Inspection on 20/02/09 for Herbert House

This inspection was carried out on 20th February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Herbert House 06/03/07

Herbert House 30/01/06

Herbert House 24/08/05

Herbert House 26/11/04

Herbert House 27/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Herbert House Christie Miller Road Salisbury Wiltshire SP2 7EN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Roy Gregory     Date: 0 5 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 35 Information about the care home Name of care home: Address: Herbert House Christie Miller Road Salisbury Wiltshire SP2 7EN 01722413244 01722416096 marion.yeates@rethink.org 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) : Rethink care home 15 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home 15 Herbert House is a care home offering accommodation and support for up to fifteen people who have recovery needs associated with mental health. The home is run by Rethink, a national mental health organisation, in premises leased from a housing association. It is located in a residential area of Salisbury. Some shops and other amenities are nearby, and the area has good public transport to the city centre. Herbert house offers single room, en suite accommodation over two floors, and a semiindependent flat for two people. Shared spaces include two sitting rooms, a large kitchen and dining room, a conservatory and small laundry room. Most of the home is light and airy. There is a grassed area with mature trees at the rear of the house, and a parking area at the front. Weekly fees in March 2009 ranged from £682.50 for people from Wiltshire to £700 for people from elsewhere. Care Homes for Adults (18-65 years) Page 4 of 35 Care Homes for Adults (18-65 years) Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: We visited Herbert House unannounced on Friday 20th February 2009, between 9:45 a.m. and 5:05 p.m., and returned by arrangement on Thursday 5th March between 10:00 a.m. and 4:30 p.m. During these visits we spoke privately in depth with three people who were living at the home, and met with most other residents at some point. We looked at all the shared areas of the home and the offices, and were able to see a currently unoccupied private room. It was also possible to visit the semi-independent flat, by agreement with one of the occupants who was in at the time. We met and talked with five members of staff, as well as Marion Yeates, the registered manager, who was not at the home on the first visit but was available throughout the second day. We sent out survey questionnaires some time prior to the inspection and Care Homes for Adults (18-65 years) Page 6 of 35 received replies from eight people living at the home, three members of staff, and two community psychiatric nurses. During the visits we looked in detail at a range of documentation. This included preadmission assessments, risk assessments, recovery plans, incident records and daily records of care. We looked at how medicines were stored and handled, and how administration of medicines was recorded. Interactions between staff and residents were observed. We looked at the homes complaints record, and staff records concerning recruitment, training and supervision. What the care home does well: The home manager had regular meetings with the local community mental health team (CMHT), through which she maintained awareness of potential applicants to the service. Link nurses at the CMHT confirmed through our survey that they had a close working relationship with the home, and high regard for the ways in which the home assisted people through recovery. On receipt of a full application, an assessment form was completed by the home. This was based mainly on one or more trial stays by the person concerned. We saw that, for a person considered as an emergency admission, the whole process of application form, supporting documentation, trial stay and homes assessment was still carried out in full. People were given a contract agreement at admission that set out the terms and conditions of their stay, and what they could expect of the service. They also had a licence agreement with the housing association that provided the property. In survey forms returned to us, six out of eight residents considered they were provided with good information about the home before they moved in. A person told us they felt fully involved in their admission. They had visited for meals and stayed overnight, before agreeing to accept a place. They saw the placement as an essential part of their progression towards independent living following a long time spent in hospital. The basis for working with each persons needs was a recovery plan. A person told us their recovery plan was important as a way of putting their needs in an order they could work on. They could itemise the components of their recovery plan, and recognise progress they had made as a result of working to the plan. Each resident had a key to the front door and to their own room. People got up and went to bed when they liked. We saw that people came and went from the home as they chose. People were asked to sign agreement to risk assessments, to show they understood their purpose and the nature of interventions that could be used to manage risks. Risk assessments seen were of good quality. As people progress to more independent living, by gaining confidence and addressing issues identified in individual recovery plans, there are opportunities for more selfcatering and thus for opting out of some aspects of group living. We saw that people could easily sustain important relationships and family contacts, at the home and outside. Residents told us the weekly house meetings tended to concentrate on meal arrangements, deciding menus, who would cook on different days and who would go shopping. People said there was no problem if individuals wanted to have an alternative meal due