Inspection on 02/04/09 for Hothfield Manor Centre

This inspection was carried out on 2nd April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hothfield Manor Centre 01/06/09

Hothfield Manor Centre 02/03/09

Hothfield Manor Centre 15/05/07

Hothfield Manor Centre 15/11/05

Hothfield Manor Centre 07/06/05

Hothfield Manor Centre 11/03/05

Hothfield Manor Centre 14/12/04

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

Key inspection report Care homes for adults (18-65 years) Name: Address: Hothfield Manor Centre Church Lane Hothfield Ashford Kent TN26 1EL The quality rating for this care home is: Zero Star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sarah Montgomery Date: 0 2 0 4 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • Be safe • Have the right outcomes, including clinical outcomes • Be a good experience for the people that use it • Help prevent illness, and promote healthy, independent living • Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • 3 stars – excellent • 2 stars – good • 1 star – adequate • 0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement They reflect the We review the quality of the service against outcomes from the National Minimum Care Homes for Adults (18-65 years) Page 2 of 42 Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for Adults (18-65) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Page 3 of 42 Internet address Care Homes for Adults (18-65 years) Information about the care home Name of care home: Address: Hothfield Manor Centre Church Lane Hothfield Ashford Kent TN26 1EL Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Physical Disability Additional conditions: The maximum number of service users to be accommodated is 24. The registered person may provide to the following category of service only: Care home only (PC) to service users with the following gender: Either whose primary care needs on admission to the service are within the following category: Physical Disability (PD). Date of last inspection: Brief description of the care home: Hothfield Manor Centre is a care facility registered to provide accommodation, personal care and support for up to 24 adults with a physical disability. The Centre provides care to people who have an acquired brain injury. The accommodation is in two specific areas, these being 12 single bedrooms in the Manor House, and 12 single bedrooms in terrace chalet bungalows within the grounds. Some of the bedrooms have en-suite facilities. Five of the chalet bungalows are for 2 people, and one bungalow has been constructed to enable 2 people to experience supported independent living. The home has well maintained gardens. Parts of the care home and grounds are not Care Homes for Adults (18-65 years) Page 4 of 42 01233 643272 01233 611433 hothfieldmanor@fshc.co.uk www.huntercombe.com Hothfield Manor Limited. Keith Hutchinson Care Home 24 Number of places (if applicable): Under 65 24 Over 65 0 1 5 0 5 2 0 0 7 fully accessible to wheelchair users. There is adequate car parking space within the grounds. The Centre is located approximately 5 miles from the town of Ashford. The home has its own transportation. There is a shop/post office within walking distance. Staffing comprises of a Registered Manager, assistant managers, support staff, a cook, domestic staff, gardeners and an administrator. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Zero star poor service. Care Homes for Adults (18-65 years) Page 5 of 42 How we did our inspection: The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This key unannounced inspection was conducted by Sarah Montgomery, Regulatory Inspector, who was in Hothfield Manor Centre on 2nd April 2009 from 11:45am until 21:00pm. We were joined on the inspection by Junetta Whorwell, an expert by experience. During the inspection we spoke with management, staff and residents, and inspected documents and records. The Commission received a completed Annual Quality Assurance Assessment from which information was used to inform the inspection process. A number of survey forms were received from residents prior to the inspection. Some statements made are quoted in the text of the report. What the care home does well: What has improved since the last inspection? What they could do better: The Care Quality Commission is significantly concerned about this registered care home. Requirements made following a random inspection in March 2009 had not been complied with. The Commission is issuing Statutory Requirement Notices concerning these breaches in Regulation. 26 standards were assessed. 23 of these standards were assessed as poor. We have made 26 requirements. The registered manager and registered provider must ensure they provide the Commission with an action plan. This action plan must meet the timescales for compliance to meeting regulations as laid down in this report. Care Homes for Adults (18-65 years) Page 6 of 42 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our websitewww.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 42 Details of our findings Contents Choice of home (standards 1 – 5) ..........................................................................9 Individual needs and choices (standards 6 – 10) .................................................... 11 Lifestyle (standards 11 – 17) .............................................................................. 14 Personal and healthcare support (standards 18 – 21) ............................................. 17 Concerns, complaints and protection (standards 22 – 23) ....................................... 19 Environment (standards 24 – 30) ........................................................................ 21 Staffing (standards 31 – 36) ............................................................................... 23 Conduct and management of the home (standards 37 – 43) .................................... 25 Outstanding statutory requirements ..................................................................... 27 Requirements and recommendations from this inspection........................................ 