Inspection on 09/07/09 for Peartree House Rehabilitation Centre

This inspection was carried out on 9th July 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 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... 19/03/09

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.

Random inspection report Care homes for adults (18-65 years) Name: Address: Peartree House Rehabilitation Centre 8a Peartree Avenue Bitterne Southampton Hampshire SO19 7JP one star adequate service 19/03/2009 The quality rating for this care home is: The rating was made on: 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 review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Janet Ktomi Date: 0 9 0 7 2 0 0 9 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 Conditions of registration: 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 Care Quality Commission to provide nursing care and Care Homes for Adults (18-65 years) Page 2 of 19 1 9 0 3 2 0 0 9 Brief description of the care home 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 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 home is owned by Peartree House Rehabilitation Limited and does not have a registered manager. Care Homes for Adults (18-65 years) Page 3 of 19 What we found: Three inspectors, including a pharmacy inspector, visited the home on the 9th July 2009 to undertake an unannounced random inspection. Information and requirements resulting from this visit are included in this report as well as information gained from the local safeguarding team and other information received at the commission. We found that six of the seven requirements made following the previous key unannounced inspection undertaken on the 19th March 2009 had not been met and the home was continuing to fail to ensure that people are safe. Additional requirements were made following this random inspection. The home does not have a registered manager and we have been informed that since the random inspection on the 9th July 2009 that the person who was in the process of applying to the commission to become the homes registered manager is no longer employed at the home. Since the key unannounced inspection of 19th March 2009 serious safeguarding concerns have been brought to the attention of Social Services and these continue to be investigated. The home has voluntarily agreed not to admit new people during the ongoing safeguarding investigation. Social services and placing authorities are in the process of reviewing people living at the home. Following the key inspection undertaken in March 2009 a requirement was made in relation to the way that medication is managed in the home. A requirement was made that the responsible person must ensure that medication is correctly recorded, managed, stored safely, administered and disposed of correctly. The safe handling of medicines was assessed by a Commission specialist pharmacist inspector. They looked at the medication records and medicine supplies for ten people, the care plan for one person, the policies and procedures for medication handling and talked to staff. The inspection focused on the requirement made on the safe handling of medicines made at the key inspection of 19th March 2009. We found that this requirement had not been met. All medicines were stored securely for the protection of people who use the service. Medicines needing cool storage were kept in a fridge. The temperature of the fridge was monitored and recorded daily. The records showed it to be running too cold and at a temperature that would damage the medicines kept in it. No action had been taken by the staff despite their recording that the fridge was too cold. This places people at risk of recieving medication at an incorrect temperature which may cause them harm. Medicines that can be misused, known as Controlled Drugs, were stored correctly. The excess stock that had been in the home when we last visited had been removed and disposed of safely. Most people have their medicines given to them by either registered nurses or by care staff who have been trained and assessed as competent to handle medicines. Two people in the independent living units look after their own medicines. One person had the risks Care Homes for Adults (18-65 years) Page 4 of 19 associated with this assessed but the other person had not. The assessment of risk did not say how the risks that had been identified were to be minimised. There was no reference to risk assessment in the services policy on self medication. This could put people at an unnecessary risk of harm. Some people have their medicines given to them via their PEG feeding lines. This means that if a liquid medicine is not available from the manufacturer then tablets have to be crushed. In line with best practice guidance the services policy is that when medicines are crushed this needs to be done with the agreement of the prescriber, as crushing can alter the characteristics of the medicine. Of the three people looked at whose medicines were given in this way only two had the agreement of the GP in place. Any handwritten additions to the medication administration record charts, supplied by the pharmacy, were signed and dated by the nurse making the entry and then checked by a second nurse to see that they were correctly written. If people were allergic to any medicines this was clearly documented on the front of their medicines record files. However allergies were not always listed on the medication administration record charts. It is important that details of peoples allergies is clearly and consistently recorded so as to prevent someone being given a medicine that they are allergic to and becoming ill. The records and medicines supplies showed us that most people get their medicines as prescribed. However one person had been without one of their medicines for three days. This could have lead to