Inspection on 19/03/09 for Peartree House Rehabilitation Centre

This inspection was carried out on 19th March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peartree House Rehabilitation... 28/09/09

Peartree House Rehabilitation... 22/09/09

Peartree House Rehabilitation... 09/07/09

Peartree House Rehabilitation... 20/04/06

Peartree House Rehabilitation... 30/11/05

Peartree House Rehabilitation... 23/06/05

Peartree House Rehabilitation... 17/11/04

Peartree House Rehabilitation... 11/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Peartree House Rehabilitation Centre 8a Peartree Avenue Bitterne Southampton Hampshire SO19 7JP     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Janet Ktomi     Date: 1 9 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 40 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 40 Information about the care home Name of care home: Address: Peartree House Rehabilitation Centre 8a Peartree Avenue Bitterne Southampton Hampshire SO19 7JP 02380448168 02380434260 lesley.humphrey@peartreerehab.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Peartree House Rehabilitation Limited care home 46 Number of places (if applicable): Under 65 Over 65 0 physical disability Additional conditions: 46 The maximum number of service users to be accommodated is 46. The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Physical disability (PD) Date of last inspection Brief description of the care home Peartree House Rehabilitation Centre consists of an extended house, 3 two-bedroom bungalows and four self-contained flats and a four bedroomed house within the perimeter of the grounds. The home is situated on the outskirts of Southampton city and is within easy access of Bitterne and local amenities. The home is registered with the Commission for Social Care Inspection to provide nursing care and accommodation for up to forty-six people who have sustained an acquired brain injury. The service can accommodate people over the age of 18 years who have a physical disability on admisison. Service users who require only personal, emotional and living skills support and have no nursing needs are housed in the flats Care Homes for Adults (18-65 years) Page 4 of 40 Brief description of the care home and bungalows with a dedicated team who enable these service users to live an independent life suited to their capabilities. Service users who need nursing care are accommodated in the main house and the four bedroomed house named Wyncroft. Peartree House employs a multidisciplinary team that comprises an occupational therapy team, physiotherapy, psychology, speech and language therapist, a rehabilitation consultant, dietician, registered nurses and care staff as well as a full housekeeping, maintenance and administration staff. The atmosphere at the home was pleasant and the internal decor was well maintained and clean. The home is owned by Peartree House Rehabilitation Limited and at the time of the unannounced inspection visit in March 2009 did not have a registered manager. Fees for the serivce are based on the individual level of assessed care and rehabilitation needs and range between 465 pounds for residential care to 3306 pounds for intensive high support nursing rehabilitation per week. Care Homes for Adults (18-65 years) Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This report contains information gained prior to and during an unannounced visit to the home undertaken on the 19th March 2009. All core standards and a number of additional standards were assessed. The unannounced visit to the home was undertaken by one inspector and lasted approximately nine hours commencing at 9.30 am and being completed at 6.30 p.m. The inspector was able to spend time with the person in charge and staff on duty and was provided with free access to all areas of the home, documentation requested and people who live at the home. The service completed an Annual Quality Assurance Questionnaire (AQAA) in June 2008, some information from which is included in this Care Homes for Adults (18-65 years) Page 6 of 40 report. Comment cards were sent to the home for distribution to people who live at the home in September 2008. Ten comment cards were received from people who live at the home and five responses were received from staff who work at the home. Information was also gained from the link inspector and the homes file containing notifications of incidents in the home. The service had a key inspection in April 2006 and an annual service review in September 2007. Compliance with the four requirements made following the key inspection were assessed during this inspection visit. During the visit to the home the inspector was able to meet with and talk to people who live at the home and staff members on duty. What the care home does well: What has improved since the last inspection? What they could do better: One requirement made following the previous inspection has not been complied with. The home was required to ensure that medication prescribed and dispensed for one service user must not be used as a stock supply and administered to other service users. Again during this inspection the home was found to be using medication supplied and dispensed for one person as a stock supply and administered to other service users. Following the inspection seven requirements and two recommendations are made. Although the home has good pre-admission assessments that should ensure that only people whose needs can be met will be admitted to the home, there were concerns Care Homes for Adults (18-65 years) Page 8 of 40 identified in care plans, risk assessments and records of care that indicated that once admitted peoples personal and healthcare needs may not be fully met. The responsible person must ensure that care plans contain all the information necessary for staff to be aware of peoples current needs so that needs can be met. The responsible person must ensure that full risk assessments are undertaken and that risk assessments are reviewed and updated so that people are safe. One qualified nurse undertakes the morning medication round which therefore takes in excess of two hours and results in some people not receiving their morning medication until 10.30 am. The responsible person must ensure that medication is administered at the time that it is prescribed. Medication no longer required by people living at the home must not be retained at the home. Medication administration records must be completed at the time medication is administered. The amount