29 Care Homes for Adults (18-65 years) Page 8 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users do not receive sufficient or appropriate information about the home prior to admission. Service users may be at risk of harm, and may not have their needs met as they do not have their needs assessed prior to admission. Evidence: Standards 1 and 2 were assessed. To assess these standards we looked at information the home provides to prospective service users and their representatives, this included the Statement of Purpose, Service User Guide, and the homes brochure. We consulted the Statement of Purpose, Service User Guide and brochure throughout the inspection process to cross reference inspection evidence with what the home say they are doing. We looked at how the home gathers information in the pre admission assessment stage. We used information provided by the registered manager in the Annual Quality Assurance Assessment (AQAA), and information provided by service users in questionnaires sent out by the Commission. We also spoke with staff and with service users. Information contained in the Statement of Purpose, Service User Guide, and brochure is significantly misleading. Prospective service users and their representatives who rely on these documents for accurate information about services and facilities at this home, and make what they believe to be an Care Homes for Adults (18-65 years) Page 9 of 42 informed choice regarding where to live, will, upon admission to the home, discover that actual facilities and services differ greatly to those described in the statement of purpose, service user guide, and brochure. These documents describe several specialist services, including our own occupational therapist, slow stream rehabilitation, training, an efficient holistic approach which aims to maximise physical, cognitive and functional recovery. Our inspection process evidenced that these services are not provided at the home. There is no occupational therapist. Evidenced findings tell us there is not a programme in place for rehabilitation or training. Staff do not have the necessary training or skills to facilitate physical, cognitive and function recovery. When questioned about specialist services, particularly assessment and rehabilitation, we were told by staff that this did not happen, that staff at the home just about managed to cope with supporting people with personal care, and no assessments or programmes of rehabilitation existed. Several staff were asked what makes Hothfield a specialist service for acquired brain injury?’ Without exception, all staff questioned replied nothing. We are just a residential home. The home is not fully accessible to people with physical disabilities. It is registered for physical disability, and advertises as a physical disability home, but it is not fully accessible. The grounds are completely inaccessible to wheelchair users (no safe paths), and wheelchair users cannot be fully independent in the home due to stairs and doors. We advised the home manager that prospective service users and their representatives would naturally assume that a home registered for physical disabilities would be accessible. There is no mention in the Service User Guide, Statement of Purpose or brochure that it is not. The home must tell prospective service users and their representatives that the home is not fully accessible to wheelchair users. Pre admission assessment documentation is essential information. It informs the initial care planning process, and outcomes from the pre assessment, cross referenced with the services described in statement of purpose, tells the prospective service user and the home whether the care home is an appropriate place to live, and whether the assessed needs can be met. Five service users were case tracked throughout this inspection. We asked to see the pre admission assessments of the five service users. No assessments were on file. The registered manager suggested they might have been archived in a building in the grounds. We questioned this, particularly as one of the residents was a recent admission. We requested several times during the inspection that the assessments were accessed and presented to us. No assessments were produced. For one service user there were comprehensive handover notes from a previous placement. These notes included details of specialist pressure relieving equipment needed by the service user. The home had not obtained this specialist equipment. When questioned why this had not been done, the registered manager told us I dont know. This equipment was in place the day following the inspection. The Statement of Purpose tells prospective service users and their representatives that all potential service users will have their needs thoroughly assessed. Information gathered at this inspection evidenced that this does not happen, and that the home not only fails to assess prospective service users, but also does not act on information supplied by previous placements. Care Homes for Adults (18-65 years) Page 10 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users do not have their individual needs or aspirations met, and are at risk of harm from inadequate assessment of risk. Service users are not supported to make decisions in their day to day lives. Evidence: Standards 6, 7 and 9 were assessed. To assess these standards we looked at care planning, risk assessments, and decision making processes for service users. We cross reference care plans with information recorded in individuals daily notes, and looked back over a one month period. This told us whether or not care plans (and activities) were being followed. We spoke with service users and with staff, and looked at information provided by the home in their annual quality assurance assessment. At the random inspection on the 2nd March we found shortfalls in care planning and risk assessment. We issued requirements concerning these shortfalls, with a compliance date of 1st April. The home had not complied with the requirements. We issued a code b notice. This notice tells the provider that an offence may have been committed because of the continued breach in meeting Regulation. Following the code b notice, Statutory Requirement notices are issued regarding the breaches of Regulation. In this case, the breaches concern care planning and risk assessment. Care Homes for Adults (18-65 years) Page 11 of 42 We looked at the care plans of three service users. As stated above, shortfalls identified in the random inspection were still present, in that, care plans did not contain sufficient detail regarding the support needs of individuals, nor had any input been sought from service users regarding their views on planning their care, including their own personal goals and wishes. Some care plans did contain more detail, and indicated a person centred approach. For example, an activities care plan for one service user stated: a programme to be developed that is interesting, stimulating and therapeutically beneficial. The aim should be that each day (service user) is encouraged to participate in a task either in or out of the home. We cross referenced this with the individuals daily notes for a one month period. Every day was spent in the smoking room. There was just one activity in the month; a massage. The care plan was written in November 2008. Another care plan stated I need staff to arrange activities for me, if