Inspection on 02/04/09 for Howbury House

This inspection was carried out on 2nd April 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Howbury House 02/04/07

Howbury House 13/10/05

Howbury House 18/04/05

Howbury House 05/01/05

Howbury House 13/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

Key inspection report CARE HOMES FOR OLDER PEOPLE Howbury House Pickersleigh Grove Malvern Worcestershire WR14 2LU Lead Inspector Emily White Unannounced Inspection 2nd April 2009 09:00 DS0000037483.V375008.R01.S.do c Version 5.2 Page 1 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. We review the quality of the service against outcomes from the National Minimum 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 older people 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. DS0000037483.V375008.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address DS0000037483.V375008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Howbury House Address Pickersleigh Grove Malvern Worcestershire WR14 2LU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01684 571750 01684 571753 www.worcestershire.gov.uk Worcestershire County Council Home Care Services Manager not registered Care Home 32 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (32) of places DS0000037483.V375008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 32 Dementia (DE) 32 The maximum number of service users who can be accommodated is: 32 2nd April 2007 2. Date of last inspection Brief Description of the Service: Howbury House is a large, single storey building located in a residential area a short distance from the main road that runs through Malvern Link. There is easy access to public transport and shops. The premises have attractive gardens including enclosed gardens and sitting areas. There is a large, open field on the one side of the premises that allows pleasant views of the Malvern Hills. The premises are owned and operated by Worcestershire County Council. The premises are designated as a resource centre and are currently registered to provide personal care for a maximum of 32 older people. People are accommodated in single bedrooms in units. The units have their own communal bathroom and toilet facilities, a combined lounge and dining area and the shared use of a small, domestic kitchen. A service is provided on two units for 17 people who require intermediate care. The maximum length of stay is normally six weeks. A third unit provides seven respite places for people. A fourth unit called the Lodge provides respite for up to six people with dementia. There are also emergency or transitional places. Although the permanent residential care service has been phased out, one person continues to reside on the premises permanently. The purpose of the resource centre is to work closely with families and in DS0000037483.V375008.R01.S.doc Version 5.2 Page 5 partnership with healthcare and other professionals in order to provide a flexible service that is responsive to the needs of local people while maximising the resources available. DS0000037483.V375008.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We carried out this key inspection without telling the home we were going. During the inspection we looked at aspects of the service that are important to people using it and checked the quality of the support provided. Before visiting the service we looked at the Annual Quality Assurance Assessment which the manager had sent us. This tells us what the service has been doing and how it plans to improve. We also reviewed all of the information we have gathered since the last key inspection, and looked at 11 surveys sent to us by people using the service. During the inspection, we met and spoke with a number of people who live in the home, some privately in their rooms and others in a small group. We had a discussion with the new manager and met several staff. During the day we observed the daily life of the service and how staff assist people living there. We also looked at records which included care records, staff files and documentation to do with the running and upkeep of the building and equipment. What the service does well: The service provides an intermediate care service which helps people to maximise their independence and return home. People using the service feel they are treated with respect and their right to privacy is upheld. They make decisions about their health care and get appropriate support to do this. People have appetising meals of their choice in homely surroundings. People know how to complain if they need to. They are kept safe by competent staff who have been appropriately recruited and who are familiar with adult protection procedures. DS0000037483.V375008.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 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 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. DS0000037483.V375008.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000037483.V375008.