of variable dose medication must be recorded and individual guidelines must be in place for as required medications. These failings put people at risk of harm. The evening meal is served at 5pm with only a drink and biscuit at 8.15 pm. The responsible person must ensure that people are able to have supper and that there is not a prolonged gap between the last meal of the evening and breakfast, so that people are not left hungry. The responsible person must ensure that all staff are fully aware of safeguarding issues and the actions they should take if they suspect that people are at risk of abuse. Staff must have safeguarding training so that they understand how to recognise abuse and people are protected from harm. The responsible person must ensure that all staff undertake all mandatory training including updates so they have the necessary skills to meet peoples needs and ensure their safety. The responsible person must ensure that all pre-employment checks are completed prior to people commencing working at the home so it is ensured that they are suitable to work with the people living at the service. It is recommended that no one employed at the home be the appointee for anyone living at the home and that independent external people fulfill this role. People should be supported to open their own individual bank accounts. It is also recommended that the home should consider how it can ensure peoples freedom under the Deprivation of Liberties Act whilst protecting others who may be at risk. 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. Care Homes for Adults (18-65 years) Page 9 of 40 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 40 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes a comprehensive pre-admission assessment to ensure that only people whose needs can be met at the home are admitted, however staff are not always aware of peoples needs on admission and therefore their needs have not been met. People or their relatives are able to visit the home as part of the admission process. Evidence: The homes admission procedure was detailed in the AQAA and pre-admission assessments were viewed for people admitted shortly before the inspection visit. The inspector discussed new admissions with staff and people living at the home. The AQAA detailed the homes admission procedure stating that where possible the potential service user or their family visit the home prior to admission. The AQAA stated that the home has a comprehensive admission process including multidisciplinary involvement and decision making with an admission coordinator nominated for each referral and that all essential equipment is identified and in place prior to Care Homes for Adults (18-65 years) Page 12 of 40 Evidence: admission. Pre-admission assessments were seen in the service users folders viewed. The homes assessment tool covers relevant areas necessary for the home to decide if it is able to meet a prospective persons needs. Information gained during the assessment is transfered to a detailed assessment report that is discussed at a multi-disciplinary meeting and a decision made as to whether the home is able to meet the persons needs and provide a rehabilitation service. The inspector was able to speak with a person who confirmed the above procedure had occurred, that their relatives had visited the home and that, as they had been unable to visit, they had looked at information about the home via the internet. The inspector spoke with care staff who stated that they felt that they did not always have enough information about new people. They gave an example of a person admitted shortly before the inspection who they had little information about. The carer who had looked after the same person on the morning of the inspection had been unaware about the need to record the persons fluid intake or that this should be carefully monitored for medical reasons. The care plans and risk assessments for the two newly admitted people are discussed in the next section of this report. These care plans and risk assessments did not contain enough information to ensure that peoples needs had been met on, or since, admission. Care staff had been unaware of peoples needs and did not identify the care plans as places where they could have obtained this information indicating that they did not see care plans as working documents used to inform care. Care Homes for Adults (18-65 years) Page 13 of 40 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are in place and have been reviewed on a regular basis however there is insufficient detail in care plans to fully inform staff as to how peoples individual needs should be met. Risk assessments are incomplete and have not been reviewed on a regular basis so that they protect people living in the home. Generally peoples rights to confidentiality have been ensured. People are able to make decisions however there is insufficient information in care plans when peoples rights are restricted and the home has failed to promote dignity in terminology used in records. Evidence: Care plans, including risk assessments for four people were viewed and discussions were held with people who live at the home and staff employed at the home. Four care plans were viewed, two for people newly admitted to the home, one for a person living in one of the homes satellite houses and one for a person with complex needs living in the main home. Care plans all followed a similar format and included Care Homes for Adults (18-65 years) Page 14 of 40 Evidence: risk assessments and records of care given on a daily basis. The inspector identified that not all information pertaining to a person is kept in the care plans. The home has a separate weights folder and also records of care provided at night are held in a separate night log. These were also viewed however all information about a person should be kept together there being a danger that relevant information may not be available at all times. One of the people whose care plans was viewed had been admitted shortly before the inspection. This person required that staff carefully monitor their fluid intake and ensure that the person does not have over a certain amount of fluid per day on medical grounds. The inspector viewed the persons fluid recording chart and noted that this had only been partly completed since admission. The person should also have been weighed daily and the staff member who was unaware of the fluid chart or restrictions was also unaware that the person should be weighed and this had