Inspection on 13/10/09 for Purbeck Care

This inspection was carried out on 13th October 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Purbeck Care 26/01/10

Purbeck Care 11/05/09

Purbeck Care 22/10/07

Purbeck Care 20/02/07

Purbeck Care 08/05/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Purbeck Care Binnegar Hall East Stoke Wareham Dorset BH20 6AT The quality rating for this care home is: zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jo Johnson Date: 1 6 1 0 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Care Homes for Adults (18-65 years) Page 2 of 63 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 mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 63 Information about the care home Name of care home: Address: Purbeck Care Binnegar Hall East Stoke Wareham Dorset BH20 6AT 01929552201 01929556441 Purbeck@bmlhealthcare.co.uk www.purbeckcare.com Purbeck Care Limited care home 52 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) : Number of places (if applicable): Under 65 Over 65 52 0 learning disability Additional conditions: 5 people in the category of LD(E) Date of last inspection 1 1 0 5 2 0 0 9 A bit about the care home STABLE COTTAGE 5 Care Homes for Adults (18-65 years) Purbeck Care Ltd is registered to provide a residential service for up to 52 people with Learning Disabilities. The accommodation is provided in four separate units and each unit offers a different type and level of support. The main house is divided into two separate wings, West Wing provides care and support to both older and younger residents and has 15 bedrooms, 4 of Page 4 of 63 EAST WING 9 WEST WING 15 GARDEN COTTAGE 5 which are on the ground floor. The East Wing provides support and care in a structured environment for people whose behaviour may be both complex and challenging to the services. There are 9 bedrooms available. Garden Cottage provides a more independent environment for residents who have a higher level of self-determination and independence. There are 5 bedrooms each with en suite facilities. Stable Cottage provides care and support to residents whose behaviour has been identified as falling within an autistic spectrum. All 7 bedrooms have en suite facilities. Each unit has ample communal rooms: lounge, dining room, and sufficient toilet and bathroom facilities appropriately sited. The two cottages have separate kitchen areas. The accommodation is set in approximately twenty acres of land. There is a productive walled garden providing fruit and vegetables, which are regularly used in the catering for the residents and in addition an area of the grounds has been set aside for animal husbandry. Entrance to the home and grounds, which are just off the main Wool to Wareham Road, is via large electronic gates, which provide extra safety for residents. There is ample parking for both staff and visitors. Care Homes for Adults (18-65 years) Page 5 of 63 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: zero star poor 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 Care Homes for Adults (18-65 years) Page 6 of 63 How we did our inspection: This is what the inspectors did when they were at the care home The inspection was unannounced (we did not let the home know we were coming) on 13th, 15th, 16th and 22nd October 2009. Two inspectors came on each day. The inspectors looked around the houses. On the first day two fire officers looked around the houses as well. The inspectors talked and Makaton signed with people who live at the home. The inspectors looked at care plans. The inspectors looked at some of the paperwork about the home and the staff. Care Homes for Adults (18-65 years) Page 7 of 63 The inspectors talked to staff and the manager. We sent surveys to people, staff and to health and social care workers. We have put what people said in the report. What the care home does well Some people have care plans with pictures and photos that they have been involved in. Some people who live at the home are given support to enjoy their leisure time and do things in the community. Care Homes for Adults (18-65 years) Page 8 of 63 Some information has pictures to make it easier to understand. Some people have jobs at the home. Staff are caring and like to work with people who live at the home. What has got better from the last inspection Care Homes for Adults (18-65 years) Page 9 of 63 There have been some lounges, dining rooms, hallways, bathrooms and toilets that have been redecorated and had new furniture. What the care home could do better There are lots of things that need to be done to make some of the houses good safe places to live and for the care and support to be safe, and for staff to keep people safe from harm or abuse. Care Homes for Adults (18-65 years) Page 10 of 63 People can only come to live at the houses if the staff know how to care for and support them. People must be involved and have an assessment that includes all of the important information about them. People and the staff need to know on what or if any basis under the Mental Health Act they are staying at the home. Care plans must include all the information about people, be kept up to date so that staff know what care and support people need. Care Homes for Adults (18-65 years) Page 11 of 63 Risks need to be assessed and managed so staff know what to do so they can keep people safe. People need to have support with their communication so that staff and other people can understand them. Information about people must be kept private so that other people cannot see it or hear it. Care Homes for Adults (18-65 years) Page 12 of 63 The out of date food needed to be thrown out of Garden Cottage. Some people need to given support to be occupied during the day and develop their social skills, and their skills around the house. People who communicate differently need to be given choices about food. People need to be given ordinary crockery and cutlery. Care Homes for Adults (18-65 years) Page 13 of 63 There needed to be instructions for how to use an injection for one person. Staff must respect peoples privacy and dignity at all times. Staff must support people to follow what health workers say, to make sure that they stay well. If a doctor says that someone needs medication