left to my own devices I would remain passive watching TV and smoking. The goal on this care plan was for (service user) to be offered regular activities to keep his life active and gain new skills. We looked at this service users daily notes. They indicated inactivity day after day, mostly watching television. We spoke with staff regarding the inconsistencies between the statement of purpose, care planning and daily notes. Staff were visibly upset and told us they do the best they can, but there simply is no time to do anything extra. Most of the time is spent on supporting people with personal care. Staff were not aware of the details in care plans, or the aspirations of service users. Risk assessments continue to have significant shortfalls. We required the registered person to ensure that robust risk assessments were put in place for two service users with epilepsy. Specifically, to record the possible triggers for seizures, and the planned staff support and responses. This has not been done, nor have any staff members received any training in epilepsy. Other risk assessments inspected indicated the home is not supporting people to take risks as part of an independent lifestyle, with risk strategies severely limiting opportunities and lifestyle choices. One service user has been assessed as becoming quite vocal when out in the community. We were informed that this has been risk assessed with the outcome being this service user not going into the community at all, but staying in the care home. This demonstrates a lack of understanding of supporting individuals to lead valued and fulfilling lives. Care plans and risk assessments were cross referenced with individual daily notes, and with the spontaneous activity book. No evidence on any document could be found to suggest that service users are being supported to make decisions. Daily notes mainly consisted of watching TV, had personal care, in smoking room. We asked to see minutes of service users meetings. We were told they do not take place. We asked if there were any forums, either group or individual which seek ideas from service users, and which support individuals to make choices and decisions. We were informed there are not. Discussion with several service users evidenced they are not consulted or supported to make decisions and choices about their lives. We were told of requests being made to go shopping in the community, with the answer being no, you have to shop on line, there is no other option available. Care Homes for Adults (18-65 years) Page 12 of 42 Staff tell us they recognise that service users are not being offered opportunities to make decisions and choices, but added that the support systems are not in place to support people because of lack of staffing. More than one resident described the home as a prison. Care Homes for Adults (18-65 years) Page 13 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are not offered opportunities, support or resources to enable to lead valued and fulfilling lives. Evidence: Standards 11, 12, 13, 15, 16 and 17 were assessed. To assess these standards we looked at how the home supports and enables residents to make decisions on and participate in activities, accessing the local community, and enjoy a healthy diet. We looked at care planning, and at documentation which supports decision making. We also looked at daily notes and spoke with residents and with staff. Information gathered at this inspection evidences that service users at this home experience poor outcomes in lifestyle opportunities and choices, and their day to day lives mainly consist of watching television. This is in stark contrast to information provided to prospective residents in the statement of purpose which states: we try to help service users to enjoy as wide a range of individual and group activities and interests as possible both inside and outside the Centre, to carry on with existing hobbies, pursuits and relationships, and to explore new avenues and experiences. Care Homes for Adults (18-65 years) Page 14 of 42 The annual quality assurance assessment (dated 4th March 2009) asserts: clients attend appropriate local community facilities for recreation and leisure and goes on to say comprehensive assessment forms have been completed for all clients to enable future care to take account of clients preferences and needs. We inspected these forms. Most remain blank and have not been filled in. Evidence gathered from daily notes, and from conversations with residents and staff evidence that activities do not happen, and activities off site are very rare. Several resident questionnaires were returned to the Commission. Answers demonstrated dissatisfaction amongst the resident group regarding lifestyle choices. We were told that the two house cars are often not working, and are not adapted for people with physical disabilities. None of the service users have a weekly activity plan. The staff do not shift plan. Although we found on some care plans details of what activities individuals want to do, there are no formal systems in place to facilitate this happening. Inspection of daily notes evidenced that month after month residents are in the house. We were told that most of the residents access the community once every 4 months. The main activity for residents is watching television. The home does have a full time activities coordinator. Inspection of the spontaneous activities book evidenced that some residents play board games during the day. A therapist comes to the home weekly, and some residents enjoy a massage. This usually works out at 15 minutes a month. Inspection of care plans demonstrated that residents are not involved in planning their care. This includes planning their lifestyle choices and activities. We noted on one care plan it stated I enjoy going out. When questioned, staff told us there is no time to offer activities either in house or community based, particularly in the Manor House. Of the 11 residents that live in the Manor House, one resident requires 2 -1 in the community, the remaining 10 require 1-1. At best three members of staff are on shift. Usually it is two. All residents require help and support throughout the day with personal care. In reality there can be as little as one member of staff supporting 10 residents while the other 2 members of staff are supporting individuals with personal care. There is no time to either offer or carry out activities other than board games or a walk in the garden. The statement of purpose tells prospective service users that Hothfield Manor is a rehabilitation centre. When questioned, staff had no concept of how to work with individuals within a rehabilitation setting. During the inspection residents were observed sitting in the lounges or wandering