not been done on the morning of the inspection. The care plan and assessment information for another person also admitted shortly before the inspection was also viewed. This again confirmed that relatives were able to visit the home prior to admission and that a comprehensive assessment had been undertaken. When admitted the person has very swollen legs and was receiving medical treatment for this. The care plan identified that the person should be weighed weekly which would monitor the effectiveness of the medical treatment for the swollen legs. Records of the persons weight were viewed in the care plans and separately held weight charts and this evidenced that the person had been weighed approximately one week after admission and then not again for two months. Full risk assessments had not been completed for either of the people whose admissions to the home were viewed during the inspection with one person not having a manual handling assessment completed, no falls risk assessment and the only risks being identified that of leaving the home and from epileptic seizures. One person had been admitted to hospital and returned to the home after approximately two months. The persons needs in many respects had altered however there was no evidence the persons care plan had been update to reflect their changed increased needs on discharge from hospital or guidance for care staff as to how the persons needs should now be met. This is further discussed in the health care section of this report. The care plan for a person living in the main house identified by the lead nurse as having high care needs was viewed along with related records held separately. As with other care plans there was limited space for sufficient details as to how the persons Care Homes for Adults (18-65 years) Page 15 of 40 Evidence: individual care needs should be met. The manual handling risk assessment was dated July 2007 and had not been fully completed making no reference to the need for a hoist and only stating that two staff were required. The manual handling assessment had not been reviewed or updated. There were records within daily notes that the person had physically assaulted staff on at least two occasions however there was no risk assessment in place in respect of the risks to the person or others that their behaviour may have. This put the person at risk of having their needs not met and other people living at the home at risk from the failure to address the impact that the persons behaviour may have on other people. The care plan for the person in one of the satellite homes viewed was of the same format as in the main house. The format of the care plan page is such that it does not provide sufficient space to enable full details as to how a persons needs should be met. An example being that part of a plan stated that a person was to help to do their own laundry in the OT kitchen in the main house. There was no further information as to what the person could do and what help they required with their laundry. Discussion with the nurse in charge indicated that the person required for staff to undertake most of the task however a new or agency staff member may not be aware of this from the care plan. There was similar limited information as to the exact support and help that was required with personal care tasks. This could result in staff doing too much or too little for people, too much and people would not be progressing with their rehabilitation and too little and care needs may not be met or people may become frustrated and upset. The nurse in that part of the service agreed that care plans required more specific detail. Care plans had been reviewed monthly and people had signed care plans. The moving and handling profile was dated 26/03/08 and had not been reviewed or updated. There was also a risk assessment dated the 30/4/07 relating to the person leaving the satellite house to go on their own to the main house, again this had not been reviewed or updated. There were no other risk assessments. The care plan contained a number of older activities plans and the service should review all care plans and ensure that only current information is held with older information archived. This will help ensure that care plans are working documents and make it easier to find relevant information. There was limited information in care plans in respect of decision making. One care plan viewed contained a risk assessment in respect of the person absconding. The home should consider the use of terms such as absconding as it implies that the person is not permitted to leave the home. The home has a range of door security devices that could prevent people leaving the home. One persons care plan detailed how they had been given the code to the front door, however other care plans did not identify why they had not been provided with this information and effectively prevented from leaving the home. Care Homes for Adults (18-65 years) Page 16 of 40 Evidence: During discussions with people living at the home they stated that they were able to do what they wanted and given choice about what time they get up and go to bed. Care staff confirmed that people are given choices. The home has access to Speech and Language Therapists with communication equipment available as part of peoples rehabilitation programmes. The inspector identified an issue about confidentiality of private information when the lead nurse was asked for a persons fluid chart. The lead nurse was unsure where this was and together with the inspector the persons bedroom was visited. The door was unlocked and open. On the wall of the persons bedroom were several forms, one a detailed description of how the persons personal care needs should be met, weight record and information that their fluid intake should be recorded and restricted on medical grounds. This information was available to all staff, and any visitors or other service users who may enter the bedroom. This was discussed with the lead nurse, and person in charge who agreed that this was inappropriate and stated that they would consider alternatives as to where in the bedroom private information should be held. The inspector looked at how the home supports people with their personal money. One of the homes administrators is appointee for a number of people at the home and also for one person who was no longer living at the home. Following the previous inspection it was identified and a requirement made that people must receive interest on the money held on their behalf in