to different tastes or preferences. All permanent staff had received external training in understanding and handling medications. There was a risk assessment concerning use of medications for each person living in the home. These showed the aims being sought by agreeing varying degrees of risk, and the positive and negative aspects of the ways of managing identified risks. People signed their risk assessments. All residents that returned surveys to us said they knew where and how to address concerns or complaints if they were unhappy about any aspect of the service. A person told us that during their stay they had three different key workers, each of whom had Care Homes for Adults (18-65 years) Page 8 of 35 been approachable and helpful in addressing concerns. The person knew how to make a formal complaint if informal measures proved insufficient. Records showed how complaints that had been received led to actions taken to meet the needs of complainants. Rethinks complaints policy states that complaints are welcomed as a means of improving services offered. Incidents arising in the home were well reported and recorded. For individual residents there was incident management guidance to staff on recognition of potential trigger points and how to respond effectively to behaviours that might make themselves or others unsafe. The guidance showed at what points staff should consult with more senior staff. All incidents were given an identifying number and were followed by a written-up investigation. Staff told us they greatly valued training they had recently received on working with testing behaviours. The home presented as a pleasant environment, with many homely touches. Sitting rooms were cosy and obviously lived in. People we spoke with were satisfied with their accommodation. All staff spoke of a strong team ethos in the home, or commented on this in surveys returned to us. We saw that people living in the home had significant time with their key workers. Records showed staff received formal individual supervision at least monthly. A set format was followed for supervision, resulting in a high quality process including detailed discussions of residents needs and staff interventions, particularly with regard to key working. Induction and training were planned and tracked. Staff received training specific to working with people with mental health difficulties. Recruitment records showed that when a new staff member was recruited, all the required checks on their background were completed before they were able to commence working in the home. After induction, staff progressed to NVQ (National Vocational Qualifications). What has improved since the last inspection? What they could do better: The prospective resident assessment form was headed to be completed by staff and the prospective resident, but had no place for the prospective resident to sign. The assessment form could ask the person being assessed for their views on what they valued about their trial stay, and what they may have found difficult, to ensure their perspective informed the development of initial care plans. Recovery plans would be more person-centred if always written in the first person, and if it was clear to residents and staff how they are to be evaluated. Some residents wished staff did more to secure peoples attendance at weekly house meetings, as they were not achieving anything like full attendance. The meetings had essential housekeeping matters to address and otherwise did not seem to provoke much discussion about, for example, staffing levels or activities. Minutes were brief. It would be helpful to encourage participation by indicating who would take responsibility Care Homes for Adults (18-65 years) Page 9 of 35 for any follow-up needed, and distributing printed minutes to each person. People might be more attracted to attending the meetings if some intended subject matter were decided in advance. Staff and residents considered there were too many times when there were just two staff on duty. Some staff said they would like to be able to offer simple walks out, or going with someone into town for a coffee, as a way of boosting confidence to interact with the community. When there were only two staff in the home, however, it was unsafe to leave one as the only staff available to the rest of the resident group. Tasks such as checking in medications received at the home were very time-consuming, and staff also needed time to keep full and accurate records of observations and recovery work undertaken with people. Some residents would like staff to have more time for one-to-one engagement on recovery work, or to promote community access. Staff were directed always to record use of as needed medicines in peoples daily notes, and did so. However, a brief explanation should also be entered on the reverse of the Medicines Administration Record, to give an audit trail of the medicine in one document, and for ease of reference for subsequent staff undertaking medicine administration. Medicines were not stored in a wall-mounted cabinet, so we have made a requirement that one must be installed. People living in the home had a rota that provided two people daily to assist staff with cleaning in communal areas. Priorities were decided each day. We found some communal areas were not very clean and posed a risk to good hygiene. This was because some cleaning tasks could be seen as above and beyond what residents and staff could be reasonably expected to take on, suggesting some designated cleaning staff hours would be of benefit. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 35 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed in detail, with the assistance of trial stays at the home, before they are offered a placement, so the home is able to offer an individualised service and people can make an informed choice about moving to the home. Evidence: Most people who move into Herbert House do so from hospital, but some people have lived in the community immediately before moving in. If a person living in the home relapses in their condition and needs to return to hospital, the practice is to keep their bed open so that they can return when assessed as likely to benefit from living in the home again. Should a person applying for a place decide against admission, the homes policy is that this does not prejudice any future application they may make. The home manager had regular meetings with the local community mental health team (CMHT), through which she maintained awareness of potential applicants to the service. There was a link nurse at CMHT, who confirmed they had a close working relationship with the home. Care Homes for Adults (18-65 years) Page 12 of 35 Evidence: The home used an application form for people wishing to be considered for a placement. The form stressed that the person must be able to work towards attaining an independent lifestyle, with support. It also made plain the expectations that living in the home would incorporate taking responsibility for ones own behaviour, and considering the needs and feelings of other residents. The application could be considered only when accompanied by evidence of work accomplished and planned by the persons consultant psychiatrist, social worker and community nursing support. Risk assessments and the persons CPA care plan were also required. On receipt of a full application, an assessment form was completed by the home. This was based mainly on one or more trial stays by the person concerned. We saw that, for a person considered as an emergency admission, the whole process of application form, supporting documentation, trial stay and homes assessment was carried out in full. Whilst the homes assessment form was wide-ranging, we considered it should have included specific comment on how the person appeared to adjust to community living, since relationships with staff and other residents are important to the success of the placement. The form could also ask the person being assessed for their views on what they valued about their trial stay, and what they may have found difficult, to ensure their perspective informed the development of initial care plans. The prospective resident assessment form was headed to be completed by staff and the prospective resident, but had no place for the prospective resident to sign. Staff were guided by an admissions folder to ensure all steps were followed for prospective and new residents. People were given a contract agreement at admission that set out the terms and conditions of their stay, and what they could expect of the service. They also had a licence agreement with the housing association that provided the property. In survey forms returned to us, six out of eight residents considered they were provided with good information about the home before they moved in, one felt they were in a position of little choice about accepting a place. A person told us they felt fully involved in their admission. They had visited for meals and stayed overnight, before agreeing to accept a place. They saw the placement as an essential part of their progression towards independent living following a long time spent in hospital. Another person did not see it as a real choice, to either stay in hospital or move to the home, but they agreed to the move only after a trial stay. Care Homes for Adults (18-65 years) Page 13 of 35 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to work towards recovery goals in a planned way. They make decisions about how they wish to live their lives, whilst risks are identified and managed. Evidence: The basis for working with each persons needs was a recovery plan. These detailed peoples needs in respect of mental and physical health, daily living skills, selffulfilment and moving-on options. Guidance to staff was that, whilst the prescribed headings must be used, others could be added, and it was recognised that there could be considerable overlap between the various sections. Whilst the plans were all clearly based on direct work with the people they related to, only one that we looked at was written in the first person and fully explained the context in which different decisions had been made. The approach used in this instance provided a good model for others to follow. Some members of staff and residents thought the variable nature of recovery plans reflected current pressures on staff time. Care Homes for Adults (18-65 years) Page 14 of 35 Evidence: A resident said they were awaiting completion of their recovery plan. They thought at admission that staff, particularly their designated key worker, would be more proactive in working with them. However, we could see that individual issues for the same person had required such attention from the staff team that they had diverted attention away from longer-term planning. A different person told us their recovery plan was important as a way of putting their needs in an order they could work on. They could itemise the components of their recovery plan, and recognise progress they had made as a result of working to the plan. Another resident said they had agreed the contents of their recovery plan and their key worker was central to their placement. Recovery plans were intended as working documents, with residents meeting with their key workers to assess progress and address difficulties arising. This gave more continuity than reliance on the less frequent formal reviews of peoples placements. For one person, an amended recovery plan had been agreed with them within three weeks of the first. Whilst this demonstrated active support planning, it would be helpful to subsequent review if the forms used had a column for recording evaluation. This would have shown clearly what was the basis of the amendments to the original plan. People were encouraged to use their personal accommodation as private space, which