the corridors. Staff were observed working hard with supporting people with basic care needs, i.e.; personal care, assistance with eating, administering medication. It is evident that service users at this home are not leading valued and fulfilling lives based on their personal goals and aspirations, and that the Care Homes for Adults (18-65 years) Page 15 of 42 insufficient staffing numbers is significantly reducing their lifestyle choices and opportunities. We inspected the kitchen and looked at the quality of food and menu planning. Two cooks are employed by the home. The brochure describes these appointments as we employ in-house caterers to prepare appetising and nourishing meals with varied menus, accommodating all dietary needs. Inspection of the kitchen evidenced that all food purchased for residents is Tesco value brand food. There are no menus. Residents are not consulted about menus, nor asked their preferences. There are no choices offered at mealtimes. Only one meal option is prepared. The total weekly food budget is £190. This is for 11 residents, and equates to less than £18.00 per day. Add to this a 12th person as a weekend respite client, plus any staff on duty which as stated can equate to 2 - 3 care staff, plus the cook, and manager, then this is greatly reduced to less than £12.00 per person per week for food. We asked for the homes budget. For April 2009, the home has been allocated £2,147 per month for food. At present the cooks are given £760 per month (4 x £190). The bungalows have the same number of service users, and are also given £190 per week. This is still under budget, and works out as £1520 per month. We inspected the quality of the food. We were informed by a member of the catering staff that Tesco value bread falls apart, the meat pies are virtually empty, and the mince is poor quality. The home advertises a specialist catering service with appetising, nourishing and varied menus. Our strong concerns are, and the evidence suggests, that residents are not offered a healthy diet, and may be at risk from harm as their nutritional needs may not be met. It is the Registered Managers responsibility to ensure that all residents receive a nutritional diet to meet their needs. At the random inspection we noted staff interactions with residents were inappropriate. A requirement was made that the care home to be conducted in a manner which respects the dignity and privacy of service users. Observations during this inspection evidenced an improvement in this area, and several instances of staff and resident interactions were observed and noted to be respectful. However, we also observed some inappropriate comments from staff, which indicated thoughtlessness. An example of this is: a resident asked when he could leave Hothfield and return to live at home. A staff member said (in front of the resident) his family dont want him. We note in the action plan regarding the random inspection, the home manager has stated there is scheduled training for all staff on respect and dignity issues. The training matrix supplied by the home manager does not identify or indicate when this training is to take place. This must be addressed as a matter of urgency. Care Homes for Adults (18-65 years) Page 16 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users may be at risk of harm as the home does not satisfactorily assess or respond to their healthcare needs. Evidence: Standards 18 and 19 were assessed. To assess these standards we looked at how the home records and supports service users with their personal care, and looked at how the home ensures service users physical and emotional needs are met. We looked at health care plans, and at health care appointment records. We also spoke with service users and with staff. As stated in the evidence in outcome area 2, at the random inspection on the 2nd March we found shortfalls in care planning and risk assessment. We issued requirements concerning these shortfalls, with a compliance date of 1st April. The home had not complied with the requirements. We issued a code b notice. This notice tells the provider that an offence may have been committed because of the continued breach in meeting Regulation. Following the code b notice, Statutory Requirement notices are issued regarding the breaches of Regulation. In this case, the breaches concern care planning and risk assessment. The breaches in risk assessment were in relation to the home not ensuring there are guidelines on triggers for epilepsy, and guidelines for staff concerning what action to take. The home is failing to ensure individual service users physical health needs are known or met. This places service users potentially at risk of harm. We spoke with staff regarding their knowledge about individual residents healthcare needs. Staff did not demonstrate understanding of epilepsy either in pro active measures or reactive responses to a Care Homes for Adults (18-65 years) Page 17 of 42 seizure. Staff have not received any training in epilepsy. We note that all staff have now received training in medication administration, and guidelines are now in place for PRN medication. We looked at health care records for five service users. On one individuals file a suspected pressure sore had been noted on a body chart. This was the same service user who did not have pressure relieving equipment in place, despite it being identified as a clear need on transition notes from the previous care home. We spoke with the home manager about what steps the home had taken to ensure the service user receives appropriate healthcare support and treatment from a specialist service (i.e.: tissue viability nurse). We were told that the home had not contacted any healthcare professional regarding this, and had put a dressing on. We issued an immediate requirement for the registered person to ensure the service user was seen by a specialist nurse, and had pressure relieving equipment in place within 24 hours. The annual quality assurance assessment states personal care is delivered in a caring and sensitive manner. In assessing Standard 18, we looked at health care plans for the five case tracked service users. None of the care plans were person centred. They did not include any evidence that the home had consulted with individuals regarding how they wanted their personal care carried out or what their preferences were. At the random inspection in March 2009 we required the home to ensure all care plans were developed in consultation with residents and included their personal wishes and preferences. This was not complied with and this breach of Regulation was included in the code b notice and statutory requirement notices. We spoke to staff about how they support people with personal care. Staff recognised