deterioration in their condition. Another persons record showed that they had been given one of their regular medicines on just two occasions in the last three weeks. When we looked at the supplies for this person all of their tablets had gone, indicating that they had possibly had their medicine but the nurses had failed to record this. The records for another person showed that they were being given their medicines, which are prescribed to be given twice daily, with a very short time gap between the doses. This was being done to fit in with this persons lifestyle. However no consideration had been taken as to whether it was safe to give the doses so close together and then to have a long interval before the next dose was given. This could be detrimental to the health of this person. A care plan was available for one person who had been prescribed a strong pain killer to be given only when they needed it. This had been reviewed and updated when the persons needs changed. Staff had access to detailed written procedures on the safe handling of medicines. They were dated 2004 and referred to outdated and illegal practices that are no longer in place in the home. So as to avoid confusion the procedures must be updated and describe the current ways staff are expected to work. The presence of policies and procedures that are out of date places people at risk of harm. Following the key unannounced inspection in March 2009 concerns were noted and a requirement made in relation to care planning and the responsible person was required to ensure that care plans contained all the information necessary for staff to be aware of peoples current needs so that peoples needs are met. We viewed care plans for four people. The home has separated out the current and historical information that had previously been held in one file. Many of the care plans have been re-written since the inspection in March 2009 and care plans and risk Care Homes for Adults (18-65 years) Page 5 of 19 assessments were in place for most areas of daily living providing basic information but lacking clarity about how individual needs should be met. People living at Peartree House have complex needs however the care plans do not provide a useful working tool to inform care and it was not evident how information from these is used to inform the delivery of care on a day to day basis. There were inconsistencies within care plans and between other records held for the same person. Care plans have not been consistently reviewed. The requirement in respect of care plans has not been met and the home cannot show that peoples needs are being met and they are safe. One care plan viewed was for a person who required support to manage their behaviours appropriately. There was an ABC (assessment chart) completed for an incident in the persons care plan however there was no further reference to this incident in the persons care plan. We asked staff about this and were informed that the incident would have been discussed at the multi-disciplinary team meeting however there was no evidence in the multi-disciplinary team meeting minutes concerning this or other events in the persons file that were of a safeguarding concern. Staff were therefore recording events and no action being taken to address the issues or of the information being used to inform care for the person. Within care plans there did not appear to be any correlation or cross referencing between one part of a plan and other parts of the plan and risk assessments. An example being a care plan for a person whose behaviour could present a risk to themselves, staff or other people. The commission had received notifications about incidents involving this person, however there was no reference to behaviour in respect of how staff should provide personal care or moving and handling. An example being of a risk assessment and plan for moving and handling which describes a particular procedure which was different to that shown to the inspector for use with the person. Staff are therefore working outside of all guidelines and placing people at risk. Another care plan had inconsistencies in place in respect of the persons fluid intake. The multi-disciplinary team meeting dated 7th July 2009 referred to fluid intake via a PEG and that the person can also have juice with a specific amount of thickener in it. The care plan states that the person is required to drink 2 litres of fluids every day and does not refer to PEG fluids or the risks of chocking or the need for thickened fluids. The same persons care plan to manage continence also states that the person must drink up to 2 litres of fluid a day and output to be monitored and a risk assessment states that the person is at risk of retention dehydration and that input and output are to be monitored. There is no mention as to how this is to be achieved and no reference to the persons PEG feed. Fluid charts were seen for this person however these had not been fully completed. On the 1st July 2009 there was a new form dated but with no entries and no record for the 2nd July 2009. On the 3rd July 2009 there was 400mls records and no totals. On the 4th July 2009 600mls of juice and 500mls water via a PEG x3 and that there had been four wet pads. On the 5th July 2009 there was 400mls juice and no information about fluids via the PEG or any urine output. On the 6th July 2009 600mls juice and one wet pad recorded. On the 7th July 2009 there was no fluid intake recorded and one wet pad and on the 8th July 2009 600mls juice and three wet pads. The enteral feeding plan for the person states that they should receive PEG 1500ml water, soft diet and at least 500mls drinks and to record intake. We had a discussion with senior nursing staff about the monitoring of the persons urinary output and were informed that as the person uses a continence pad that it is not possible