others entered only with permission. Circumstances in which this would not apply were specific in the licence agreement. People got up and went to bed when they liked. We saw that people came and went from the home as they chose, subject to informing staff for safety reasons. Each resident had a key to the front door and to their own room. Agreement was sought on participation in activities such as cooking and shopping for the larger group, and cleaning in communal areas. In particular, people were asked to agree at admission to join in weekly house meetings, where they could take joint responsibility for such decisions. Individual recovery planning aimed to support people to develop increasing independence, and thus reduced participation in group catering in particular. However, the house meetings also maintained some emphasis on mutual responsibilities as neighbours. For example, they challenged each other about noise levels and participation in chore rotas. Some residents wished staff were more diligent in securing peoples attendance at house meetings, given the initial expectation of participation, as they were not achieving anything like full attendance. There was a range of risk assessments in place for each resident. People were asked to sign agreement to risk assessments, to show they understood their purpose and the nature of interventions that could be used to manage risks. Risk assessments seen were of good quality. However, for a person relatively recently admitted, a number of Care Homes for Adults (18-65 years) Page 15 of 35 Evidence: evident areas of risk had been identified, but a management plan was still in preparation. This left staff vulnerable, and underlined the importance of completing a risk management plan quickly, even if on an interim basis at first. Staff monitored peoples responses to life in the home by way of daily notes. These were objective and gave a good picture of peoples wellbeing and how they were spending their time, without being intrusive. This process facilitated reviews of recovery plans and risk assessments. Care Homes for Adults (18-65 years) Page 16 of 35 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have some opportunities to engage with the local community, although staff are not always available to give the extra support they may need. People are able to develop skills and increasing independence in their daily lives. Significant relationships are encouraged and facilitated. People have a healthy diet and there is flexibility in how and when they have meals and snacks, together with the social cohesion of community living. Evidence: People take responsibility for their own rooms and lifestyle choices when they begin their period of living at Herbert House, but at that stage they join with others in arrangements for meals and shared tasks within the home. As they progress to more independent living, by gaining confidence and addressing issues identified in individual recovery plans, there are opportunities for more self-catering and thus for opting out Care Homes for Adults (18-65 years) Page 17 of 35 Evidence: of some aspects of group living. Two places in the home are in a flat that is almost independent of the home, although with regular support still available. People obviously vary in the degree to which they like to join socially with others or to be alone. There were two sitting rooms where people could relax together or alone, whilst the kitchen and dining room provided a place where people met when getting drinks and snacks. We saw that people could easily sustain important relationships and family contacts, at the home and outside. For one person, staff had assisted in trying to re-form a poor family relationship. Some people spent significant time away with families, for example at weekends. Many people living in the home had computers in their rooms, with internet access, as well as audio equipment and televisions. There was also a computer for use by anyone, in the larger sitting room, although there were reportedly problems of it getting clogged. Most people chose to eat as a group for the evening meal, including staff on duty. Residents told us the weekly house meetings tended to concentrate on meal arrangements, deciding menus, who would cook on different days and who would go shopping. People said there was no problem if individuals wanted to have an alternative meal due to different tastes or preferences. An entry in a persons daily notes noted they had missed a meal as they were on a lengthy phone call at the time, so they cooked (themselves) something after. Twice a week, two residents (the people involved differing each time) would go out together to undertake the bulk shopping for the house. They were trusted with cash, and were encouraged to make the trip a social one as well, having a drink in town and getting a taxi back. The residents undertaking this changed each time. Some residents received self-catering money from the house budget, so they could acquire confidence in increasingly catering for themselves. They signed up to an agreement about accepting some staff monitoring, for example to ensure maintenance of a healthy diet, and keeping personal supplies separate from food bought for the main group. They were asked to keep cooking equipment clean and to accept monthly review of how successfully their self-catering arrangement was working. Some people living at the home said that they looked to staff to arrange or encourage some activities, but limited staff availability meant things like impromptu picnics were unlikely to happen. Others were less inclined to want organised group activities, but also saw staff availability as a limiting factor in one-to-one engagement. One person had been supported in some leisure activities by an outreach worker, and would have liked it if home staff could have sustained this. Some staff said they would like to be able to offer simple walks