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. People using the 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 a full assessment of their needs and opportunity to visit the service beforehand. People are given an information pack and contract which helps them understand what the service is providing for them. Intermediate care services support people to maintain their independence. EVIDENCE: The Annual Quality Assurance Assessment tells us that We have a brochure that includes all information about the resource centre including charter of rights, and agreements of care. Social care assessors also take a booklet with information about our service, which also includes photographs of our bedrooms and communal areas when assessing people for the intermediate care. We also have a statement of purpose, which is displayed, on notice boards and in the brochure. Most people who returned surveys said they had DS0000037483.V375008.R01.S.doc Version 5.2 Page 10 enough information about the service before they arrived, and people we met told us they had enough information. However in some surveys carried out by the service, people said that more information would have been useful. The manager recognises that people who have come to the service from hospital may need more information once they have arrived. The service has recently been awarded for customer service excellence by one of the governments approved awards centres. Following the last inspection a requirement was made that people have an assessment of their needs which covers all aspects listed in the National Minimum Standards. People coming to the service for intermediate care are assessed by trained social care assessors who use a single assessment format which links in with assessments from social workers, nurses or other professionals. People staying in the dementia respite unit are assessed by a registered mental health nurse who coordinates the unit. Peoples care files show that all assessments are detailed and identify particular needs and risks for that person. During our visit we met several people using the service who told us why they were there. Peoples descriptions of their own needs matched with the assessments carried out by the service. The Annual Quality Assurance Assessment tells us that people accessing respite come in for a pre-admission visit, so that we can assess their needs and they can express their wishes and expectations. We have developed an admission checklist to guide them with what they will need during their stay. Some people we met during our visit told us they had been to see the service before they came for respite. A large part of Howbury House is to provide intermediate care and rehabilitation. The Annual Quality Assurance Assessment tells us that We have Physiotherapists, Occupational Therapists and a unit nurse. We also access community teams such as homecare, Social Workers, District Nurses, Podiatry, Community Matrons, Speech and Language Therapy. Home visits are an integral part of our service and carried out by Occupational Therapists and outreach workers. Outreach workers also support people with social interaction into the community. Through joint working with Health and Social Care we can ensure people have the assistance they require to return home safely and as independently as possible. During our visit we met the intermediate care coordinator, other support staff, and met people using intermediate care and looked at their support files. People have the right support from specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable them to return home. People have a therapy timetable which shows their goals for the week, their current aims and activities, long term goals, and current personal care abilities. Different staff such as physiotherapists record progress in these files and there is also a weekly meeting where planning happens for the persons DS0000037483.V375008.R01.S.doc Version 5.2 Page 11 development, such as home visits, or equipment. No action is taken until plans have been discussed with the person using the service. Support staff tell us they have had training provided by the health service and social services which provides an overview of basic occupational therapy, physiotherapy and nursing skills. People using the service tell us that the support staff sometimes help them with their exercises. We were not able to see certification of this specialist training as the service has not developed a suitable training management system. This is discussed under the staffing section of this report. DS0000037483.V375008.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People using the 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’s health and personal care needs are met through good contacts with community health professionals, monitoring by staff and respect to privacy and dignity. People have a plan of care which the service has been working to improve so that staff know how to help people appropriately. The system for managing, recording and giving medication has improved. EVIDENCE: Following the last key inspection a requirement was made that the care plans must set out in detail the action which needs to be taken by the staff to ensure that all aspects of peoples needs are met. We looked at the plans for support of one person using the intermediate care service, one person using the respite service and one person using the dementia respite service. All plans are detailed and reflect the persons needs identified in their assessment. Identified risk areas in a persons assessment are linked to those in their care plan, for example leaving the building, moving and handling, skin care, eating DS0000037483.V375008.R01.S.doc Version 5.2 Page 13 and food. The plans are set up with the involvement of the person if possible, either before they arrive or within the first week, depending on the service they are receiving. The plans look at the persons current situation, the expected outcome from using the service and what staff are expected to do to help them achieve this. Where appropriate, staff complete an agreement of care with the person which is signed by that person. People using the intermediate care service say they are involved with their plans and the goals they want to achieve by the time they leave the service. The care plans for all areas of the service describe peoples needs in areas such as mobility, personal care, and mental well being. Although the plans follow a specific format, the information is specific to the individual. The plans use appropriate supportive