service. There is no firm information yet about when or how this will happen. Fees charged for care and accommodation vary, depending on the assessed needs of an individual service user. Information about the service is available on request. It is also displayed in a number of locations around the home. A copy of the most recent CSCI inspection report is kept in the entrance hallway. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed in September 2007. It included a review of what we know has happened at the home since its last inspection. This included the notification of various events, and a change of manager. We also received written information about the service before visiting, by asking them to complete an Annual Quality Assurance Assessment (the AQAA). We sent out surveys, and received replies from six members of staff. The inspection visit to Greathouse was unannounced, and took place over two consecutive days, for a total of 13 hours. During the visits we spoke with service users, staff and management; looked at records; toured the building; sampled a meal; and observed daily life in the home. The judgements made in this report are based on all the evidence gathered, including the visits to the home. What the service does well: Service users can be confident that Greathouse will meet their mobility and health needs. Adaptations and equipment are provided in all parts of the home. Individual service users have been supported to obtain items which meet their own requirements. The home employs a physiotherapist, who provides therapy and also advises on measures to promote independence. Service users benefit from good support. Training opportunities are available for all staff. There is a training co-ordinator who oversees this. Leonard Cheshire Homes provides a range of courses within the organisation. People also access external training relevant to their roles. Service users can make decisions about their own lives, and about the conduct of the service. They participate in their own care planning and review. There are regular meetings to discuss a range of topics relevant to the running of the home. People can also join wider discussion groups on particular issues. Prospective service users can be confident that assessment and admission processes assist them to make an informed decision about whether Greathouse can meet their needs. Service users are often referred from other parts of the country. Nursing staff travel to meet people and carry out assessments. Relevant information is gathered from the service user and from other people who know them. Individuals then have the chance to visit the home for a trial stay, to see if they like it. Once they have moved in, there is a review process to check that they are settling and having their needs met. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plan guidance needs to be kept clear and up to date, so that there is consistent, effective and safe support for all service users’ needs. Sampled care records show that relevant information is available, but not always clearly presented. Care plans may not be updated promptly when new information is received, or cross-referenced to other important documents. This creates the risk that, in referring to the care plan only, staff may not give the correct care. A particular example of where such deficits may place service users at risk is in the area of diet and nutrition. Several individuals have significant needs, with their health and well-being closely dependent on up-to-date care guidelines being followed exactly. Feedback from staff and some evidence in records showed that practice is not sufficiently robust to guarantee safe practice. Guidelines need to be in place for use of medication other than painkillers which is prescribed ‘as required’. For instance, they may be prescribed as a possible intervention in the management of behaviour. Objective definition of the circumstances in which such drugs may be administered will help to ensure that they are given in line with the prescribers’ intentions, upholding the welfare and safety of service users. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 7 Incidents where staff have been placed at risk need to be recorded and reported effectively, so that they can be properly followed up. This will enable risks to be reviewed and any necessary actions taken to minimise the possibility of similar incidents. This will help to promote the safety of staff and to identify the most effective means of supporting service users. All parts of the home must be kept clean and free of offensive odours, to ensure the safety and comfort of service users and promote their dignity. Concerns raised by some staff about standards of cleanliness were not substantiated in all areas. But carpets in parts of the ground floor are heavily stained and a strong offensive odour was present in one service user’s bedroom on both days of this inspection visit. Work in progress on changes to the home’s bathroom facilities has created difficulties in the provision of personal care for service users. These need to be resolved without delay so that all service users can receive the personal care they need, in ways which they prefer. Service users would benefit from the continuing development of the activities programme offered by the home. In particular, people would like more opportunities for outings, and for evening activities. Comments from service users and staff showed a wide range of views about the quality of service being provided at Greathouse. Some were very satisfied, and felt that recent changes have brought improvements. Others raised significant concerns and felt that standards at the home have declined. The variety and strength of views need to be reflected in the service’s quality assurance process. Consideration should be given to ways to increase opportunities for everyone to comment and to get feedback about how their views are influencing service delivery. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed, so that a decision can be agreed about whether or not the home will be able to support them. EVIDENCE: Assessments are carried out by nursing staff. They visit a prospective service user if possible. Information is also obtained from other professionals who have been working with the individual. Sampled files for two recent admissions showed that relevant information was obtained from the settings in which the service users lived previously, along with other documented assessments. Potential service users, their relatives and representatives are encouraged to visit Greathouse if they are able to do so. One new service user explained that they stayed for a week at both this and another home before choosing where to live. They have particular reasons for preferring Greathouse and are happy with the decision they have taken. They spoke about how they have been able to maintain important relationships and go on holiday and to other social events. This service user enjoys the community aspects of living in a home such as Greathouse and prefers it to the option of living more independently. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 10 Once service users have moved in, they are involved in drawing up their own care plan as they settle in. Reviews take place after a few weeks to check that the placement appears suitable to meet the person’s needs. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate overall, but there is a particular shortcoming in the quality of service users’ individual plans. This judgement has been made using available evidence including a visit to this service. Service users are placed at risk by not having all of their abilities, needs and goals clearly reflected in their individual plans. Service users can make choices and decisions in their daily lives, and about the conduct of the home. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. EVIDENCE: There were 23 service users in the home at the time of this inspection, including two people staying for short term care. Five sets of service user records were checked in detail, along with some documents relating to others when following up on specific issues. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 12 The home has done a lot of work on its individual care planning systems. This has promoted greater service user involvement in planning and reviewing their care. Service users work closely with an allocated staff keyworker to discuss their needs and wishes, and how they would like these to be supported. Care plans address physical healthcare needs and other areas such as communication and activities. There is a range of topics covered at initial assessment. From this, it can be highlighted which parts are relevant to each individual service user. The format has been changed to make it simpler and more user friendly. This has involved combining some information, to reduce the number of pages whilst still keeping all relevant content. Signed consents are in place to show that service users or their representatives have been consulted on major decisions about care, such as what to do when people are seriously ill. Service users participate in their own care reviews. These meetings provide an opportunity to consider all aspects of the service provided at Greathouse, and also any other goals people may have in their lives. The sampled care records show that information is available about assessment, planning and review of support for all relevant areas for each individual. However, this information is not always clearly presented. For instance, recent important updates about aspects of a service user’s care have been included in the folder, via letters or other documents received, but have not been incorporated into updated support guidance. The care plan has not been reviewed or updated; the other documents are not cross-referenced; nor are they filed next to each other in the folder. This creates the risk that, in referring to the care plan only, staff may not give the correct care. Service users confirmed that they can make choices in their daily lives. They said that the atmosphere is homely and flexible. For example, there is no problem in having breakfast at a time of their own choosing, depending on when they prefer to get up. Service users hold meetings at least once a month about the day to day running of the home. This enables them to put forward ideas or suggestions about all aspects of the service. The time of day when meetings are held is varied, to try and promote wider attendance and different participants. Normally, between eight and twelve service users are present for these meetings. The sessions are facilitated by an independent person, and key bullet points are then given to the manager for her attention. Surveys are also carried out, to get the views of service users and others on various topics. There are two designated service user representatives from Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 13 among the group currently living in the home. They can act on behalf of the others in taking any comments or concerns to the manager. One of these representatives spoke positively about recent and planned future changes in the home. They also confirmed that service users have involvement in all aspects of service delivery. Leonard Cheshire also has a Service User Network Association, giving people from a number of different services the chance to meet to discuss issues. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate overall, but there is particular concern about how service users’ dietary needs are met. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to maintain and develop skills. Service users are provided with a range of activities and opportunities but would benefit from further development of these. Service users are able to maintain appropriate relationships with family and friends. Service users are not all satisfied with the arrangements for provision of meals, and some are placed at risk by a failure to have evidence that their dietary needs are being suitably met. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 15 EVIDENCE: Activities are offered for all service users. This includes up to six people not living at Greathouse who may attend for day care. One member of staff leads on co-ordination of these areas. There are designated activities staff, including volunteers. Staffing levels have been adjusted recently to reflect that the service is now contracted to provide fewer hours to day service clients. There are various activities areas in the home, mostly on the first floor. Some activities are also carried out in the ground floor dining room. This encourages other people to take part. Sessions offered are based on people’s hobbies and interests, and include cooking, quizzes and games, film shows, and coffee mornings. A game was taking place in the dining room on the first day of the inspection visits, with five service users participating to varying degrees. Larger social gatherings also take place, including outside entertainers coming in. Service users have agreed to contribute a small sum to help subsidise the cost of such occasions. Unfortunately a number of planned outdoor events have had to be cancelled this summer, due to poor weather. Some therapy sessions, such as special massage techniques, are also provided by people coming into the home. There is an IT room which has been decorated and equipped, to make it a welcoming and accessible facility for all service users. A staff member is employed to lead on this work with service users, offering them a range of computing options, based on needs and preferences. However, this post was vacant at the time of the inspection. There is also a room with various sensory equipment. This is felt by staff to be an underused resource at the moment, and the home is trying to identify suitable training so that staff can be equipped with the skills to help service users benefit more from it. Service users also have space in their own rooms for equipment such as televisions, stereos and personal computers. Some people spoke about the various hobbies they enjoy. The home hopes to incorporate some of these into its activities programme, for instance by offering art and craft sessions. As well as activities at home, Greathouse can support people to access opportunities elsewhere. The service has a number of vehicles suitable for transporting physically impaired people, and a designated driver is employed for two days a week. Service users mentioned outings including ten pin bowling and a trip to Longleat. Some individuals went out with staff during the inspection visit to go shopping and to the bank. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 16 The home is hoping to expand the range of activities and opportunities, with particular attention to meeting the needs and preferences of younger service users. The possibility of accessing relevant college courses is one priority for the manager. Use of volunteers is being considered as a means of supporting service users to access a wider range of opportunities outside the home. Service users also have the opportunity to go on holiday, if they wish to do so. Specialist facilities, able to care for the physical needs of the group living at Greathouse, may have to be accessed. Two service users had recently returned from such a holiday and spoke about how much they enjoyed it. For those less able to go away, day trips can be arranged. Visitors are welcome at any time. Overnight accommodation can be provided, if required. Service users can receive guests in their own rooms, or various other quiet areas are available. The home is also seeking to build contacts with families generally, via meetings. Service users also have the opportunity to develop and maintain personal relationships. For instance, one service user’s fiancee regularly visits them at the home and they are able to spend as much time together as they wish. There is a chapel area in Greathouse itself. There are also regular contacts with the local church. Any rules relating to residence in the home are made clear in the information available. In general the principle is to respect users’ personal choice. There is flexibility in daily routines. Some service users are keen to have the chance to move on from Greathouse to live more independently. Some of the support offered by the home aims towards enabling this. For instance, there are laundry and kitchen facilities on the first floor which are intended for service users. The kitchen is specially adapted to be suitable for wheelchair users. People with very restricted movement have equipment that assists them to communicate, and to operate environmental controls in their own rooms. The home has a large dining room area on the ground floor. Most service users tend to eat there. But they can take meals in their own rooms if they prefer. Staff are available to support service users at mealtimes as necessary. Individuals are also supplied with suitable equipment, such as adapted cutlery and crockery, which helps them to be as independent as possible. There is always a choice of two items for the midday and evening meals. Other alternatives can also be provided if wished. Breakfast can be selected from various options. The kitchen is staffed throughout the majority of the day, and into the early evening. At other times, care staff can access it to Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 17 make drinks or snacks for service users. The adapted kitchen on the first floor also gives the option of some service users preparing their own meals and is used when anyone wishes to have a cooked breakfast. Some service users have special dietary or nutritional requirements. Some staff expressed concern that these needs are not being supported safely, with service users having their health placed at risk by a failure to follow individual guidelines correctly. Sampled care plans and other documents partially support this concern. They show that guidance on key dietary needs is available and up to date. There has been involvement from relevant professionals, such as a dietitian, a diabetes nurse and a speech and language therapist, to