staff need to be trained to do this. Care Homes for Adults (18-65 years) Page 14 of 63 There need to be as needed plans for taking medication. This is to make sure that people have this medication safely. There needs to be somewhere to put medicines in Garden Cottage so staff do not have to walk over from East Wing. There needs to be records kept about complaints that show how it was looked into, what happened after to try and stop it happening again and the feedback to the person who made the complaint. Care Homes for Adults (18-65 years) Page 15 of 63 There needs to be records and care plans for when staff physically stop people from hurting others or themselves or leaving the home. The manager needs to tell us about it. Staff need to have training on what is abuse, how to report it and how to keep people safe. The manager needs to tell us and Dorset Social Services when people hurt each other. The manager needs to write down when people have been harmed, why it happened, what they have done about it and what they have done to try and stop it happening again. Care Homes for Adults (18-65 years) Page 16 of 63 One person did not have a mattress on their bed and needed one. There were some windows in East Wing and Stable Cottage that were not safe. People could have got hurt or fallen from them. The home must do what the fire officers told them to do so that the home is safe from fire. People need to have furniture, bedding, curtains and flooring so that they are comfortable in their home. Care Homes for Adults (18-65 years) Page 17 of 63 There needs to be a new kitchen in Stable Cottage and the tops of the toilets need to be made safe so to try and stop infections spreading. There need to be more staff on duty at times to meet peoples needs. New staff who have not been fully checked need to have a senior staff member who is working with them. This is to make sure staff are safe to work with people. Staff need to be trained in how to care for and support all of the people who live at the home. Care Homes for Adults (18-65 years) Page 18 of 63 Staff need to have support meetings with their manager. The management of Purbeck Care needs to improve to make sure that people are safe and live and benefit from a well run home. The management need to look at how staff support and work with people so that people are well cared for and supported. Care Homes for Adults (18-65 years) Page 19 of 63 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Jo Johnson CQC South West Citygate Gallowgate Newcastle upon Tyne NE1 4PA 03000 616161 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Care Homes for Adults (18-65 years) Page 20 of 63 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 21 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is information about the home that it is accessible to some people. Peoples needs are assessed but they cannot be sure that staff have the skills, knowledge and experience to be able to safely care for them and meet their complex needs. They cannot be confident that important information about them is available to staff. Evidence: The Statement of Purpose was reviewed in September 2009. It now includes the correct details of the manager. The home is registered for 52 people with a learning disability five of whom can also be older people with a learning disability. However, there are only 36 bedrooms in four separate living units. The Statement of purpose details which unit or house can accommodate: West wing is for fifteen people who are predominately older, East wing is for nine people who may present challenges to the service, Garden Cottage is for five people who are more independent with a domiciliary care model of support and Stable Cottage is for seven people whose behaviour has been identified as falling within an autistic spectrum. Page 22 of 63 Care Homes for Adults (18-65 years) Evidence: There have been a number of people who have been admitted to the home who also have mental health diagnosis. Staff have not received any training to meet peoples complex mental health needs. The service users guide has also been produced supported by pictures and photographs. The surveys from health and social care professionals told us that the care services assessment arrangements always (1), usually(2) or sometimes (1) ensure that accurate information is gathered and the right service is planned for people. We looked at the pre admission assessments for the last four people to move into each of the living units/houses. Pre-admission assessments were completed for all four people including one person who was admitted as an emergency. Some of the assessments seen did not explore all of the elements identified in the assessment format such as culture, faith and income. Prior to admission two of the people were under a section of the mental health act whilst they were staying in hospital and this information has just been transferred on to their assessments and care plans. It has not been established whether people are placed at the home remain under any section of the Mental Health act for example under Guardianship or Section 117 aftercare. We made a requirement at the random inspection that the status of one person was to be established and this has been completed. However no action had been taken to establish the status of some other individuals who live at the home. There was information that was gained during the assessment process that was then not used to establish whether the home was registered or the staff had the skills, knowledge and experience to care for the people who were then admitted. For example: One persons care management assessment information identified that as an individual with a criminal history and diagnosis of schizophrenia that they should only be placed in an all male household. Information relating to how the individual will talk to staff about sexually inappropriate thoughts and that may increase the risks to others had not been transferred on to the care plan information and risk assessment that staff have access to. The assessment for one person identified that they do not like males and will scream when unsettled and unhappy. The individual likes working with and the company of female staff. This person was admitted