the limitations in the home regarding insufficient staffing, but told us this is the only thing we can do properly, we make sure we take our time, and that everyone gets their needs met with personal support. Staff are required to use a hoist for safe transfers. We noted one care plan for moving and handling stated: at least one member of staff should have a current moving and handling certificate. We shared our concern with the registered manager regarding this statement, and advised him that all staff must be trained to use the hoist to ensure the safety of the service users and of staff. Until this February, none of the staff at the home had received any training in moving and handling despite this being a home for people with physical disabilities. Care Homes for Adults (18-65 years) Page 18 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are not confident their concerns are listened to by staff, and are not aware of the homes complaints procedure. Evidence: Standards 22 and 23 were assessed. To assess these standards we looked at how the home informs and enables the service users to complain, and looked at how the home ensures the service users are protected from harm. We looked at the complaints procedure, and spoke with residents about how they make complaints, and looked at adult protection protocols, and spoke with staff regarding their responsibilities in keeping residents safe. We also looked at the information provided to residents regarding complaints in the service user guide, and looked at information in the homes annual quality assurance assessment concerning complaints and protection. The annual quality assurance assessment states (under what we do well): that the home has an Effective and simple complaints procedure, and client meetings. The Statement of Purpose states: A copy of the complaints procedure is displayed on notice boards. We know from evidence collected in outcome area 2 that residents meetings do not take place, nor are there any individual meetings with service users to ascertain whether or not they may have a complaint. Several resident questionnaires were returned to the Commission. The majority of these indicated that service users do not know how to complain. We spoke with several service users about their knowledge of the complaints procedure, and experiences of making a complaint. All but one service user did not know how to complain. The one Care Homes for Adults (18-65 years) Page 19 of 42 service user who did know how to complain stated that there was no point, nothing was ever done, and the home was like a prison. The complaints procedure is not displayed in the home. When questioned the registered manager said that before the refurbishment there was a notice board, but it was not replaced and the procedure is not displayed. We asked the registered manager how he ensures how service users know about the complaints procedure. He said it was given to them on admission in the service users guide. Given that many service users have lived at the home for a number of years, and it is likely they do not look at the service user guide, we asked how else they were regularly informed? For example in residents meetings, 1-1 meetings, service user training and information days? independent advocates? He informed us that none of the above happens, and accepted that the home has not done enough to ensure the residents are aware of the complaints procedure and how to complain. We inspected the complaints procedure. This procedure was last reviewed in March 2006. It is a very formal policy, requiring service users to write to a number of people at different stages of their complaint. Given the responses of the service users both in the returned surveys to the Commission, and when speaking with us, it is clear that this policy is not clear and effective, and does not meet the needs of the current service users. Adult protection policies and protocols were inspected. We also spoke with staff about their roles and responsibilities within the protocols, and looked at the way the manager responds to areas of concern in the home. The adult protection policies had not been reviewed since March 2006. This must be reviewed urgently. We receive regular notifications from the home, and are confident that the manager is aware of his responsibilities in this area. Staff were spoken with regarding safeguarding protocols. Their answers demonstrated acceptable knowledge regarding recognising abuse, and their roles in reporting abuse. Care Homes for Adults (18-65 years) Page 20 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not meet the needs of service users. Service users are unable to access all areas of the home and gardens as it is not fully wheelchair accessible. Evidence: Standards 24, 26, and 30 were assessed. To assess these standards we looked at information provided in the statement of purpose, service user guide, brochure and annual quality assurance assessment regarding the environment, and looked at communal areas of the home and one bedroom. We also spoke with service users about how they felt about the environment they live in. The statement of purpose tells prospective service users that the home will: maintain the buildings and grounds in a safe condition and see that service users have safe, comfortable bedrooms, with their own possessions around them. We know from the evidence gathered in outcome area 1 that the home is not fully wheelchair accessible. This is a significant concern as the home is registered for physical disabilities. There are no paths in the garden which are wheelchair friendly. The lift is small and barely accommodates wheelchair users. Internal doors do not open easily, and wheelchair users cannot be fully independent when moving around the home. We inspected one service users bedroom. Boxes of belongings remain unpacked, despite the service user being in the home for 3 months. This service user chooses to spend most of his time in his room, and it is unacceptable that he has not been supported to unpack his belongings. Care Homes for Adults (18-65 years) Page 21 of 42 We spoke with several residents about the environment. Although it is recognised that some refurbishment has brought improvements to communal areas, many residents expressed dissatisfaction about broken equipment and the homes responses to ensuring repairs. We were told that an oven had been not working for 6 weeks in one of the bungalows, and that the boiler had broken down and there was no heating. We were told that these had been reported but nothing had been done. The home is kept clean and hygienic by a team of domestic staff. Care Homes for Adults (18-65 years) Page 22 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users cannot be sure staff have the