conduct swallowing assessments. But information is not always filed and cross referenced in a way that promotes confidence that all relevant staff will follow it. Records also show references to some service users having been served with foods that are not safe for them. There is no response to show if any action has been taken after reported errors, despite their potential seriousness. There were also widely differing views on the quality of food served in the home. Some service users and staff were not happy about it, going so far as to call it “disgusting”. However, others felt that it is satisfactory and has improved over recent months. The inspector joined service users for their main midday meal on the first of these inspection visits. The meal sampled, a chicken curry served with vegetables, was of good quality. Service users were having the same dish or alternatives. Some appeared to enjoy their meals. Others were less satisfied and in some cases did not finish. The home already has a number of systems in place for ongoing review of mealtime arrangements. There have been various improvements to the dining room, addressing its décor, furniture and equipment. More changes are planned shortly. A steering committee, with representation from service users and staff, meets to discuss food in the home. The committee includes the chef and the hotel services manager. A comments book is kept in the dining room, and a number of service users have made use of it. Comments include compliments as well as some concerns. The chef is available to meet and chat with service users, and was seen to do this throughout the meal that was observed. Menus have been devised, with input from service users, with the intention of having them printed and available at mealtimes. But these measures have not yet proved fully effective. Comments and criticisms in the book in the dining room have not received any response. Menus on display are not an accurate reflection of the meals actually being served. Issues raised by the steering committee or in service user’s meetings have not been resolved. These failings mean that dissatisfaction remains. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 18 Some concern was also raised by staff about food hygiene standards. Meal preparation was not observed. However, records showed that all catering staff have qualifications to at least the minimum required level. Also, a check of the kitchen found it to be clean, and arrangements for food storage were appropriate. Records are also maintained as evidence of appropriate practice, for instance on cleaning schedules and fridge temperatures. There were dripping taps at three different sinks in the kitchen, which needed attention to ensure cleanliness and hygiene. The manager stated that these were due to be addressed. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 19 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There needs to be clearer evidence to provide reassurance that service users are receiving consistent and effective support for all their personal and health care needs. Service users are protected by most of the home’s policies and procedures for dealing with medicines. But some people who are prescribed ‘as required’ medication are placed at risk by a lack of guidance on how it is used. EVIDENCE: The service user group have complex and varied needs, and the range of support they receive reflects this. People’s nursing care needs are assessed in house, to define the support to be provided at Greathouse; and by external assessors, to work out the free nursing care element of their fees. Sampled care plans have a lot of detail on physical health needs, reflecting the nursing specialisms in the home. A range of health assessments are Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 20 completed, and support is then based on the needs identified from these. Plans are put in place for relevant need areas such as continence, epileptic activity, nutrition and pressure area care. (Please refer to Lifestyle section regarding concerns about how nutrition guidelines are followed) Concerns were raised by other agencies in November 2006 about pressure area care in the service, in response to an issue affecting one service user. In response, the home provided information about its practice at that time. The topic was also considered again at this inspection. We found no evidence to support concerns. Suitable guidelines are in place to minimise risk when service users have been assessed as needing this. Where previous issues have occurred, wound care plans have been effective in promoting healing. The home has also accessed advice and support from the specialist tissue viability nurse. Nursing staff receive appropriate training. One reported that she has three wound care training sessions booked during the next few months. One service user had some pressure damage at the time of the inspection, which was recorded as responding well to treatment. The needs of some service users at Greathouse include learning disability. These issues are picked up within individual care plans, and relevant professionals give support to help meet these particular areas of need. The home’s training programme and resources provide input on lots of topics relevant to the service users’ health care needs. In-house information packs have been compiled by the training co-ordinator, on subjects such as stroke, asthma, epilepsy and Braille. Professionals who work with the home are invited to give talks and training, covering issues such as diabetes, diet and nutrition, and pressure area care. They can focus on specific care interventions and techniques which are used in the home, as well as giving more general information. Provision of personal care has been affected by work to change the bathroom facilities at the home. This has led to increased reliance on bed bathing whilst there is a reduced number of baths. Some staff expressed concern that service users are not having all their personal care needs met at the moment. But others felt that minimum standards are