to monitor the output. We asked if they were aware Care Homes for Adults (18-65 years) Page 6 of 19 how they could calculate fluid output for people who use continence pads and there were unaware how to achieve this. This is possible if pads are weighed. Staff do not have the necessary skills to meet this persons needs and they are at risk of becoming dehydrated. We looked at other fluid charts and found that these had also not been fully completed and did not provide an accurate record of what people have received. An example being fluid charts for a person where records were available for 20th June 2009 when the chart was not totaled and only 500mls output was recorded for that day, and on the 21st June 2009 only 800mls intake was recorded and the chart had not been totaled. No charts were then available for this person until the 26th June 2009 when again the chart had not been totaled. There were concerns noted in the inspection report following the unannounced key inspection in March 2009 when it was noted that staff had failed to monitor the fluid intake of a person who required a restricted fluid intake on medical grounds. A care plan identified on the 11th June 2009 that staff should monitor a persons continence however there were no records on this. Nursing staff provided a chart that was in the persons bedroom however this had not been completed since the 4th July 2009. One senior nurse stated that staff must have missed filling in the form and another that the form had been discontinued as recording was no longer necessary (although the form was still in the persons bedroom). We asked if the persons needs had changed and were informed that the persons needs had not changed however it had been agreed at the multi-disciplinary team meeting that it was no longer necessary to keep records. When we looked at the multidisciplinary team meeting minutes for the 7th July 2009 the meeting stated that the recording should continue. There was no mention of the persons needs changing in the service users notes or care plan. A number of people living at the home receive nutrition via a PEG feeding system. The records for these were viewed and most contained no reference of the additional fluid that people would have been receiving when the systems were flushed prior to or following a feed or medication being received. The charts had also not been consistently totaled at the end of each day to record the full amount a person had received. Other inconsistencies in care plans and Multi-disciplinary team meeting notes were also identified. One care plan viewed stated on the personal hygiene sheet that they should have a bed bath except on a Thursday when they should have a shower using an varifoam pillow to aid the base of the shower chair. There was no information in the care plan about the use of the shower chair with the varifoam pillow. The records for the persons personal care for June 2009 stated that they had had a bedbath every day, the personal care records for other months did not state which month they related too and had not been fully completed. There was no evidence that the person was receiving a shower on a Thursday. Another care plan viewed contained gaps on their personal hygiene record throughout June 2009 when it would appear from records that no personal care was provided. There was other information in care plans viewed which indicates that people are not getting their personal and health care needs met. One care plan stated that a person should be weighed weekly with records showing that they had been weighed on the 8/6/09 (59kg), 28/6/09 (56.5kg) and 3/7/09 (55.5 kg). There was other information in the persons care plan that indicated that the person was not receiving all their nutritional needs as stipulated by the dietitian, with notes of not all feed being given. Care Homes for Adults (18-65 years) Page 7 of 19 The persons care plan stated that they had received new glasses in June 2009 however they were not wearing these on the day of the inspection. One care plan viewed stated that a person should receive thickened fluids however there was no indication throughout the care plan on pages relating to nutrition how thick these should be. At the end of the care plan we found guidelines provided by the Speech Therapist dated January 2009 which stated that the person should have thickened fluids to syrup consistency, pureed diet and that they should have their meals in an area free from distractions. The person was seen having their lunch time meal in the busy dining room. We asked the senior nurses how care staff would know what type of diet and fluids the person should have and were informed that copies of the speech therapist guidelines were kept in the dining room. We looked at this in the dining room and a folder containing a number of peoples guidelines was present. The one for the person whose care plan we were viewing was dated July 2008 and stated normal fluids and mashed food. it was later confirmed by the speech therapist that the person should be receiving thickened fluids and pureed diet. Another person whose care plan was viewed was observed in their bedroom resting in bed. They had been identified at high risk of developing pressure injuries (the home using the term pressure sores in care plans) and were on an airflow pressure mattress. The person did not look as if they weighed much and the pressure mattress was set on level 4. We checked the persons weight and asked the senior nurse about the pressure settings as these appeared high considering the persons weight. The senior nurse was unsure about the mattress settings and informed us that the maintenance person set the mattress settings. We asked her to find the manual and she returned approximately ten minutes later stating that the settings were on the reverse of the power pack. We returned to the persons