language which respects peoples dignity such as, • talk through fear of being away • find time to talk to and listen and give reassurance and encouragement • greet and do not assume x will recognise you • offer guidance and assistance when needed, encourage x to complete tasks for himself People using the intermediate care service should have regular reviews of how the person is progressing towards their goals, which involves that person. One person using intermediate care said they were not sure how well they were getting on or what the next steps would be for them. The Annual Quality Assurance Assessment tells us that the service wants to improve how often reviews happen. The manager says that the key worker scheme is being renewed which will help with this. A key worker is the staff member responsible for co-ordinating the plan, for monitoring its progress and for staying in regular contact with the person and everyone involved. The majority of people who sent us surveys say they always receive the care and medical support they need. Comments include • Very good • I have not needed to see a doctor yet since coming here but help would be there I am sure • I control my own medication and we have a nurse available • I am very happy with all the care I am being given here • Almost always day to day care is very good. I did not see a physiotherapist until I had been here six days and after a hip replacement I felt this was not soon enough People we met during our visit had similar views, that the health and personal care support is very good, but one person felt they should have been seen by the physiotherapist sooner. Records show that this person saw a physiotherapist after four days at Howbury House, after a period of settling in. As part of a more personalised approach, the service should recognise different peoples willingness and ability to start the therapy programme at DS0000037483.V375008.R01.S.doc Version 5.2 Page 14 different times. This will be supported by the key worker role and regular reviews of peoples development. The Annual Quality Assurance Assessment tells us that an area the service could be better is in reviewing care plans at timely intervals and allocating time for care staff to spend with therapists to complete competencies for physiotherapy. Records in peoples care files show that they receive good support from physiotherapists, occupational therapists, nurses and doctors, who either work within the service or from outside agencies. People who have specialist needs such as nursing needs for leg ulcers have regular visits from community nurses who record in the care files so that information is passed on to staff at the service. People are also able to continue to keep health appointments for opticians and dentists. People who have regular respite have a folder which they take home and which can be updated by professionals while at home, so that track is kept of their health care. Staff say that communication is good, senior staff have a handover book, and other staff have a message book so that all staff are kept up to date with changes to peoples support needs. We looked at the daily records for all staff involved with the people we met. Daily records in general are detailed regarding peoples personal care, eating, and activity. The notes show staff knowledge of peoples preferences and are written in respectful language. Intermediate care staff say they work with the therapists, observe exercises and then can be signed off to work with that person. For one person who uses intermediate care, we did not see any records by care staff to show they had been working with the physiotherapy exercises. This person told us only the physiotherapist had been helping her. It is important that staff working in the intermediate care unit are given time and training to assist people with their therapy programme. During our visit to the dementia respite unit, concerns were raised by staff about being able to meet peoples needs particularly when people stay who have high physical or mental health needs. Daily records in this area vary between staff members, some being very detailed and recording with reference to the persons care plan, and others very brief, which may be an indication that staff have little time for recording. Before our inspection we also received a complaint from a family member about the dementia service. The service recognises that improvements are needed in this area and has identified some actions, for example until more space can be provided they will reduce the number of people using the service and extra staff will be considered for individual cases. We met several people using the service who all say their privacy and dignity is respected at all times. Records and observations of staff at their work shows that they have an understanding of the needs of people using the service which includes promoting their privacy and dignity. One person using the service told us that the phone in the hall is not very private and would like to be able to move it to a more private place. DS0000037483.V375008.R01.S.doc Version 5.2 Page 15 A Pharmacist Inspector (Morag Ross) undertook an inspection of the control and management of medication within the service on 2nd April 2009. We spoke with four members of staff and one person using the service. All feedback was given to the senior in charge. Overall there had been improvement in medication management since the previous pharmacist inspection on 18th September 2008. We were shown a medication policy available from Worcester County Council Social Services Directorate, however it was not detailed or specific to the service. For example, there was no information on the individual storage of medication in each bedroom or how this is managed. In the