a pooled account. The home provides a banking facility for some people and the inspector was shown the records relating to this. People are now receiving interest on a three monthly basis based on what money they have in the account. The home also supports some people with small amounts of personal money. The records and arrangements for this were viewed. Money is held individually with full records kept of what money people have spent and on what it has been spent. The home should explore alternative arrangements for appointeeships and wherever possible people should be supported to open their own external individual bank accounts. Care Homes for Adults (18-65 years) Page 17 of 40 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to enjoy a varied and flexible lifestyle. People are offered a healthy diet and enjoy their meals, however there was a long gap between the evening meal at 5pm and breakfast the next morning and people are at risk of becoming hungry with only drinks and biscuits at 8.15pm provided. Evidence: Discussions with people who live at the home and staff as well as information from surveys completed by people who live at the home in September 2008 and information in care plans are considered. The home provides a range of relevant activities both as part of their rehabilitation programme and to meet social and emotional needs. Pre-admission assessments contained information about the service users interests and previous occupations. Care Care Homes for Adults (18-65 years) Page 18 of 40 Evidence: plans and daily records contained information about activities people had taken part in. Ten people living at the home completed surveys for the commission in September 2008. Seven stated that they could do what they wanted during the day, evening and at weekends. One that they could do what they wanted during the day and at weekends but not in the evening and the remaining two that they were unable to do what they wanted at any time. Discussions with people during the visit to the home in March 2009 indicated that people felt they were able to undertake a range of activities to meet social, leisure and rehabilitation goals. The home employs Occupational Therapists and assistants. The inspector spoke with them and the assistants confirmed that they work until 8pm and at weekends providing a range of activities in and out of the home. They stated that they had a range of equipment and could get additional equipment if this were required. The home has transport suitable for people who live at the home and this is used for social and rehabilitation activities. The home has a computer room with a range of computers. People were seen using this facility, which has staff support, throughout the inspection. People confirmed that the computers can access the internet and that there are the necessary adaptations for people unable to use standard keyboards. People confirmed that they can have visitors and the inspectors observed some visitors during the day of the unannounced inspection. Care plans contained records of visitors and one completed survey stated that the person went home every weekend. People are able to access local health facilities and social and leisure activities in the surrounding area and Southampton. The home has internet and telephone systems available for use by people who live at the home. The inspector observed the main lunchtime meal and was present at the home when the evening meal was being prepared to be served. The inspector spoke with people about the food provided at the home and with kitchen staff. The home has a large dining room where many people were observed to have their lunch with others having their meal at tables in the lounge and in the OT Kitchen. People living in the satellite houses can have either their meals in the main house, however this is generally on special or exceptional occassions, or have them delivered chilled to the satellite houses and these can then be heated up at times suitable for the person. People are provided with a choice at meal times with special diets catered for. Information about special dietary requirements in terms of content or consistency were seen in the kitchen. The chef confirmed that wherever possible fresh vegetables and Care Homes for Adults (18-65 years) Page 19 of 40 Evidence: produce are used and that he has access to a dietitian for advice regarding specific peoples requirements. The kitchen was seen to be of a good size, well equipped and fully staffed. Special equipment is provided when required to maximise peoples independence at meal times. People confirmed that they like the food provided at the home and that if they do not want either of the options available they can request something else which will be provided. The main lunch time meal was served at 12.30 and the evening meal at 5pm. The inspector asked staff serving the evening meal if a supper was provided and was informed that people have a hot drink and biscuit at 8.15 pm. Considering that people living at the home are younger adults, who are likely to want to stay up later, the home should consider how a supper can be provided in the evening. There is currently a long gap between the evening meal at 5pm and breakfast the next morning and people must be provided with the option of something more substantial than just biscuits in the evening. Care Homes for Adults (18-65 years) Page 20 of 40 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not always have their personal and health care needs fully met as care plans do not clearly identify how needs should be met and staff are not aware of all peoples needs. Medication is stored securely however the home has failed to comply with a previous requirement concerning the use of one persons medication for other people, guidelines for individual as required medication are not in place, medication is not always administered at the time that it is prescribed and full and accurate records have not been maintained. The home has failed to ensure that must not keep controlled medication that people no longer require is not routinely kept. Evidence: Information from care plans and risk assessments and other records relating to care are considered along with discussions with qualified nurses, care and other staff and observations during the inspection visit. The arrangements for the storage and administration of medication and related records were viewed and discussed with the qualified nurse on duty. Care Homes for Adults (18-65 years) Page 21 of 40 Evidence: People