bedroom with another senior nurse and looked at the settings and information. These indicated that the settings should have been at level 3 based on the persons weight. Senior nursing staff should be aware of how to use equipment correctly. Within care plans there were daily record sheets however these did not always appear to run consecutively. One viewed contained two page 85s and also an added page for the 4th June 2009 and another page with information for the 4th June 2009 and following on to the 5th June 2009. Care plans are written on to forms which have limited space for the actions that staff should take to meet the persons needs. It was noted that some staff had continued onto the reverse of the form and others had tried to squeeze information into the available space. The limiting of space on care plan forms means that staff may be discouraged from writing enough information or that the information is not in order as more is written at the bottom or reverse of the forms. There was no information in any care plans viewed about access to dentists. There was reference to podiatrists and opticians however one person was seen not wearing their new glasses. One care plan daily notes stated that a person had vomited coffee grounds, which may indicate a gastric bleeding problem. We asked what had happened about this as there was no further information in the care plan. We were informed that it would have been reported to the GP but the senior nurses could find no record of this and the senior nurses had been unaware of the incident. Care Homes for Adults (18-65 years) Page 8 of 19 In one care plan there was a bowel chart which evidenced that the person was not having regular bowel actions. Recordings had not been made every day but when they had either small or smeary had been recorded for ten days until one nurse gave suppositories. Other records in the persons care plan stated that the person was agitated and unsettled during these ten days. There was no specific bowel management plan in place for this person. There were issues identified in all care plans in respect of reviewing these. One stated that a specific need should be reviewed fortnightly and was seen to have been reviewed on the 4/5/09, 22/5/09, 26/5/09 with no reviews in June and then 7/7/09. Within the same plan which stated review monthly there had been no reviews since the 26th May 2009. Care plans do not fully inform the delivery of care and therefore the requirement in respect of care plans has not been met. An additional requirement is also made that the home must ensure that full records are maintained for all people to ensure that their needs have been met and keep them safe. An additional requirement is also made that the home must ensure that peoples health and personal care needs are fully met to ensure that they are safe. A requirement was made following the previous inspection that full risk assessments must be undertaken and that risk assessments must be reviewed and updated. This was required to ensure that people are safe. Risk assessments were seen in peoples care plans and many, but not all, had been written since the inspection in March 2009. As with care plans risk assessments are completed on to forms which have limited space considering the needs of some of the people living at the home. One risk assessment viewed had additional information on the reverse of the sheet which provided clear guidelines and information as to exactly how a risk should be managed. One person had a pressure area risk assessment (waterlow) which showed that they were at very high risk of developing a pressure injury however they did not have a plan of care to describe how this risk should be managed and the persons needs met. We requested the senior nurses to check the file to see if we had missed this, however they confirmed that it was not present and that they had omitted to do a pressure area care plan for that person. Pressure area plans were in place for other people. One risk assessment seen was dated May 2007 and stated that a person should have an airflow mattress with a fitted sheet over this. The use of fitted sheets with airflow mattresses is incorrect and prevents the mattresses working effectively to reduce the risk of pressure injuries. When we looked at the persons bedroom they did not have an airflow mattress on their bed. One plan contained a risk assessment that the person was at risk of neglecting their personal care due to the level of their disability, however it was not clear how this risk should be managed. The risk assessment dated 25th May 2009 stated review one month however there was no evidence that this had been reviewed. In the same care plan there were other risk assessments which stated monthly review or ongoing review however again there was no evidence that these had been reviewed. Similar issues concerning the Care Homes for Adults (18-65 years) Page 9 of 19 reviewing of risk assessments that stated they should be reviewed monthly were found in all care plans viewed. The manual handling profiles/risk assessments seen in care plans were general documents and did not contain specific information about a persons individual characteristics such as behaviours that may impact on moving a person safely. There were also no risk assessments for other equipment such as shower chairs that were in use for people. The requirement for risk assessments has not been met and is repeated. The responsible person must ensure that full risk assessments,, are undertaken and that risk assessments are reviewed and updated to ensure that people are safe. Following the previous inspection a requirement was made that the responsible person must ensure that people are able to have a supper and that there is not a prolonged gap between the last meal of the evening and breakfast. This was required to ensure that people are