Lodge we saw an admissions and discharge procedure dated 1/4/04, however it was out of date and had not been reviewed. This means that it was difficult for staff to follow a working medication policy to ensure that people using the service were safeguarded. The service uses two different types of medication storage. We saw that one unit stored medication in a locked medicine trolley, which was neat and tidy and it was easy to locate peoples medication. The person in charge of the unit held the key. The other units used individual locked medicine cabinets within each person’s bedroom. We saw that a master key for the cabinets was held by the person in charge of the unit and people who looked after their own medication held their own key. Medication was also seen stored in a locked cupboard in a hallway. The keys for this cupboard were seen kept in a safe in the main office. However, it was of concern that the safe could be accessed by any of the senior carers and two receptionists at any time. This meant that some medication was accessible with no safeguards and therefore people were at increased risk of harm. The majority of the medicine records seen were documented with staff signatures to record that medication had been administered or a code was recorded to explain why medication had not been administered. We also saw records for the receipt and disposal of medication, which were double-checked by two members of staff. We looked in detail at three peoples medication records. One of the records in The Lodge was confusing. The handwritten directions on the medicine administration record (MAR) chart did not match the labelled directions on the box of tablets in the medicine trolley. A second box of tablets was shown to us in a locked cabinet for the same person but with different directions on the label to the first box and did not match the directions on the MAR chart. We spoke to a member of staff who explained that the person went to the Day Care Centre next door and the medication required at lunchtime was administered by The Lodge staff. The records for the receipt of the two boxes of medication for the same person were kept in separate folders. It was difficult to ensure that an audit trail could be followed to ensure that medication was being administered safely and correctly. The records were confusing and this increases the risk of a medication error. The DS0000037483.V375008.R01.S.doc Version 5.2 Page 16 other two audit trails were correct and did show that medication was being recorded and documented accurately. We were informed that some people were looking after their own medication, which shows that the service is willing to help and support people to live independently. We spoke to one person who looked after their own medication in their bedroom. They showed us where the keys were kept in the bedroom and allowed us to look in the locked medication cupboard. She told us that she managed her medication herself and knows what the medication is for, mainly my pain. She explained that she sometimes has to remind staff to assist her with administering the eye drops. We saw a risk assessment and consent form signed by the person available in the care plan dated 22/3/09. It detailed additional notes for staff to be aware of, for example, Eye drops care staff to administer. This means that the service was ensuring the safe administration of medication to people who looked after their own medication. DS0000037483.V375008.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to stay part of their local community during their stay and keep in touch with family and friends. People are offered a choice of nutritious and attractive meals. Opportunity for therapeutic activity and the ability to exercise autonomy and choice is sometimes limited. EVIDENCE: The Annual Quality Assurance Assessment tells us that We encourage and support people using the service to continue with social and leisure activities within their normal daily living and recreational activities also take place on a regular basis for example card games, quizzes, crafts, art and bingo. These activities are offered either in a group session or individually. People tell us that they can keep up with their outside interests and they have as many visitors as they wish, at times to suit them. Staff say that they encourage activities such as music, computer games, walks, scrabble, games, and chats. Peoples care plans encourage activity for example DS0000037483.V375008.R01.S.doc Version 5.2 Page 18 staff to find time to talk to and listen and give reassurance and encouragement • staff to initiate daily one to one social interaction • staff to incorporate interests and hobbies into a programme of activities However most people who use the service who sent in surveys said there are only sometimes or even never any activities they can get involved in. People using the service that we met during our visit say they are not aware of activities being proposed. In the intermediate care and respite areas, some daily records in peoples care files do not record activity, either related to their rehabilitation or for leisure. During our visit we observed interactions in all units of the service. At the time of our visit the dementia unit had two staff supporting two people having respite. We observed a warm friendly atmosphere, with chatting and dancing, music playing, and staff showing a good understanding of interacting with people with dementia. Care plans in this area show activities recorded such as listening to music, dancing, playing football and records of when activities are declined. This shows that access to and recording of therapeutic and leisure activities is varied throughout the service and a more consistent approach should be considered. People using