the inspector spoke with all stated that they felt their personal and health care needs were met. People looked as if their personal care needs were being met. All bedrooms are for single occupancy, some with ensuite facilities, providing privacy with personal care tasks. The home has the necessary equipment within bathrooms and shower rooms. Care staff stated that they generally have sufficient time to meet peoples personal care needs. The home has a visiting GP and in house a clinical nurse specialist for acquired brain injuries. The home has regular multi-disciplinary team meetings and reviews were seen in care plans. Rehabilitation programmes produced by the homes Occupational Therapists were seen for personal care, however the home should consider confidentiality issues when these are displayed on bedroom walls. Concerns about the homes care plans and risk assessments have been identified in previous sections of this report. Requirements in respect of care plans and risk assessments have been made. Care staff stated that they had been unaware of a new persons care needs and there was evidence from records of fluid intake and weights that peoples health care needs were not being fully monitored. People are therefore at risk that their health needs are not being met placing them at risk. There were also gaps in the recording of peoples PEG feeds. The home does not record all information in one place, information was found in separate weight records folder and in a night care folder. Some of the information held in a different places contradicted itself. The home must review the way it records information about people with all information about people being held in one place so that all information is readily available and peoples needs are met safely. Of the four people whose care plans were viewed, moving and handling risk assessments had not been reviewed for one person, had not been completed for another, and had only partially been completed for a third person. A qualified nurse showed the inspector the storage, administration and records relating to medication. Although two qualified nurses are on duty in the morning, only one of them is responsible for administering the morning medication. The qualified nurse stated that the medication round commences at about 8.15 am and is usually completed by 10.30 am. The morning round therefore lasting in excess if two hours. Whilst viewing the home with the person in charge the inspector observed the qualified nurse administering medication at 10.15am. The Medication Administration Records showed that most morning medication should be administered at 8am. The length of the morning medication round will mean that some people will be receiving their morning medication late and with regular medication there may be an insufficient gap before the next administration at lunch time is administered. Too close or too long a Care Homes for Adults (18-65 years) Page 22 of 40 Evidence: gap between administrations may result in people becoming ill. The home is required to ensure that medication is administered at, or near, to the time that it is prescribed. All medication was seen to be stored securely either in a trolley secured to a wall or in locked cabinets in a locked medications room. The home has suitable storage for controlled medication and the necessary recording books. The inspector identified that much of the controlled medication being held was no longer in use. The home must not retain medication that is no longer required by people living at the home. The medication and related records for one of the new service users was viewed. The home has spare medication administration record sheets that it uses for new people with nurses handwriting the medication onto the sheets. The home must ensure that two nurses sign the medication administration record sheets when they handwrite prescriptions onto them. This provides a double check of the medication being transcribed. The home had all the medication for the service user sampled. There were gaps in the medication administration record. The qualified nurse realised that they had not signed the record sheet when they had administered the morning medication and signed this at 2pm. There were other gaps and the medication was audited which indicated that the person had not received the medication where it had not been signed. Following the previous inspection a requirement was made that medication prescribed and dispensed for one service user must not be used as stock supply and administered to other service users. Within the medications trolley was one bottle of a liquid laxative with a service users name on it. In the cupboards used to store additional medication supplies there were several bottles of the same medication with a range of service users names on them. These had all been dispensed shortly before the inspection visit. The qualified nurse confirmed that the one bottle in the medications trolley was the only one in use and that it would be administered to other people than the person whose name was on the bottle. The home has therefore failed to meet this requirement. This was discussed with the person in charge and they stated that they would ensure that this practice stopped. They had been unaware that this was occurring. When viewing medication administration records it was noted that there was no photo for the new service user. It was also noted that some people are on variable doses of medications and that it had not been recorded on all occasions how much had been administered. Some people are on as required medication. The qualified nurse confirmed that they did not have individual guidelines as to when nurses should administer as required medication putting people at risk or not receiving medication when they needed it. Care Homes for Adults (18-65 years) Page 23 of 40 Evidence: The home has a fridge for the secure storage of medication that must be kept at cooler temperatures. The home had a maximum/minimum thermometer but was only recording the actual temperature of the fridge at the time of recording. The home could therefore not demonstrate that the fridge had not become too hot or too cold and medication stored therein not damaged. Care Homes for Adults (18-65 years) Page 24 of 40 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. The home does not have the necessary procedures in place to ensure that peoples health and personal care needs are met placing people at risk of neglect. Evidence: Information from the homes AQAA, comment