not hungry. The evening meal is served at approximately 5pm. We looked at the menu record for service users. The catering staff record any exceptions to the published menu in the food diary. We asked the kitchen staff if they kept a record of the supper/snacks eaten by service users in the evening. We was told that the catering staff did not do this. It was the responsibility of the care staff. We were provided with a copy of a supper and snack menu available to service users. When we asked senior nurses about how the home had addressed the requirement made at the last inspection related to the long period between dinner and breakfast the next day we were informed that well everyone has tea and biscuits and one service user has a sandwich because of his diabetes. We asked if it could demonstrate that other service users had anything more substantial than a biscuit and did the home keep any records of meals eaten in the evening. we were informed that there were no records available. We asked if there was any other information or examples to show that service users were being offered something more than a biscuit but none was available. We were informed that if people request food this would be given, however many people have communication needs and would not be able to request additional food if hungry. There is therefore no evidence that this requirement has been met and that people are being provided with supper and that there is not a prolonged gap between the evening meal at 5pm and breakfast the following morning. It was identified during the inspection in March 2009 that staff working at the home had not received safeguarding training and were unaware of safeguarding issues and the actions they should take if they suspect that people are at risk of abuse. This was required to ensure that people are safe from abuse and harm. Since the inspection in March 2009 the local safeguarding team and police public protection unit have been conducting an investigation into allegations of abuse at the home. The investigation is ongoing and concerns peoples needs not being met. The issues were not raised by staff from the home but by external professionals and family members. Care Homes for Adults (18-65 years) Page 10 of 19 The commission received a notification from the home which should have been reported to safeguarding as it related to bruising and marks of unknown origin. The commission passed this information on to the safeguarding team. Records viewed during the inspection indicated that there had been a delay in the home acting to protect a person from injury. Records showed that night staff reported bruising but no action was taken which might have prevented more significant bruising several days later. No reference to safeguarding was made and the home undertook an internal investigation. An incident report dated 25/6/09 stated that the persons bed rail bumpers were noted to be worn and cracked however a risk assessment completed on the 22/6/09 stated that the bed bumpers should be replaced as they were suffering from wear. Approximately two weeks prior to this it was noted that the padding on the persons chair required replacing and had been removed and they were awaiting agreement for funding. It would therefore appear that timely action was not taken to ensure that equipment was fit for purpose and to prevent injury to the person. In another persons care plan there were a number of entries where the person had made allegations or raised concerns about their personal safety including specific allegations that they had been assaulted by a staff member. Although these incidents had been recorded on behaviour charts there was no evidence that any action had been taken in respect of them. We asked the senior nurses about this and were informed that this would have been discussed at the multi-disciplinary meeting but there was no evidence that this had occurred or that the incident had been reported to safeguarding as per correct procedures. The senior nurses did not appear to appreciate that this was a serious allegation and were unaware of how they should report allegations or incidents of abuse or where they could seek guidance about this. Also seen were records where a service user had expressed concern that another service user may enter their bedroom at night and had requested that their door be locked to prevent this occurring. These had been recorded by the night staff. We asked the senior nurses if any action had been taken and they had been unaware of the concerns or incidents. The multi-disciplinary team record dated 7/7/09 stated in the section on behaviour one area of concern is that the service user has persecutory paranoid thoughts. No further episodes of this behaviour since February 2008. Discussions indicated that the concerns were legitimate as the person they were concerned about was independently mobile and had a history of entering peoples rooms. The home had either taken no action to address a real concern or taken no action when a persons mental health needs had increased and previous mental health needs had returned. No action had been taken to make the person feel safe at night. We discussed safeguarding procedures with senior nursing staff. They stated that they would look into the issues, talk to staff etc and decide what action should be taken. We prompted staff and they still failed to identify that social services were the lead for safeguarding and should be informed of safeguarding allegations or concerns. We asked the senior nurses when they last had safeguarding training and we were informed that this was planned for the week of the inspection. We looked at the homes training matrix and twelve of the homes seventeen qualified nurses have not had adult abuse training and ten have not had POVA training. Both the senior nurses we spoke with were listed on the