the intermediate and respite service tell us that their independence is well supported. Generally people say their day is flexible according to their wishes, however one person told us she is woken at 6.40 am which is too early, as she does not have breakfast until 8.30. Some concerns were also raised about the dementia respite unit. One of these is in relation to the use of the lounge as a day service which is not open to people staying on respite. This means that the remaining space at the unit is very small, and the nature of the day service may be disruptive to people with dementia. During our visit we observed people using the service becoming distracted by sights and sounds from the day service, and staff having to move them away. We also observed that access to the sensory garden is restricted during the day. Staff say that when people leave the day service some people having respite can become distressed as they are not able to leave. Although during our visit only two people were using the service, it was possible to see that the space available and the distractions of the day service could limit the autonomy and choice for people with dementia. The service has identified a way of creating extra space by using an office to create a second lounge area for the interim period until they can find a long term solution. The Annual Quality Assurance Assessment tells us that the Catering Supervisor discusses dietary needs with individuals respecting their likes, dislikes, special diets and cultural preferences. This information is recorded on a dietary checklist which is given to kitchen staff on admission. The Catering Supervisor devises a four weekly seasonal menu. This is all home cooked food using fresh produce. All cakes are baked on the premises. Catering is very DS0000037483.V375008.R01.S.doc Version 5.2 Page 19 • highly thought of. We met the kitchen staff who confirmed this and showed that they had also recently had a five star environmental health inspection. Most of the surveys we received from people using the service say they always like the food. One person commented that more vegetarian options should be available. People we met during our visit told us comments such as we love the food, there is lots of choice and variety. We observed lunch times in the intermediate care and respite units, which showed good staff interactions and chatting. The food looked appetising. Staff in the dementia unit showed us how they offer choices, and compile peoples known likes and dislikes for use on future visits. DS0000037483.V375008.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People using the 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 safeguarded from abuse by the service because they have policies and procedures that people and staff can understand and act on. People who use the service know how to complain if they need to. EVIDENCE: The Annual Quality Assurance Assessment tells us that the system for logging informal comments and complaints will be improved, and senior staff are to be trained in the procedure to follow for complaints and comments. Until April 2009 Worcestershire County Council has dealt with complaints about the service, however this has now changed so that complaints are dealt with internally. We received one complaint relating to the standard of care at the dementia unit which the service and local authority has responded to appropriately according to its procedure. People who sent in surveys and who we met during our visit generally say they know how to complain. Several people made comments such as not always sure about senior management, Ive not been told who to speak to, wouldn’t know who was in charge. This may be because the service has not had consistent management in the past year and may improve now that a new manager has come into post. DS0000037483.V375008.R01.S.doc Version 5.2 Page 21 Following the last inspection a requirement was made that the senior staff must undertake training in the protection of vulnerable adults from abuse and all the care staff must receive training in basic awareness of abuse. We spoke to staff who show a good understanding of how to safeguard vulnerable adults and staff also said they have had relevant training or have their names down for this. We met one member of relief staff who says she has not had formal training but showed good understanding of the local procedure. The Annual Quality Assurance Assessment tells us that there has been training for all staff in the protection if vulnerable adults, however we were not able to check training records as a suitable monitoring system has not been set up. It is important that staff training in safeguarding vulnerable adults is monitored and all staff are kept up to date so that everyone using the service can be confident they will be kept safe while staying at the service. DS0000037483.V375008.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People using the 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 stay in a safe and well maintained home that is clean and hygienic. Consideration should be given to the use of space in the dementia unit. EVIDENCE: Howbury House is a single level purpose built building. There are individual units that accommodate up to six people each with their own dining area, shared kitchen facilities and bathrooms. All bedrooms are single and have wash hand basins. All rooms are lockable and furnished. Outdoor space is accessible to wheelchair users. Seating areas are available outside. There are two therapy kitchens for intermediate care, and the living and dining areas are small and homely. DS0000037483.V375008.R01.S.doc Version 5.2 Page 23 Concerns have been raised about the use of space in the dementia respite service. Staff report some difficulties