out, or going with someone into town for a coffee, as a way of boosting confidence to interact with the community. When there were only two staff Care Homes for Adults (18-65 years) Page 18 of 35 Evidence: in the home, however, it was unsafe to leave one as the only staff available to the rest of the resident group. The staff group were able to help access information about leisure and educational resources in the Salisbury area. Some people in the home had voluntary jobs. None were currently on college courses at the time of our visit, but college attendance was encouraged and facilitated where people wanted to pursue personal development that way. We saw a persons recovery plan where college courses had been identified as a potential way of following up personal interests. Another person told us they felt they did not do enough with their time, but saw it as their personal issue rather than the homes. Care Homes for Adults (18-65 years) Page 19 of 35 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The nature of staff support, together with established links with physical and mental health professionals, ensures that health needs are met. Staff are competent to handle and administer medicines, whilst helping people work towards taking responsibility for their own medications, but central storage of medicines is unsafe and some recording of administration could be improved. Evidence: People living at Herbert house do not require assistance to personal care. People are supported as necessary to make and keep appointments with doctors, opticians, psychiatrists and community psychiatric nurses when required, and records are kept to track these. All residents attend mental health reviews on a regular basis and this is then reflected in the care plan. Staff had a very full handover of information about residents wellbeing between outgoing and incoming shifts. One resident had spent intermittent periods in general hospital. Daily records had been maintained in the home about information obtained from the hospital, and observations of the person when visited by staff. Care Homes for Adults (18-65 years) Page 20 of 35 Evidence: The CMHT link nurse confirmed individual health care needs, including peoples medications, were reviewed on a regular basis. Records provided much evidence to support this. Support to manage medicines was seen as a significant issue for many people. The service aimed to provide the skills so when people moved on they could manage this aspect of their care. People were at various stages of self-administration. Some people attended at the office to receive medication. Some had from two days to a weeks worth of medication at a time, to take themselves. Such arrangements were monitored closely. For example, a person had become more unwell and full responsibility for their medicine regime had been taken back by the staff. Previously, the person had been organising and collecting their own repeat prescriptions. Medicines were delivered to the home within a monitored dosage system. Central storage of medicines was unsafe, relying on a filing cabinet, albeit in a locked room used for no other purpose. Medicines are required by law to be stored in a bespoke medicines cabinet, attached to a wall. For self-administration this was not a problem, as all individual rooms had lockable wall-mounted medicines cabinets. People signed a form to show agreement to store self-administered medicines in their cabinet, and accepting staff might make random checks. A person living at the home said they felt in control of their use of medicines. They were pleased that their compliance with accepting administration on time was a measure by which they could be trusted to move on to limited self-administration. Where staff administered medicines, this was recorded in medicines administration records (MAR) charts. These were well kept. The recording of any refusals by people to accept medication was improved, in line with our recommendation from the previous inspection. Any additional handwritten entries in the MAR were counter-signed by a second member of staff to help ensure accuracy. In addition to MAR charts were individual procedures for as needed medications. These indicated safe maximum dosages and minimum time gaps between administrations, as well as setting out the purpose of the medicine. However, a space to show what the approach and response should be from all staff, to be consistent was not used in most cases, and this would be useful guidance. The as needed procedures were always signed by the individuals to whom they related, to show understanding and consent. Staff were clear that people needed to be in control of use of as needed medicines, telling staff when they recognised a need and wanted to take such a medicine. In one instance, however, it was evident that staff would have to take initiative in prompting use of a particular medicine, and in deciding which of two alternative dosages to give. Written guidance in this case was insufficient. Staff were directed always to record use of as needed medicines in peoples daily notes, and did so. However, a brief explanation should also be entered on the reverse Care Homes for Adults (18-65 years) Page 21 of 35 Evidence: of the MAR, to give an audit trail of the medicine in one document, and for ease of reference for subsequent staff undertaking medicine administration. As good practice, there was a risk assessment concerning use of medications for each person living in the home. These showed the aims being sought by agreeing varying degrees of risk, and the positive and negative aspects of the ways of managing identified risks. People signed their risk assessments. All permanent staff had received external (ASET) training in understanding and handling medications during 2008, and staff recruited more recently were now undertaking this training; one member of staff received a tutor visit during our time at the