necessary skills or training to meet their assessed needs. Service users cannot be sure their needs will be met as the home is insufficiently staffed. Evidence: Standards 32, 33, 34 and 35 were assessed. To assess these standards we looked at information which told us about staff competencies, skills and training, and looked at staff recruitment records. We spoke with staff and observed working practice. We also looked at information contained in the statement of purpose and annual quality assurance assessment. The statement of purpose tells prospective service users that staffing levels will be maintained sufficient to meet the needs of service users. It also states: Staff will receive training in order for them to fulfil their duties. Information gathered during this inspection evidences significant shortfalls in the numbers and competencies of staff. The home supports up to 12 service users in the Manor House, and up to 12 service users in semi independent bungalows. At this inspection we concentrated on the staffing of the Manor House. In the absence of any pre admission assessments, coupled with inadequate information contained in either care planning or risk assessments, we relied up staff telling us about levels of need at the manor house, and historical information on resident files regarding support needs. Care Homes for Adults (18-65 years) Page 23 of 42 We looked at the rotas from October 2008 to April 2009. Over this 6 month period, the maximum number of staff on shift is three, with several occasions dropping as low as two members of staff. Staffing numbers are too low. The needs of service users are not being met. This is evident in all outcome areas of this report being assessed as poor. We were informed that activities do not happen because of staff shortages and transport problems, and that months can go by without a resident leaving the home. We observed that staff struggle to cope on a daily basis, and at best can only manage to cover the basics. Staff defined the basics as ensuring all residents receive support with personal care. We were informed that often it takes up to 11.30am to complete this task. Staff morale is low, this is attributed to the take over (2007), shortage of staff, paperwork and inspections. Communication between the registered manager and staff is very poor. The deputy manager is always on the rota as being on shift. She does not participate in the management of the home. It is impossible for her to take on or complete additional responsibilities generally recognised as part of the deputy role. At the random inspection we required that all care plans were reviewed, and new care plans developed which fully recorded assessed needs, personal goals and wishes of service users. We also required that all risk assessments fully describe the identified risks and subsequent support needs for individual service users. We received an action plan from the registered manager. Regarding the above two requirements, we noted that he had actioned the deputy manager to undertake the above tasks. During this inspection we identified that these requirements had not been met. We questioned the deputy manager as to how she was going to achieve these tasks given that she is always on shift. She told us she was not made aware of either the random report or the action plan, and until we spoke with her that day, had no idea she had been tasked to ensure all care plans and risk assessments were reviewed and updated. Staff have been inadequately trained. Although this home is for people with acquired brain injury, staff at the home have never received training in this area. Until recently, none of the staff had received any training in manual handling. To date, none of the staff are trained in epilepsy. Staff describe all of the service users as having behaviours which challenge. One member of staff received training in this in 2008. None of the other staff members have received training. Low staffing numbers also means that staff do not have opportunities to have team meetings. This means that information is not shared. and staff do not get time together as a team to look at working practices or receive updates on specific issues. Staff recruitment records were inspected. All files inspected contained appropriate information on staff, and evidenced that the home ensures necessary checks are undertaken for the protection of residents. Care Homes for Adults (18-65 years) Page 24 of 42 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 who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are not adequately cared for in this home. The home is not well run. Evidence: Standards 37, 38, 39 and 43 were assessed. To assess these standards we looked at information about how the home is run. This included budgets, information contained in the statement of purpose and annual quality assurance assessment, and policies and procedures of the home. We spent time speaking with the registered manager, and sought views from staff and service users. All outcome areas have been assessed as poor. This means that residents living at this home experience poor outcomes in all areas of their care. Evidence gathered at this inspection tells us the home is not well run, and that service users are not adequately cared for. We communicated the evidenced shortfalls to the registered manager throughout the inspection. He told us that everything you say is right. He indicated that he would take urgent action to remedy the identified shortfalls. While this is encouraging, we are concerned that the registered manager indicated to us that everything we say is right, leading us to conclude he was aware of the significant failings of the home, but had not taken appropriate measures to address them. Staff told us that morale was low, and we evidenced poor communication. The manager has been described by some service users as very sarcastic, and doesnt listen, nothing is done. We have Care Homes for Adults (18-65 years) Page 25 of 42 also been told that staff are never told well done, or praised for good work. The manager has failed to recognise how significantly his home is failing, and has not communicated in an appropriate manner with staff or service users. We are concerned the home may not be financially viable. To fail every standard suggests that a sound financial investment has not been made in the key area of staffing numbers and staff competencies and skills. This must be addressed without delay, and staffing numbers must reflect meeting the assessed needs of all service users. Although the annual quality assurance assessment tells us that there are systems in place to critically evaluate service delivery, we found this not to be the case. Residents have told us both in returned questionnaires and