cards received, discussions with service users and staff and records viewed are considered. The AQAA stated that the homes formal complaints procedure is displayed in the main reception area and this was seen to be the case during the unannounced inspection visit. Comment cards from people who live at the home completed in September 2008 stated that they all knew how to complain. Discussions with people who live at the home also evidenced that they were aware of how to complain and that should they have any complaints they would raise them with the person in charge. No complaints about the home were made to the inspector during the visit to the service or in comment cards received. Comment cards from staff also stated that they were aware of what to do if a person or their relative wished to complain or raised a concern. Care Homes for Adults (18-65 years) Page 25 of 40 Evidence: The AQAA stated that the service had not received any complaints in the preceding year. No complaints about the service have been received at the commission. The home has a policy and procedure relating to safeguarding adults and ensuring that people are not at risk of abuse. The training matrix provided to the inspector evidenced that many staff have not undertaken safeguarding training. During discussions with staff (of all groups) they were clear that they would not accept abuse of people at the home and that they would challenge this however none were completely aware of the actions they should take if they suspected that abuse may have occurred other than informing the person in charge. They did not identify that they should contact the local social services if they felt that people at the home were at risk. This was discussed with the person in charge who agreed that clear and straightforward guidance could be provided on staff notice boards about safeguarding procedures including phone numbers for local social services safeguarding teams. The person in charge also stated that safeguarding adults training was planned for May 09. People living at the home stated that they felt safe and happy and did not raise any safeguarding concerns. Safeguarding training is not included in the homes induction programme with two new staff spoken with confirming that they had not yet undertaken safeguarding training. The inspection identified concerns, and requirements are made in respect of the management of medication, care plans and risk assessments that evidenced that peoples health and personal care needs are not always being met. Evidence in respect of this is recorded in the relevant outcome groups. The homes policies and procedures in respect of recruitment do not currently fully ensure that unsuitable people are not employed at the home. Care Homes for Adults (18-65 years) Page 26 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well maintained home that meets their individual and collective needs. Evidence: The person in charge showed the inspector round the main home towards the start of the inspection visit. The inspector also visited one of the satellite houses Wyncroft. The inspector viewed records related to the homes environment and discussed the home with people who live there and staff. The home is fully accessible to people with a physical disability, however freedom of movement is restricted by keycodes and high buttons to open doors. Within two of the care plans viewed there were no risk assessments to indicate that people should not have freedom of movement. In one care plan viewed there was a risk assessment that determined that a person should have the key-code number to enable them freedom of movement to leave the home. The fourth care plan contained a risk assessment that the person was at risk of absconding. This terminology is negative and implies that the person does not have freedom of movement. The home should consider how the environment can meet the requirements of the Deprivation of Liberties Act. The home comprises of a large older house that has been extended to provide a Care Homes for Adults (18-65 years) Page 27 of 40 Evidence: purpose built environment for the service user group accommodated at the home. There are also several houses located nearby and accessible via the homes grounds that are within the registration of the home. The home has pleasant gardens to the rear and a good sized parking area to the front of the home. All areas of the home are accessible to service users with a lift provided to the first floor. The home was noted to be well maintained throughout and provides all single bedrooms, appropriate communal areas and space for therapists, nursing, ancillary and administration staff. Furnishings, fittings, adaptations and equipment are good quality and are as domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose. The home has its own maintenance staff. The home has a large amount of equipment as required by the people who live there, however storage for equipment is limited. All bedrooms are for single occupancy and suitable for their occupant. Discussion with the person in charge indicated that consideration is given as to where in the home vacant rooms are located when a new person is considered for admission. All bedrooms are fitted with a nurse call system and doors have locks. At the time of the previous inspection some bedrooms were noted to have an unpleasant odour and a requirement was made that the home must ensure that there are no unpleasant odours in bedrooms. This requirement has been met and no unpleasant odours were noted during this unannounced inspection visit. People stated that the home was usually clean. The home has specific domestic staff who stated that they have sufficient time and the necessary equipment to keep the home clean. Care staff confirmed that they have undertaken infection control training and have the necessary infection control equipment such as disposable gloves, aprons and antibacterial hand gel to prevent the risk of cross infection. Care Homes for Adults (18-65 years) Page 28 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home employs appropriate numbers of staff who should be able to meet peoples needs. People have commenced working at the home before all pre-employment checks have been completed placing people at risk. All staff have not completed all mandatroy training or relevant additonal training to ensure that they have the necessary skills to meet peoples needs and ensure their safety. Evidence: Information from discussions with staff and people who live at the