home. The task of checking in medicines received necessarily involved two trained members of staff, which presented time management issues when staff were low in numbers, or augmented by bank staff who may not have had medications training. Checking in or out medicines that people needed on absences from the home presented similar staffing considerations. There was an internal recorded review system for regularly checking the competency of staff to administer medicines. Care Homes for Adults (18-65 years) Page 22 of 35 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to voice concerns, and there is a sound procedure for addressing complaints. Staff have been trained to keep people safe and they know how to respond to any concern about possible abuse or self-harm. Evidence: All residents that returned surveys to us said they knew where and how to address concerns or complaints if they were unhappy about any aspect of the service. Complaints and compliments leaflets and cards were made available prominently on notice boards in the home, as part of Rethinks complaints policy. One person living at the home was currently making use of external advocacy support. We saw that a person had been invited to raise a particular issue as a formal complaint, but they confirmed they preferred to continue seeking a resolution through the house meetings and their personal recovery work. A person said that during their stay they had three different key workers, each of whom had been approachable and helpful in addressing concerns. The person knew how to make a formal complaint if informal measures proved insufficient. The homes complaints record showed six complaints had been received since the previous inspection, of which four had been in 2007. They included complaints from residents, neighbours and relatives. For each it was possible to see how the complaint had been received and progressed, always within shorttimescales. The records showed Care Homes for Adults (18-65 years) Page 23 of 35 Evidence: how complaints led to actions taken to meet the needs of complainants. Rethinks complaints policy states that complaints are welcomed as a means of improving services offered. Incidents arising in the home were well reported and recorded. For individual residents there was incident management guidance to staff on recognition of potential trigger points and how to respond effectively to behaviours that might make themselves or others unsafe. The guidance showed at what points staff should consult with more senior staff. All incidents were given an identifying number and were followed by a written-up investigation. Staff told us they greatly valued training they had recently received on working with testing behaviours. Members of staff confirmed they each received the No Secrets brief guidance to local inter-agency safeguarding procedures. Training in abuse awareness and reporting was delivered as part of induction and within National Vocational Qualification training. Staff we spoke to expected this to be revisited every two years, but there was no evidence of planning to ensure this standard was met. Rethink had recently introduced a new policy about staff handling peoples personal monies. All residents completed forms about how they preferred to manage personal monies. When we visited, one person was choosing to make use of safe keeping of money by the home. There was a procedure for daily checks to ensure the accuracy of records of safekeeping. Rethink managers carrying out internal unannounced visits always checked adherence to company policies on complaints, medicines and handling monies, and they reviewed accidents and incidents that had occurred. Care Homes for Adults (18-65 years) Page 24 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Herbert House provides a homely, comfortable and well-maintained environment, let down by some shortfalls in cleanliness, which may need more attention than residents and staff can reasonably give. Evidence: The home presented as a pleasant environment, with many homely touches. Sitting rooms were cosy and obviously lived in. There was also a sunny conservatory, although it would benefit from a facelift. Corridors and the stairway were wide and the bedroom areas had a hotel feel. All bedrooms had en suite showers and toilets. A vacant room seen was light and airy. People we spoke with were satisfied with their accommodation. The semi-independent flat had its own external entrance as well as an internal connection with the main home. It had two bedrooms, whose occupants shared a kitchen, bathroom and sitting room. Three offices gave sufficient space for administrative purposes and private space for interviewing. The outside grounds were given over mainly to grass and mature trees, security being provided by fencing and movement-sensitive lighting. There was evident prompt attention to maintenance issues inside and out. The front garden was recently landscaped. People living in the home had a rota that provided two people daily to assist staff with Care Homes for Adults (18-65 years) Page 25 of 35 Evidence: cleaning in communal areas. Priorities were decided each day. Arrangements were being made to provide infection control training to all staff. This could usefully be made an option for residents too. We found that some areas of the home were not cleaned to a good standard. A stale odour in one corridor seemed to come from the carpet. The laundry room, for which residents had allocated time slots to ensure equal sharing, was excessively dusty. High level cleaning was being missed in the laundry and kitchen. A shared toilet in a downstairs corridor had marks on the wall that needed cleaning off. These areas represented high risks to infection control in a shared living environment. It could be seen as above and beyond normal domestic cleaning to tackle these cleaning needs, suggesting some designated cleaning staff hours would be of benefit. The