training matrix as having undertaken safeguarding training, however neither were aware of correct procedures of safeguarding Care Homes for Adults (18-65 years) Page 11 of 19 issues. The training matrix also showed that no care staff have undertaken safeguarding training and twenty-three of the sixty-one care staff have had adult abuse training. Five of the fifteen therapist have had safeguarding training. The home has contracted with a management/training consultant who showed us flyers about safeguarding that he stated had been placed in staff rooms to raise staff awareness. We were also informed that staff training has commenced with sixteen places for safeguarding available in July 2009 and thirteen staff had completed safeguarding training in June 2009. People have also been placed at risk by the home as staff have not had all mandatory training and there is evidence on care records and notifications about injuries which may be due to poor manual handling techniques. The requirement in respect of safeguarding has therefore not been met. People continue to be at risk that staff will not recognise or respond appropriately to abuse. Following the inspection in March 2009 a requirement was made that the home must ensure that all pre-employment checks are completed prior to people commencing working at the home. This was required to ensure that people living at the home are safe. We looked at the recruitment records for the three staff who have been recruited since the previous inspection in March 2009. These all contained the necessary evidence to show that the home had completed all the pre-employment checks including references, POVA and CRB prior to people commencing working at the home. These also evidenced that people had received an induction and undertaken shadow shifts. This requirement has therefore been met. Following the inspection in March 2009 the responsible person was required to ensure that all staff undertake all mandatory training including updates so that staff have the necessary skills to meet peoples needs safely. The home has contracted with a management/training consultant who has completed a review of the training situation in the home and produced new a training matrix showing all staff and the training they have completed. We were provided with a copy of the homes training matrix and informed about planned training that is to take place. This evidenced that most staff have not completed any or all mandatory training and people are therefore being placed at risk. The home has seventeen qualified nurses of whom none had completed first aid, only two had completed infection control. One had completed manual handling and five moving and handling theoretical and practical skills. Five had completed breakaway training and five had not completed any fire training. None had completed nutritional and diet training and seven Pova and five adult abuse. Four had completed managing challenging behaviour training and two deprivation of liberties and four equality and diversity training. Acquired brain injury did not appear on the qualified nurses training list. The home employs sixty-one care staff. None had completed first aid. Thirty-three required infection control training and 27 have not received any moving and handling training. Twenty-nine require fire training and fifty-six health and safety and challenging Care Homes for Adults (18-65 years) Page 12 of 19 behaviour. Thirty-eight require adult abuse and sixty-one POVA and safeguarding training. According to the training matrix none of the homes care staff have an NVQ in health and social care however at the inspection in March 2009 the inspector was informed that over half the staff had this qualification. There was no record of acquired brain injury training for care staff. The home employs twenty therapists. Sixteen require infection control training, seventeen moving and handling and thirteen require fire drills and fire evacuation. all therapists require health and safety training and eighteen require risk management and challenging behaviour. Nineteen require specific training on brain injury and eleven breakaway techniques. All require mental capacity and equality and diversity training. Training information was also provided about the ancillary staff employed at he home however it was not clear in what capacity they are employed so it is not possible to determine if they have undertaken training for their role. However only two of the eighteen ancillary staff have completed infection control training. We considered this information in respect of the staff on duty on the day of the inspection visit in relation to those who were trained to provide assistance with moving and handling of service users. Of the six qualified nurses on duty throughout the day only one was up to date with manual handling. Six of the ten care staff on duty throughout the day did not have up to date moving and handling training and of the eight therapists four were up to date with moving and handling training and two did not appear on the training matrix. The home does have training planned and we were provided with information about this with training being contracted to an external training provider. Staff are paid for attending training and training is now compulsory with procedures in place if staff fail to attend training. The evidence shows that the requirement in respect of staff training has not been met and evidence recorded elsewhere in this report gives examples of where people have been placed at risk due to the lack of staff training. People continue to be placed at risk and this requirement has not been met. What the care home does well: What they could do better: It is clear that the registered provider still does not have systems in place to ensure that compliance with requirements is not only secured at the time but also sustained