home, recruitment and training records, information from surveys completed in September 2008 by service users and staff and observations during the inspection are considered. All comments from people who live at the home were positive about the homes staff. People felt that they received the care and support that they required. People also felt that there were generally enough staff and that they were available when they need them. Of the ten comment cards completed by service users in September 2008 eight stated that staff always treat them well the remaining two responding usually to this question. In addition to nursing and care staff (rehabilitation support workers) the home also Care Homes for Adults (18-65 years) Page 29 of 40 Evidence: employs appropriate numbers of cleaning, administration, maintenance and kitchen staff. The home has its own Occupational Therapy staff and OT assistants who confirmed that they work until 8pm and at weekends providing rehabilitation and social/leisure activities and opportunities. The home also has physiotherapy, speech therapy and dietitian staff available. Staff stated that they felt they generally had enough time to meet peoples needs and that although agency staff are sometimes used staff will also cover additional shifts when required. Comment cards from five staff completed in September 2008 stated that the home always (1), usually (2) and sometimes (2) has enough staff. One of the staff who stated sometimes added the comment staffing is always a difficult issue, you can never have enough, in a unit where you strive to deliver the best, more staffing equals more time and just means you aim to do more and your expectations of your service are greater and of a higher quality. Another added we use agency staff if there is a shortage or someone has called off sick. We tend to use the same staff who are regular for us from the agency. The duty rotas were viewed and evidenced that in the main house two qualified nurses and care staff (rehabilitation support workers) are provided throughout the day and night. The satellite homes are supported by their own staff teams with qualified nurses in Wyncroft and rehabilitation support workers in the other satellite accommodation. Occupational Therapy assistants work until 8pm and at weekends. During the inspection visit there appeared to be sufficient staff on duty with staff having time to complete NVQ paperwork and assessments during their working day. The home has its own training manager who provided information about staff training and qualifications. A copy of the training matrix showing what training staff have undertaken was provided to the inspector. The training manager stated that fifty-two percent of the homes care staff have an NVQ level 2 or 3 in care. Additional care staff are undertaking an NVQ in care with an assessor in the home on the day of the inspection visit and staff completing units of the course. The training manager provided the inspector with a copy of the homes training matrix. This was discussed with him and with the person in charge. The matrix evidenced and the training manager and person in charge confirmed that not all staff have completed all mandatory training including manual handling updates and safeguarding. Staff confirmed that they had not all completed safeguarding training. The home must ensure that all staff undertake all mandatory training including updates so that they have the basic skills to meet peoples needs safely. Care Homes for Adults (18-65 years) Page 30 of 40 Evidence: The home has a comprehensive induction for new staff which lasts a week and includes initial training in fire, manual handling, an introduction to brain injury, food hygiene and infection control. Safeguarding is not included in the homes induction training. The training matrix provided to the inspector evidenced that few care staff have undertaken training in managing and understanding challenging behaviour, or further training in acquired brain injuries. Three of the four care plans viewed contained evidence that the people whose plan it was had some level of challenging behaviour. The home must ensure that staff have relevant training, in addition to mandatory training to give them the skills to meet peoples needs. The homes recruitment processes were discussed with the services Human Resources manager and records relating to these were viewed. Staff confirmed that they had completed application forms, attended interviews, met service users as part of the interview process and undertaken CRB checks. The records for new staff on duty on the day of the unannounced inspection were viewed. Three were seen and none contained all the necessary evidence to show that correct recruitment procedures had been followed to ensure the safety of the people who live at the home. The first was for a staff member who had previously worked at the home, then worked abroad for a year and then returned to England and to work at the home. The home had sought only one reference for this person from the hospital they worked in whilst abroad. This had been received five months after the person had commenced working in the home. The person had also commenced working in the home four weeks before the POVA check had been received. The person had therefore commenced working at the home before any pre-employment checks had been received. The second person had only one reference received when they commenced employment although the POVA and CRB were in place. The third person whose file was viewed had commenced working at the home on a weeks induction the day that their POVA check came through, and approximately two weeks later the first reference was received and a second reference had still not been received. The inspector was informed that verbal references had been received however the home could provide no evidence of this. People have been placed at risk by the homes recruitment procedures and the home must ensure that all pre-employment checks are completed (two written references and a clear POVA check) prior to people commencing working at the home. The inspector was shown evidence that the home checks the registration details of qualified nurses and professional allied to medicine (OT, Physiotherapists etc) as part of the recruitment process and has procedures in place to check re-registrations as these become due. Following the previous inspection a requirement was made that staff must receive Care Homes for Adults (18-65 years) Page 31 of 40 Evidence: supervision from an