being maintained despite the current difficulties. Service users did not raise any specific concerns about this topic, although some made general comments about not being happy with the standards of care. Records of how often service users receive a bath show frequent alterations and crossings out, suggesting that practice in this area has been hampered over recent weeks. The Regional Director for Leonard Cheshire has assured us that plans were in place to reduce any inconvenience to service users whilst bathroom facilities at Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 21 Greathouse were upgraded. The provider is confident that any temporary difficulties have been resolved since the inspection was completed. Service users’ preferences about personal care, such as the gender of staff they would like to support them, are shown in their individual plans. None of the home’s current service users are assessed as capable of retaining responsibility for their own medication. Therefore, qualified nursing staff are responsible for this task. Systems for medication were checked. All drugs in the home are kept securely. Storage arrangements have been reviewed since the previous inspection. There is a combination of fixed cupboards and a medicines trolley. A lockable fridge is used for any medicines which need to be kept below a certain temperature. There is a suitable contract for the disposal of waste medication, which reflects the additional measures required for homes providing care with nursing. Some service users are assessed as capable of managing their own medication. They are supported to do this in the way they find most suitable. All other service users have their medication managed on their behalf. Records clearly identify each service user, with a photo attached to their own administration charts. Sampled records are maintained to the required standard. The chart is signed by the relevant nurse if the drug has been taken by the person. Codes are used to denote various reasons for nonadministration, such as refusal or absence. Where the prescription instructions allow for varying doses, the record shows which one has been given. If medication administration or recording errors do occur, these are notified to the CSCI without delay, as required. The home also ensures that any incidents are followed up appropriately, and corrective actions are taken if necessary. Some service users are prescribed medication to be given ‘as required’. At Greathouse, the majority of such prescriptions are for pain control. Service users may ask for them, and staff may have to make a judgement on whether or not to agree to such requests. Or the decision might have to be initiated by a staff member. In either case, it is important to define the criteria for use as objectively as possible, so that the drug is given when it is indicated, and not more or less often. The home has taken steps since the previous inspection to have much clearer information about this. However, an ‘as required’ prescription for a drug used in the management of behaviour did not have clear guidance regarding when it should be given. The written policy stated to do this “for aggression”, without being more objective about what this would mean for this individual. A recorded use of the drug Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 22 stated that it had been given for “untowards behaviour”, with a brief description of an incident that, although a kind of assault, did not appear to include aggression. There was no further recorded information about the event or how it had been followed up. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 23 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are protected by procedures for the investigation of complaints. Systems are in place for the protection of service users from abuse, including the appropriate involvement of other agencies. But there is not always evidence of an effective response to situations which have placed staff at risk. EVIDENCE: Suitable complaints procedures are in place. Information about these is readily available. Each service user receives a copy of a complaints leaflet and other copies are also on display in the home. Leonard Cheshire has its own processes for investigating complaints. Other agencies may also be involved, where appropriate. The home has notified the CSCI about issues when required. Service users confirmed that they know how to raise concerns. They would speak with a service user representative, their staff keyworker or a more senior staff member. Service users also feel confident to approach the service manager if they wish to. One service user brought a concern directly to her during the inspection visits. Since the previous inspection there were some complaints from service users who stay at Greathouse for short term care. These were investigated through Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 24 Leonard Cheshire’s procedures and some action points were identified as a result. The home now has a policy of asking these service users for comments as they leave, so that any issues can be resolved before the individual’s next planned stay. Some staff and service users’ relatives reported that they have recently found it more difficult to raise concerns and receive a constructive response. There are also policies and procedures relating to abuse and protection. The service is aware of local multi-agency adult protection processes, and has accessed these when required. Some incidents have been reported under these arrangements since the previous inspection. The home has responded appropriately to issues affecting service users both at Greathouse and in connection with situations outside the home. The majority of staff have attended training on relevant topics. Abuse and protection are key areas covered with all new employees during their induction. Staff get a copy of a booklet which explains the local arrangements for safeguarding adults. They also get information about Leonard Cheshire’s procedures for staff wishing to raise concerns. More input is planned in the near future, with a representative of the local Police vulnerable adults team due to give a talk to service users and staff. Some staff expressed concern about the difficulties in supporting certain service users. They were not confident that they have been given enough training and support to manage some situations. They also felt that, although guidelines for managing behavioural issues are in place, there can be inconsistent responses, depending on which staff are present. Some training in how to manage service users with challenging behaviour has been provided. The training co-ordinator also said that Leonard Cheshire is working on developing its own approach. Records included an incident where an assault on a staff member had not been reported or followed up effectively. This was discussed with the manager during feedback, and she has since made further investigations. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 25 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Quality in this outcome area is adequate, but improving. This judgement has been made using available evidence including a visit to this service. Not all parts of the home are comfortable, clean and suitably equipped to meet the needs of service users. But actions are being taken which should help to improve quality in this area. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 26 EVIDENCE: Greathouse dates from various periods. The original section has some attractive features and the property is listed. Although not an ideal building, it has been adapted and maintained to meet the needs of service users. The home is set in its own substantial grounds, with a garden that service users can access. Many rooms also offer views of the surrounding countryside. The building has accommodation for service users on the ground and first floors. The second floor is used to accommodate overseas volunteers. Various redecoration has taken place, and was continuing at the time of this inspection, to enhance the appearance of the home. This includes repainting a number of areas and providing new floor coverings in several corridors. Some service users are pleased that they have had improvements in their bedrooms, including new flooring and furniture. Work has taken place on both floors of the building that are accessed by service users. Service users commented positively on the changes to the home. They are also involved in planning for changing a communal space in one hallway, known as the ‘circulation area’. This is to be made into a coffee bar. Service users spoke enthusiastically about this development and are clearly looking forward to it. The intention is that service users will be directly involved in operating this facility, which will provide a new social hub. The home has a hotel services team leader, with overall responsibility for premises issues. There are two part-time maintenance staff, who cover five days per week between them. In the longer term, the aim is to reprovide the service for users. It is likely that new purpose built accommodation may be provided. This is in keeping with other projects undertaken by Cheshire Homes elsewhere. Specialist adaptations and equipment have been provided throughout the home. These are based on the assessed needs of service users. There are four vehicles used by Greathouse. All are suitable for wheelchair users. Staff receive training in the use of the various equipment, such as hoists. This is usually given by the home’s physiotherapist. Bathroom facilities were in the process of being changed at the time of the inspection. This was creating some short term difficulties. One bathroom remained in use. However, staff said that it was not suitable for all service users. As previously reported, some service users were receiving only bed baths until the current works are completed. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 27 One bath has been relocated upstairs, but had not yet been put back into use. There are significant concerns about how this room could now be used. The bath has been installed, but further work is needed on the room to make it safely accessible. Space needs to be available for service users and supporting staff. There also needs to be sufficient space for a drying table. Otherwise service users would have to go back downstairs covered only in towels, which would be inappropriate for their dignity, comfort and safety. Another ground floor bathroom is to be converted into a ‘wet room’ style shower facility. This will meet the expressed wish of some service users to have such an option. However, some staff raised concern about the proposed arrangements to support service users in this room. They also felt that only a limited number of service users will benefit from it. Greathouse employs its own housekeeping staff. They undertake National Vocational Qualifications in relevant topics. There was also a review of staff resources under the previous manager, which transferred some hours from housekeeping to care. This means that care staff must now take on more cleaning tasks, including being mainly responsible for the cleaning of service users’ rooms. The aim is to promote service user involvement as well. Some service users and staff were critical of recent standards of cleanliness in the home. Various areas were mentioned as being of particular concern, although when inspected most of these were in satisfactory condition. However, carpets in the corridor of the ground floor extension, and in some of its bedrooms, were heavily stained. Staff reported that repeated attempts at deep cleaning have failed to remove these marks. An unpleasant odour was also very noticeable in one service user’s bedroom, and was present on both days of the inspection. An outbreak of infection occurred at the home in December 2006. Appropriate steps were taken to report this to relevant agencies and to minimise the spread of the infection. The service has procedures and systems for managing infection control risks, including information about what to do if any individual service user has a known infection. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 28 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. EVIDENCE: Because the home is registered to provide care with nursing, there is always at least one registered nurse on duty. They are supported by seven carers in the morning, five in the afternoon, and three at night. An extra carer may be provided on some mornings. If there are any shortages from within the home’s own staff team, cover is maintained by relief or agency workers. Where possible the home aims to have two nurses on duty for daytime shifts, especially in the mornings. This means that one can focus on administrative tasks, and be responsible for medication. The other is able to work alongside carers to deliver support to service users. This practice is felt to improve the quality of care and to strengthen the links between nurses and carers. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 29 Since June 2005, three staff work waking shifts at nights. Previously, one person had slept in. The change is felt to have been beneficial in promoting service users’ choice and safety. Deployment of staff is based on a group system, with service users divided into three groups, one of which is people in receipt of residential care only. A review is being conducted to ensure that the three groups represent a fair division of the workload amongst staff on duty. The home also employs a physiotherapist and staff for day care, activities, catering, housekeeping, administration and maintenance. Some volunteers also assist with certain tasks. Steps are taken to promote communication between the various departments. The heads of each meet together regularly. Staff had differing views on the suitability of staffing levels and the quality of teamwork. Some were very positive about this aspect of the home and felt it was a key element in their job satisfaction. Others were critical and felt that there are unresolved problems within the team. Most did say that there were senior colleagues who they found supportive and receptive to their concerns. The manager was aware of the differing perspectives. The records of two recently appointed staff were sampled. These show that recruitment practices are in line with all statutory requirements. The necessary checks are carried out and completed before someone takes up post. Service users also participate in the selection process, with some of them sitting on interview panels. Each new member of staff has a period of induction. This includes a three day course covering various key topics, which takes place before they start working with service users. Greathouse links with other Leonard Cheshire services in the region, so that the induction courses are put on every month, meaning that each new starter is able to attend one soon after joining the organisation. Staff are issued with an induction folder and must work through this. The subjects covered include health and safety, food hygiene, infection control and disability and the law. There are targets for completion at six weeks, and again at three months. These are linked to the national training standards for the social care workforce, and provide a pathway into National Vocational Qualifications (NVQs) in care. Greathouse has achieved the minimum target of 50 of care staff to have an NVQ, at Level 2 or above, and is now hoping to move significantly above this. Sixteen staff have completed NVQs at Level 2 or 3. Other staff are working towards the award, and more are due to register for it shortly. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 30 Once initial induction is complete, each staff member has a development portfolio and a personal development plan. This highlights their own training needs and is regularly reviewed with them at individual supervision meetings. Nursing staff have a personal responsibility to update their knowledge and skills, to enable them to maintain their nursing registration, which gives them the right to practise. Leonard Cheshire has developed packs which nurses can use for self-directed learning which will assist with this. Topics include nutrition and multiple sclerosis. Nurses also attend training to update and extend their knowledge on topics which are relevant to working with the home’s service users. These include continence and palliative care. The home has a training co-ordinator, who covers Greathouse and another Leonard Cheshire home in the same region. Networking with the organisation’s other homes helps to promote efficiency in the timing of courses and to ensure good attendance levels. Staff attend a range of training. In addition to NVQ studies, this includes topics such as medication, challenging behaviour, and relationships and boundaries. In-house sessions are held every fortnight with talks on relevant topics. Training opportunities are publicised on noticeboards in the home, and staff are welcome to put themselves forward for any relevant courses. Records show the training that all staff have undertaken, and when refresher sessions are due. The individual training records for all staff can be crossreferenced with the list of required topics, to help with overall planning of training needed for the home. This is usually done for three months at a time, depending on issues like staff turnover. Staff commented positively about the training they receive. This included both recently employed and longer term staff. One described the training opportunities as “superb”. As at the last inspection, staff felt they need more knowledge and skills to support service users with learning disabilities and those with challenging behaviours. Plans are in place to provide suitable training, but the training coordinator reported that it has been difficult to find appropriate courses. Service users can also attend training on certain topics, such as health and safety, relationships, and information technology. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 31 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures would benefit from further review to ensure that service users, staff and others all have more frequent opportunities to contribute comments and raise concerns. Service users’ health and safety are protected by the systems in place. EVIDENCE: The registered manager for Greathouse is Mrs Joyce Amor. She took up her post in November 2006 and completed the process of registration in August 2007. Mrs Amor has previously managed other services for Leonard Cheshire. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 32 There have also been changes in other senior and administrative posts since the last inspection. Various heads of department lead on specific areas, including day care and activities, hotel services and volunteer co-ordination. There are weekly meetings of senior staff, to discuss any issues and steps to address them. The home’s administrator is responsible for overseeing several aspects of the service. This includes financial arrangements, including the systems for management of any money held on behalf of service users. Storage is secure, with access only to senior staff, and suitable records and receipts are kept. Service users also have lockable storage within their own rooms. The administrator is also responsible for the maintenance of personnel files. The service completed an Annual Quality Assurance Assessment (the AQAA) for us as part of this key inspection. This demonstrates that they have audited themselves, identifying their own strengths, areas of improvement and future development targets. Future plans for the service include a strong focus on greater service user involvement, in areas such as care planning, staff recruitment and developing the quality of the home environment. Several quality audits are carried out. Consultation also takes place with a range of people, by various methods. For instance, residents’ meetings take place every month. Surveys have also been carried out with service users, and with staff, on topics such as the role of the keyworker. Action plans have been drawn up in response to findings from these sources. Working parties have also been set up to develop ideas for improvements on certain topics, such as menus and fire safety. The groups involve a mixture of service users and staff, from various roles and levels of seniority. Meetings take place every two months. At a national level, the Leonard Cheshire organisation has devised a self-audit tool. This is applied to each service annually, with different areas being focused on over the course of the year. The audit is conducted by people from within Leonard Cheshire, but independent of Greathouse. Comments from service users and staff showed a wide range of views about the quality of service being provided at Greathouse. Some were very satisfied, and felt that recent changes have brought improvements. Others raised significant concerns and felt that standards at the home have declined. The variety and strength of views were not reflected in the service’s quality assurance process. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 33 A range of systems are in place for checking that health and safety is maintained throughout the service. This area is overseen by the hotel services team leader. The home employs its own maintenance staff, who can attend to a range of general tasks around the house and grounds. External contractors are used for other works as necessary. Risk assessments are in place for a range of safe working practice issues. Staff also receive regular training in relevant topics. This includes practical demonstrations in the use of any new products or equipment. Records relating to fire safety checks, practices and instruction were noted as being carried out and up to date. In response to the new smoking legislation, the home is providing an area in the garden as a designated smoking area. All service users who smoke have been reminded of the rules and asked to enter into agreements about their own behaviour if necessary. Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 35 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Each service user’s plan of care and associated records must set out the actions to be taken to meet all their needs, and must be updated to reflect changes. All service users with assessed needs for support regarding diet and nutrition must have suitable care guidance in place. There must be clear guidance on the criteria for administration of medication prescribed on an ‘as required’ basis. (Original timescale of 24/02/06 partly met) Support for service users who may present challenges must include suitable systems to minimise risks to staff, and to enable staff to respond effectively if incidents occur. All floor coverings must be kept clean and in good condition. Timescale for action 31/10/07 2 YA17 15 31/10/07 3 YA20 13-2 17-1a Sch3-3m 31/10/07 4 YA23 12-5 31/10/07 5 6 YA24 YA27 23-2d 23-2j 31/10/07 There must be suitable numbers 31/12/07 of bathroom and shower facilities DS0000015913.V340592.R01.S.doc Version 5.2 Page 36 Greathouse Cheshire Home to meet the needs of service users. 7 YA30 16-2k All parts of the home must be kept free of offensive odours. 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA12 Good Practice Recommendations The service should continue with the planned development of activities and outings for service users, to ensure an appropriate range of choices for each individual. The service should continue with its review of mealtime arrangements to try and resolve the concerns expressed by some service users and staff. On completion of the work on bathrooms, there should be a review of personal care arrangements to ensure that the needs and preferences of all service users are taken into account. Service users, staff and others should be given more frequent opportunities to contribute comments and raise concerns, so that the quality assurance process for the home is informed by their views. 2 YA17 3 YA18 4 YA39 Greathouse Cheshire Home DS0000015913.V340592.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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