over time. The service has failed to meet six of the seven requirements made following the key inspection on the 19th March 2009 and additional requirements which are fundamental to the care of the people living at the home have been made following this inspection. The commission has undertaken management review meetings to discuss the findings of this inspection and will be informing the responsible person of the action it intends to take concerning the failure to meet requirements made following the inspection in March 2009. Care Homes for Adults (18-65 years) Page 13 of 19 This inspection demonstrates that the responsible person has failed to ensure the safety of people living at the home. The systems in place in respect of medication at the home do not ensure that people will receive their medication as directed by their medical practitioner. This places people at risk of harm and deterioration of their health. The requirement made following the inspection on the 19th March 2009 with a compliance date of the first June 2009 is repeated. The responsible person must ensure that medication is correctly recorded, managed, stored safely, administered and correctly disposed of within the home so that medication is managed correctly and people are safe. Care plans are inconsistent and do not inform care delivery to safeguard people living in the home and ensure their needs are met. The home has failed to ensure that care plans contain all the information necessary for staff to be aware of peoples current needs and people continue to be at risk that their needs will not be met. The requirement made on the 19th March 2009 with a compliance date of the 1st June 2009 has not been met. The responsible person must 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. Risk assessments are not in place for all activities that may present a risk, have not been regularly reviewed and this places people at risk of harm. The requirement made following the inspection on 19th march 2009 with a compliance date of the 1st June 2009 has not been met. The responsible person must ensure that full risk assessments are undertaken and that risk assessments are reviewed and updated to ensure that people are safe. This inspection has shown that there have been occasions when peoples health and personal care needs have not been met placing them at risk. A requirement is made with a compliance date of the 15th August 2009 that the responsible person must ensure that all health and personal care needs are met and that there is evidence to demonstrate that this is the case. There was no evidence to show that people are not becoming hungry during the long gap between the evening meal at 5pm and breakfast the following day. The requirement made following the inspection on the 19th March 2009 with a compliance date of the 1st June 2009 has not been met. 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 hungry. Staff have not all have safeguarding training and were not aware of the correct procedures they should follow should there be safeguarding concerns. Appropriate action has not been taken and people have been placed at risk of harm. The requirement made following the inspection on the 19th March 2009 with a compliance date of the 1st June 2009 has not been met. 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 working at the home have not received all mandatory and service specific training to ensure that they have the skills to meet peoples needs. There is evidence that people are at risk due to the lack of staff training. The requirement made on the 19th March with Care Homes for Adults (18-65 years) Page 14 of 19 a compliance date of the 1st of June 2009 has not been met. The responsible person must ensure that all staff undertake all mandatory training including updates so that they have the necessary skills to meet peoples needs safely. During the inspection on the 19th March 2009 on the 9th July 2009 there were gaps and inaccurate record keeping identified in respect of fluid charts and PEG feeding charts. there were also irregularities in the daily notes with additional pages added to care plans. A requirement is made with a compliance date of the 15th August 2009 that the responsible person must ensure that full and accurate records are made in respect of all care provided to people. This is to ensure that their needs are being met and they are safe. 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 2. Care Homes for Adults (18-65 years) Page 15 of 19 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. 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 correctly recorded, managed, stored, safely administered and correctly disposed of within the home. Care Homes for Adults (18-65 years) Page 16 of 19 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 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 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. Care Homes for Adults (18-65 years) Page 17 of 19 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, 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 19 12 The responsible person must 15/08/2009 ensure that all health and personal care needs are met and that there is evidence to demonstrate that this is the case. So that people are safe and have their needs met. 2 41 12 The responsible person must 15/08/2009 ensure that all records are accurately and fully completed. So that people are safe. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 18 of 19 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got 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 Helpline: 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. 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. Care Homes for Adults (18-65 years) Page 19 of 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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