during the inspection that they are unhappy with the home. We could not find any evidence that they are consulted or their views sought about the running of the home. The Care Quality Commission has significant concerns about the fitness of the Registered Manager and the Registered Provider. We are holding regular management review meetings as part of our internal processes which inform the type and frequency of our regulatory activity. Care Homes for Adults (18-65 years) Page 26 of 42 Are there any outstanding requirements from the last inspection? Yes X No Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 15 The registered person must develop care plans which fully record all assessed needs and personal goals and wishes of the service user. The care plans should cover aspects of medicine management such as medicine prescribed only when needed, giving medicines in food and procedure for self managing medications. This will ensure residents are supported appropriately and are protected from harm. 01/04/2009 2 9 13 The registered person must 01/04/2009 ensure risk assessments fully describe the identified risks and subsequent support needs for individual service users. This will ensure service users are supported appropriately and are protected from harm. 3 9 13 Have policies in the home that are relevant to the home. So that staff have guidance to work in a consistent manner. 08/05/2009 Care Homes for Adults (18-65 years) Page 27 of 42 4 32 12 The registered person must 12/03/2009 ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. This will ensure service users are treated with respect. Care Homes for Adults (18-65 years) Page 28 of 42 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 1 18 16 To provide pressure relieving 03/04/2009 equipment for a service user. To enable the service user to be comfortable, and to prevent pressure sores. 2 18 13 To receive treatment from a healthcare professional. To ensure the service user receives appropriate treatment for a suspected pressure sore. 03/04/2009 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 1 5 5(1) The registered person 26/06/2009 shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include – (a) (b) a summary of the statement of purpose; (b) the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees; Page 29 of 42 Care Homes for Adults (18-65 years) (c) A standard form of contract for the provision of services and facilities by the registered provider to service users; The most recent inspection report; A summary of the complaints procedure established under regulation 22; The address and telephone number of the Commission. (d) (e) (f) The current service user guide does not accurately reflect services and facilities at the home, and is misleading. The registered person must revise and update the service user guide to accurately reflect the services and facilities at the home. 2 1 4 The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of – (a) a statement of the aims and objectives of the care home; a statement as to the facilities and services which are to be provided by the registered person for service users; and a statement as to the matters listed in Schedule 1. 26/06/2009 (b) (c) Care Homes for Adults (18-65 years) Page 30 of 42 The current statement of purpose does not accurately reflect services and facilities at the home and is misleading. The registered person must ensure that the statement of purpose reflects current services and facilities to ensure prospective service users and their representatives are given correct information about the home to assist them in making a decision about where to live. 3 2 14 14(1) The registered person 05/06/2009 shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (a) needs of the service user have been assessed by a suitably qualified or suitably trained person; the registered person has obtained a copy of the assessment; there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. (b) (c) (d) Care Homes for Adults (18-65 years) Page 31 of 42 To ensure the care home is suitable for the service user and meets his assessed needs. 4 7 12 Regulation 12(3) The 05/06/2009 registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. The registered person must ensure that the views, wishes and feelings of service users are sought and acted upon. All service users must be involved in planning their care. This must be recorded and reflected in care planning documentation. 5 7 12 12(2) The registered person 05/06/2009 shall so far as practicable enable service users to make decisions with respect to the care they are to receive and their health and welfare. The registered person must ensure that all service users are consulted about their care and support needs, and are enabled to make decisions about their lives, and that these decisions are recorded. 6 11 12 12(1)(b) The registered 05/06/2009 person shall ensure that the care home is conducted so as – (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of Care Homes for Adults (18-65 years) Page 32 of 42 service users. To ensure service users have opportunities for personal development, and that staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 7 12 16 16(2)(n) The registered 05/06/2009 person shall having regard to the size of the care home and the number and needs of service users – (n) consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of the service users, activities in relation to recreation, fitness and training. To ensure that staff enable service users to continue their education or training, and/or take part in valued and fulfilling activities. 8 13 16 16(2)(n) The registered 05/06/2009 person shall having regard to the size of the care home and the number and needs of service users – (n) consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of the service users, activities in relation to recreation, fitness and training. Care Homes for Adults (18-65 years) Page 33 of 42 To ensure that service users are offered appropriate opportunities to access activities in the local community, and that staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual plans. 9 17 16 16(2)(i) The registered 22/05/2009 person shall, having regard to the size of the care home and the number and needs of service users – (i) provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such times as may reasonably required by service users. To ensure that service users are offered a healthy, nutritious and well balanced diet. To ensure service users are offered choices at mealtimes. To ensure service users are consulted and have input into menu planning. 