using the bathroom sue to the awkward positioning of the bath, and that the bathroom is one of the only through routes. The service has identified some areas where the use of space can be improved, such as changing the use of a large office space. Access to the sensory garden should also be considered in recognition of the importance of physical environment to people with dementia illnesses. Despite these comments, during our visit we saw that the dementia unit has been decorated in a homely way, with pictures and therapeutic dolls, creating a friendly atmosphere. Everyone who returned surveys and who we met during our visit commented that the home is always fresh and clean and that the cleaners do an excellent job. We observed good hygiene practices throughout the house. The Annual Quality Assurance Assessment tells us that Our unit nurse is also a link to infection control and is always updating our procedures with us. Several senior staff are also trained as infection control key persons. We were not able to check whether infection control training is up to date as a suitable monitoring system has not been set up. It is important that staff training in infection control is monitored and all staff are kept up to date so that everyone using the service can be confident they will be kept safe from infection while staying at the service. DS0000037483.V375008.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are kept safe by the recruitment practices of the service. In some areas of the service staffing levels are not suitable for the needs of people. The service is not able to demonstrate how training is used to provide people with the most up to date standards of care practices. EVIDENCE: The Annual Quality Assurance Assessment tells us that we have good retention of staff. This means that we have a group of very experienced staff enabling a good skill mix. People who returned surveys to us said that staff always listen and act on what they say, and staff are usually or always available when they are needed. Comments include the members of staff are always caring and kind, staff are always very busy. We looked at staff rotas and spoke to a senior member of staff. There is always one senior staff member to cover the whole house, and the different units have between two and five staff to cover them. There are also unit coordinators and use of long term relief staff. Staff on the intermediate care and respite units say there are usually enough staff to carry out their jobs although sometimes there is little time for activity. DS0000037483.V375008.R01.S.doc Version 5.2 Page 25 At the time of our inspection the dementia respite unit used two staff to support up to six people with moderate to severe dementia. During the past year we received a complaint from a family member about the staffing levels at the unit. During our visit staff said that at times it is very difficult for two staff to support people who may have very high physical or mental health needs. Although there were only two people using the service at the time of our visit, one of these people required a staff member to be present with them at all times. With just two staff on duty this may have posed difficulties if there had been other dependent people at the unit. The service recognises these concerns and has proposed changes such as providing extra staff for those people with higher needs, reducing the numbers of people staying, and ensuring the unit coordinator is regularly based at the unit. The service will need to make these changes to ensure that people with dementia receive the most appropriate support. The Annual Quality Assurance Assessment tells us that 35 out of 73 staff have NVQ level 2 or above. There are also plans for senior staff to do NVQ 3 and the deputy manager to do NVQ4. The service has qualified physiotherapists, occupational therapists and a nurse. The dementia unit coordinator is a registered mental health nurse. We met staff who are fully aware of their role and what it entails. We would expect staff to be fully qualified having had training in dementia and intermediate care to support the specialist nature of the service. However we were not able to check certificates for these and were not able to see up to date records for some specialist areas. We met several staff members who said they have had training in person centred care, medications, dementia, food hygiene, moving and handling and other mandatory training. We checked the training files for three staff. The manager and staff say all new staff have an induction, however the induction checklist is held by staff. Every staff member has a training and development file but these have not been updated recently. We saw the three different systems for monitoring training, none of which match each other. Before we looked at the files the manager and deputy raised the issue of monitoring training as a priority for the service. It is important that a record is kept of staff induction and training, so people using the service can be confident they are receiving the most up to date and highest quality of specialist support. We saw three recruitment files and note that recruitment practices are adhered to. People can be confident staff are recruited having had the appropriate background and safety checks. DS0000037483.V375008.