appropriately trained senior staff team. Discussions with staff indicated that they felt appropriately supervised and that they could approach a senior person within their profession (OT etc) or the person in charge should they have any concerns. Five staff completed comment cards in September 2008 and these stated that they receive supervision regularly (3) and often (2), one adding its done two monthly through supervision and informal discussion through team briefing and handovers times. The person in charge explained that the home uses a cascade system for supervision and that training for staff who undertake supervision is planned. This requirement has therefore been met. Care Homes for Adults (18-65 years) Page 32 of 40 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home lacks the benifit of a registered manager. People are consulted about their home and a representative of the provider visits the home on a monthly basis to assess the quality of the service provided. Shortcomings in the homes recruitment, medication and care planning/risk assessments means that people living at the home may not have their needs fully met and they may be at risk of harm. Evidence: Information from the homes AQAA, discussions with the person in charge, service users and staff and records viewed during the inspection visit are considered. The home does not currently have a registered manager. The person in charge at the time of this inspection stated that they would be applying to become the homes registered manager but has failed to commence the process. The previous registered manager left the home following promotion withing the provider company in December 2008 and the new person in charge commenced working at the home in December 2009. The commission was informed about these changes at the time they occurred. Care Homes for Adults (18-65 years) Page 33 of 40 Evidence: The inspector clarified the registration process with the person in charge. The person in charge stated that she is a qualified nurse and has a professional background in management and quality auditing. The person in charge is supported by a clinical nurse specialist in acquired brain injury. The AQAA was completed by the previous registered manager in June 2008. The AQAA was completed to a good standard and identified future improvements the home wanted to make. The inspector was provided with copies of the visits undertaken to the home on behalf of the provider (Regulation 26 visits). A representative of the provider undertakes regulation 26 visits every month with copies of these being viewed. It was not clear if these were unannounced however the reports showed that service users and staff are consulted about the service during the visits. The person in charge has to complete a response to any points raised by the reg 26 visits and reports. The Regulation 26 reports identified some, such as the fact that in December and January the homes fire alarm system had not been checked every week, but not all of the issues raised in this report. The commission will be requesting an improvement plan from the home. The home has a service user charter group that meets to raise issues and the person in charge stated that when issues are raised these are addressed. The person in charge gave an example of how the variety of food had been changed as a response to the charter group. Service users stated that they felt able to raise issues with staff and the manager. Service users or their representatives are fully involved in their care reviews. The home fails to keep satisfactory records relating to peoples care such as care plans, risk assessments, medication records, incident sheets, fluid, food and bowel records placing people at risk that their needs may not be safely met. There were also concerns about the homes recruitment records. Requirements have been made in respect of these and the home must ensure that full and accurate records are maintained. Concerns in respect of the safety of people living at the home have been raised in that there is evidence that they are not always receiving the care they require and staff have not all completed all mandatory or additional training. Concerns in respect of administration of medication have also placed people at risk. One requirement made following the previous inspection has not been complied with. Care Homes for Adults (18-65 years) Page 34 of 40 Care Homes for Adults (18-65 years) Page 35 of 40 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 36 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 The responsible person must 01/06/2009 ensure that care plans contain all the information necessary for staff to be aware of peoples current needs. To ensure that peoples needs are met. 2 9 13 The responsible person must 01/06/2009 ensure that full risk assessments are undertaken and that risk assessments are reviewed and updated. To ensure that people are safe. 3 17 16 The responsible person must 01/06/2009 ensure that people are able to have supper and that there is not a prolonged gap between the last meal of the evening and breakfast. So that people are not hungry. 4 20 13 The responsible person must 01/06/2009 ensure that medication is Page 37 of 40 Care Homes for Adults (18-65 years) correctly recorded, managed, stored, safely administered and correctly disposed of within the home. So that medication is managed correctly and people are safe. 5 23 13 The responsible person must 01/06/2009 ensure that all staff are fully aware of safeguarding issues and the actions they should take if they suspect that people are at risk of abuse. So that people are safe from abuse. 6 34 19 The responsible person must 15/06/2009 ensure that all preemployment checks are completed prior to people commencing working at the home. So that people are safe. 7 35 18 The responsible person must 01/06/2009 ensure that all staff undertake all mandatory training including updates. So that staff have the basic skills to meet peoples needs safely. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 It is recommended that no-one employed at the home be the appointee for anyone living at the home and that independant external people fulfill this role. Page 38 of 40 Care Homes for Adults (18-65 years) People should be supported to open their own individual bank accounts. Care Homes for Adults (18-65 years) Page 39 of 40 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 40 of 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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