job description for existing staff did not specifically require domestic work, other than giving support with housework as an element in assisting the general running of the service. There was a bathroom that could be used by any residents, although it had little if any use as all had en suite showers. However, it was in need of attention to bring it to a standard whereby it could be kept hygienically clean. In particular, a wide and dirty gap between the flooring and base of the bath needed to be re-sealed. There was also a damp problem in that area of the home, which Marion Yeates confirmed was being actively addressed by the housing association. Care Homes for Adults (18-65 years) Page 26 of 35 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. Provision of induction and relevant training, together with regular good quality supervision, ensures people are supported by competent and motivated staff. Recruitment practices include vetting to make sure people unsuitable for a caring role are not employed. The number of staff on duty does not always allow for the amount of support that people living in the home would like. Evidence: The staffing rota provided for two support staff (who were designated as community mental health workers) from morning to mid afternoon, when they handed over to two staff to cover late afternoon and evening. The manager or other senior staff provided on-call back-up if not actually on duty in addition to the rota. Two staff provided sleeping-in cover at night, one upstairs and one down. Staff we spoke to at each visit saw themselves as under unreasonable pressure. One said, I can be chairing a review meeting one minute and cleaning toilets the next. All staff spoken to said they would like to be able to provide more one-to-one interaction with residents, both planned and spontaneously. They felt their administrative duties had increased. We saw that people living in the home made a lot of contact with staff by going to the office and engaging with them in conversation. Staff demonstrated patience and understanding, often whilst simultaneously engaged on other tasks. Sometimes they closed the office to Care Homes for Adults (18-65 years) Page 27 of 35 Evidence: callers so confidential work could be completed. Staff and some residents felt the restricted staff availability impacted on one-to-one recovery work and community rehabilitation. During one of our visits, an incident between two residents resulted in one of them leaving the home unexpectedly. The two staff on duty were concerned for the persons well being but were undecided whether one of them could be spared from the home to follow the person to offer support. The issue of staff time needed for checking medications has been noted elsewhere in this report. Marion Yeates said different factors had combined to limit staff availability during the months preceding the inspection. She was confident that staffing would be increased in the financial year commencing April 2009. There was provision for an additional afternoon shift. One resident said it was the staff that were particularly good about this home - always available, its made a positive difference to have been here. Despite their concerns, all staff spoke of a strong team ethos in the home, or commented on this in surveys returned to us. We saw that people living in the home had significant time with their key workers. Records showed staff received formal individual supervision at least monthly. A set format was followed for supervision, resulting in a high quality process including detailed discussions of residents needs and staff interventions, particularly with regard to key working. Induction and training were planned and tracked. Each supervision included setting a date for the following meeting, to ensure continuity. Identified issues were always followed up from one meeting to the next. A person recruited relatively recently said they valued supervision greatly. Rethink employed a regional staff development worker, who had an office base at Herbert House. They organised and booked training courses for staff. All staff were to benefit from a course in recovery planning during 2009. It was Marion Yeates responsibility to identify the training needs of staff in the home, including when refresher training was due for mandatory training courses. She acknowledged that training needs spreadsheets were out of date. In particular, there was no evidence that abuse awareness training was planned to ensure staff received it at least twoyearly. However, individual training records were good, based on Rethinks knowledge and skills framework, which was introduced in 2008 to make professional development a consistent and ongoing process for all staff. These records, and talking with staff, confirmed that training was an ongoing part of working at the home. Staff received training specific to working with people with mental health difficulties. The supervision folder for a person recruited showed how their initial six months probationary period had been appraised. They had been able to spend a lot of time as Care Homes for Adults (18-65 years) Page 28 of 35 Evidence: an extra person on shift, shadowing experienced staff, and had visited other services, both within and outside Rethink. The appraisal showed the manager had a good appreciation of the persons working relationships with the staff team and with the people living in the home. After induction, staff progressed to NVQ (National Vocational Qualifications). A persons supervision folder showed when their NVQ training arrangements were planned, commenced and completed. The three staff respondents to our survey considered their inductions had been good. On each shift, one staff member was designated as shift leader. Peoples competency to undertake this role was revisited regularly. There was resident participation in the interview process for prospective new staff. Recruitment