10 22 22 22(5) The registered person 25/05/2009 shall supply a written copy of the complaints procedure to every service user and to any person acting on behalf of a service user if that person so requests. Care Homes for Adults (18-65 years) Page 34 of 42 To ensure the service users and their representatives receive an up to date copy of the complaints procedure. 11 22 22 22(2) The complaints procedure shall be appropriate to the needs of the service users. The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales, for the process, and that service users know how to complain. 12 24 23 23(2)(f) The registered 10/05/2009 person shall having regard to the number and needs of the service users ensure that – (f)the size and layout of rooms occupied or used by service users are suitable for their needs. The registered person must ensure that resident’s rooms are comfortable and meet their needs, preferences and wishes. Residents must be supported to put their belongings in their room, and not have their personal possessions left in boxes. 13 24 23 23(2)(c) The registered 10/05/2009 person shall having regard to the number and needs of service users ensure that – (c)equipment provided at the care home for use by service users or persons who work at the care home is maintained and in good working order. 22/05/2009 Care Homes for Adults (18-65 years) Page 35 of 42 The registered person must ensure that all cookers and boilers are working and residents are not left without heat, hot water, or cooking appliances. 14 24 23 23(2)(o) The registered shall 31/08/2009 having regard to the number and needs of service users ensure that – (o) external grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained. The registered person must ensure that work is undertaken in the gardens and grounds which will ensure that all people with physical disabilities, including wheelchair users, can access the gardens and grounds of the home by way of appropriate pathways, and that this access is safe. 15 32 12 12(4) The registered person shall make suitable arrangements to ensure the care home is conducted – (a) in a manner which respects the privacy and dignity of service users. 15/05/2009 The registered person must ensure that staff respect service users and have attitudes and characteristics that are important to them. This includes being accessible to, approachable by, and comfortable with service users. 16 32 18 18(1) The registered person shall, having regard to the 12/06/2009 Care Homes for Adults (18-65 years) Page 36 of 42 size of the care home, the statement of purpose and the number and needs of the service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person must ensure that there are staff employed in sufficient numbers to meet the assessed needs of all individual service users. 17 32 18 18(1)(c)(i) The registered 12/06/2009 person shall, having regard to the size of the care home, and statement of purpose and the number and needs of the service users – (c)(i) ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they perform. The registered person must ensure that staff at the home receive appropriate training to ensure the needs of service users are met. 18 33 18 18(1)(a) The registered 17/07/2009 person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users – (a) ensure that at all times suitably qualified, competent and Page 37 of 42 Care Homes for Adults (18-65 years) experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person must ensure that the home has an effective staff team, with complementary skills which enable them to support service user’s assessed needs at all times. This includes receiving suitable training in acquired brain injury. 19 37 12 12(1)(a) The registered 30/06/2009 person shall ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service users. The registered manager and registered provider must ensure that the written aims and objectives of the home are achieved and that policies and procedures are implemented. 20 38 10 10(1)(a) The registered 29/05/2009 provider and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home (as the case may be) with sufficient care, competence and skill. The registered provider and the registered manager must Care Homes for Adults (18-65 years) Page 38 of 42 ensure that service users benefit from the ethos, leadership and management approach of the home. 21 39 24 24(3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. The registered person must ensure that he consults with, and seeks the views and opinions from, service users and their representatives, in relation to carrying out the review of the service. 22 39 24 24(1) The registered person shall establish and maintain a system for (a) reviewing at appropriate intervals; and improving, the quality of care provided at the care home. 31/07/2009 30/06/2009 (b) The registered person must ensure that there is effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 23 39 24 24(2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service 31/07/2009 Care Homes for Adults (18-65 years) Page 39 of 42 users. The registered person must undertake a review of the service, send a copy to the Commission, and share the report with service users. 24 42 13 13(5) The registered person shall make suitable arrangements to provide a safe system for moving and handling. The registered manager must ensure safe working practices. This includes ensuring residents who require support with moving and handling receive this support from staff who have been appropriately trained. 25 43 25 25(2) the registered person 30/06/2009 shall, if the Commission so requests, provide the Commission with such information and documents it may require for the purpose of considering the financial viability of the care home, including, (a) The annual accounts of the care home certified by an accountant; A reference from a bank expressing an opinion as to the registered provider’s financial standing; Information as to the financing and financial resources of the care home; Where the registered provider is a company, information as to any Page 40 of 42 10/05/2009 (b) (c) (d) Care Homes for Adults (18-65 years) of its associated companies; The registered person must supply the Commission with all the information and documentation listed in this requirement. This will enable the Commission to make a judgement on the financial viability of the care home. 26 43 25 25(1) The registered person 29/05/2009 shall carry on the care home in such manner as is likely to ensure that the care home will be financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. The registered person must ensure that the care home has a sufficient budget to meet the aims and objectives of the care home, and meet the assessed needs of individual service users. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 41 of 42 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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