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. People using the 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 using the service can be confident that the new manager has recognised where improvements to the service need to be made and is able to manage them well. EVIDENCE: The service has experienced a year without permanent management, as well as changes in deputy management and unit coordinators. A new manager started in January 2009 and must now register with the Commission in order to provide the clear leadership and accountability that the service needs. DS0000037483.V375008.R01.S.doc Version 5.2 Page 27 While there are clear areas for improvement as identified in this report, the manager of the service recognises them and we are confident the areas will be addressed. The service measures the quality of what it does by carrying out audits against the National Minimum Standards. One of the areas for improvement identified by the manager is getting more comments from people who use the service, so the service can develop according to what people want. The Annual Quality Assurance Assessment tells us that we use ‘Having your Say’ questionnaires for everyone who uses our service. Regular having your say meetings are held at Howbury. These meetings are recorded and actioned as necessary. Also questionnaires are given if someone is receiving outreach service at home. Minutes of meetings are displayed on notice boards within Howbury. We have a new audit that is in process by our social care assessors people following 6 months of being at home from intermediate care to ask how they are getting on and if the service helped them stay at home. The manager also recognises that they need to record how the service responds to suggestions from people. The Annual Quality Assurance Assessment tells us that people using the service are encouraged to manage their own finances. A safe facility is available if needed and there is a form recording debits and credits, double signed by staff. Records are held confidentially in the main office and is accessible at all times. We saw appropriate records being kept of transactions. Staff say that they have not been having regular supervisions but the new manager has set this up recently. The Annual Quality Assurance Assessment tells us that Each member of staff has a supervisor who will carry our appraisals and supervisions with their staff group, seeing staff a minimum of six times in a year. We discussed this with the manager who recognises that support for staff has been difficult with management changes, particularly in the dementia unit. Proposals for the unit coordinator to be present at the unit on a more regular basis will ensure staff are fully supported and able to carry out their roles effectively. We saw that health and safety records are maintained including fire and water. Some problems with Legionella means the water is flushed regularly, however Legionella testing is done and water temperatures recorded at the same time as this. We saw that some water temperature records in bathrooms which were last used in August 2008, should be removed. Due to the training monitoring systems not being set up appropriately, we were not able to check mandatory health and safety training however staff say that they have had relevant training such as fire safety, moving and handling, infection control, food hygiene and first aid. DS0000037483.V375008.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 x 3 DS0000037483.V375008.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement Timescale for action 02/07/09 2. OP9 13 (2) 3. OP31 Care Standards Act 2000 Section 11. Storage of medication must be made safe and secure in order to ensure the safety of people who live in the service. The service must make 02/07/09 arrangements to ensure that all medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. The manager of the service must 02/07/09 apply to the Care Quality Commission for registration. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations People who have come to the service from hospital may need more information once they have arrived. The DS0000037483.V375008.R01.S.doc Version 5.2 Page 30 2. 3. OP6 OP7 4. OP8 5. OP9 7. 8. OP12 OP14 9. OP16 10. 11. OP19 OP30 development of the key worker system would assist in making sure people are well informed about the service as they settle in. All the staff involved in the provision of intermediate care should undertake formal intermediate care training including techniques for rehabilitation. The development of a key worker system would ensure that peoples support and rehabilitation is regularly reviewed and personalised to their individual circumstances. As part of a more personalised approach, the service should recognise different peoples willingness and ability to start with the therapy programme at different times. For this reason it is important that staff working in the intermediate care unit are given time to assist people with their therapy programme. The medicine policy should be reviewed and updated in order to ensure it is specific to the service and that the health and welfare of service users taking medication are safeguarded. The service should develop a more consistent approach to offering activities, both therapeutic and for leisure, in all areas of the service. The service should ensure that the action plan for improvements to the dementia respite unit are put into place to ensure the well being, autonomy and choice of people with dementia are fully supported. The service should make sure that people using the service are made aware of the most senior person on duty. This will ensure people are supported and feel confident should they have a concern or complaint. Access to the sensory garden should be considered in recognition of the importance of physical environment to people with dementia illnesses. The manager should have a method of monitoring staff training and development so that staff are able to fulfil the aims of the service and meet the changing needs of people using the service. DS0000037483.V375008.R01.S.doc Version 5.2 Page 31 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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