records showed that when a new staff member was recruited, all the required checks on their background were completed before they were able to commence working in the home. Three references were taken up, with further checks on detail as necessary. If a Criminal Records Bureau (CRB) disclosure showed a person had a past conviction, Rethink had an effective procedure for carrying out a risk assessment. This helped make a decision whether it was safe to make an appointment, and provided for considering what supports and monitoring should be put in place through supervision. Care Homes for Adults (18-65 years) Page 29 of 35 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager and provider organisation have various systems to ensure the home is well run. Residents meetings, as well as individual working relationships, allow people to have a say in how the home is run, although staff and management could give a more definite lead in promoting feedback on a wide range of topics. There are policies and procedures that protect the health and safety of people living in the home, and the staff. Evidence: Marion Yeates has NVQ level 4 in care and the Registered Managers Award. She was supported in her management role by monthly supervision from Rethinks area manager, and she also attended monthly managers meetings. Records of unannounced monthly monitoring visits by Rethink showed they were based on random sampling of records, checks on complaints and medicines handling, and interaction with people living in the home. Staff meetings were held monthly in the home, to discuss operational and resident issues. This had been reduced from fortnightly. Some staff thought the reduced frequency not enough for keeping Care Homes for Adults (18-65 years) Page 30 of 35 Evidence: everyone up to date, especially while pressures on staff time generally, made it difficult to read up on all care and recovery plans. Rethink had a centralised quality assurance system. Marion Yeates said questionnaire exercises had been carried out with residents in the past, but not for a while. The weekly house meetings were seen as the primary forum for obtaining feedback from the resident group, together with individual feedback at an individual level through key work and reviews. House meetings had essential housekeeping matters to address and otherwise did not seem to provoke much discussion about, for example, staffing levels or activities. Minutes were brief, showing who attended and what had been discussed. It would be helpful to encourage participation by indicating who would take responsibility for any follow-up needed, and distributing printed minutes to each person. It would be worth seeing if people were more attracted to attending the meetings if some intended subject matter were decided and publicised in advance. Residents who always attended the meetings saw it as a staff responsibility to ensure beter attendance by the whole resident group. There was weekly and monthly monitoring of health and safety in personal and communal rooms. For example, a weekly check sheet was used to monitor how people were keeping their rooms risk-free. If a shortfall was found, a letter to the resident concerned asked them to put it right. We saw that matters such as faulty radiators and lighting were also identified this way and repairs were quickly arranged with the housing association responsible for the building. One member of staff had particular responsibility for fire precautions and had recently been on an appropriate course. Residents were sometimes directly involved in monitoring of various kinds. Care Homes for Adults (18-65 years) Page 31 of 35 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 32 of 35 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 20 13 The registered person must 28/08/2009 ensure medicines are stored in a wall-mounted locked cabinet, which complies with current regulations. Security of medicines must always be in accordance with the relevant legislation. 2 30 13 The registered person must ensure the flooring in the shared bathroom is made good. So that the room can be kept clean to infection control standards. 30/06/2009 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 homes assessment documentation should take account of the prospective residents initial responses to community living. It should provide space for the person being assessed to comment on their experience of Page 33 of 35 Care Homes for Adults (18-65 years) assessment and their view of the prospects for them, should they be offered and accept a placement. 2 6 Recovery plans should usually be written in the first person, and should incorporate written evaluations of how well they achieve their aims. Interim risk assessment should be a priority task when a person is admitted. Consider ways of ensuring staff availability to give regular direct support to individuals to access the community or develop social interests. Any administration of as needed medication should be recorded in greater detail on the reverse of the Medicines Administration Record chart. Serious consideration should be given to how appropriate staffing is made available to ensure all parts of the home can be kept clean to infection control standards. Training should be planned in such a way as to ensure all staff receive refresher training in abuse awareness and prevention at least every two years. There should be a review of key duties, such as support to community access and checking in of medications, to identify when the staffing rota should aim to provide more than two staff on duty. Consider ways of encouraging increased resident participation in the regular weekly meetings, and of obtaining, recording and using feedback from all people that live in the home. 3 4 9 13 5 20 6 30 7 35 8 35 9 39 Care Homes for Adults (18-65 years) Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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