into the cottage were six males with autism live. The registered provider has advised that there have been positive outcomes for this individual. However, there appears to have been no consideration of their need to be with females as identified in their assessment or the impact that their noise levels could have on people who can be sensitive to noise due to their autism. It is not clear how other people who live in each living unit or house are consulted about Care Homes for Adults (18-65 years) Page 23 of 63 Evidence: who is going to move in. There were not any records of any planned visits (where it was appropriate) and or how other people were asked or their reactions recorded when people visited. One person was admitted as an emergency, there had been reviews with their placing authority. However, the homes six week review that was in the individuals file was dated but blank. One person has moved from Garden Cottage to West Wing. The reason for this move was that the individuals health and mobility had deteriorated. We requested the copy of the review where the individual had been involved in the decision making about the move. The individuals funding authority review stated that a move to West wing would be their best interests but that it should be the individuals choice and work should be done with them. There was no evidence of how the individual was supported to move or how staff attempted to ensure that the individual understood why and where they were moving to. There were just records that stated that the individual did not want to move or see the room. The individual told us they moved my stuff without me. It was also recorded in the staff meeting minutes that XXX very upset that his things were moved to west wing whilst he was out. Care Homes for Adults (18-65 years) Page 24 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and risk assessments are not completed for all areas identified in assessments to ensure that peoples specific needs and risks are identified and met. The lack of risk management strategies places people who live at the home at risk of harm or abuse. Evidence: We looked in detail at the care records and plans for five people including the last four people to move into the home. Each person has a care plan, risk assessments and daily records. Incident records are made that detail the circumstances before and during the incident, staff involved and what worked. Body maps are also completed following any incidents of self harm, physical intervention or harm from other people. We found serious shortfalls in the care planning and risk assessments that mean that people are not being safely supported by staff, that they are placing other people at risk of harm or abuse and their care, support and communication needs are not being identified or met. Examples of this are: Care Homes for Adults (18-65 years) Page 25 of 63 Evidence: One person has a diagnosis of paranoid schizophrenia that can lead to identified behaviours. These behaviours are referred to as disturbed and behaviour that challenges rather than an indicator that they are having an episode that may require them to be supported to their identified low stimulus environment. The guidance does not detail how the individual is to be supported to this space (which is in another living unit) and which staff are to support them whilst they are in there. The plan does not identify any other strategies to support the individual at an earlier stage to minimise the use of the low stimulus environment. The risk assessment completed by Dorset Healthcare had not been reviewed since 2004 and the care plan had not been reviewed since March 2008. The assessment information for one person details the serious risks that they present to other people and that staff are to monitor XXXs whereabouts at all times. We spoke to the individual for some time in the garden and there were no staff around. The plan identifies that the individuals behaviours mean that female staff and members of the public are at risk. However, there was no risk assessments, acknowledgment of risk or plan of how to protect the females or other vulnerable people who live at the home. The registered provider has advised that they plan to put further details of trigger behaviours in the care plan for this individual. The same individual also suffers from schizophrenia and is on anti-psychotic medication. Staff action detailed in the plan is to monitor their mental health and feedback concerns. However, there is no information in the care plan about behaviours that they may display which are potential triggers to alert staff to a decline in their mental health. One person who communicates differently did not have their wishes or aspirations identified in their care plan due to communication difficulties. The individual had lived at the home for over a year and there were no communication systems in place to seek their views. One person had identified in their plan that they would like someone to talk to at times however no goals were set around this or how they were to be achieved. This had been identified in two reviews. One persons assessment and care plan refers to the fact they do not want to live with other people with a learning disability. They have identified in their plan that they wish to live in caravan with xxx(hamster) and a dog. The registered provider has advised that a referral has been made to the placing authority regarding this individual’s wishes, but this was not available at inspection. One person presents significant risks to themselves, to others, to staff and property. There was a behaviour management plan in place that included the interventions (including physical interventions) to be followed. However, this plan did not include any Care Homes for Adults (18-65 years) Page 26 of 63 Evidence: interventions when the individual is targeting other people that they live with. There are a high number of incidents where the individual has threatened and or harmed people that they live with. Some of the care plans are reviewed on monthly basis by key workers. Care plans should be reviewed at least once every six months. We also identified that people should be involved in their monthly reviews where possible. This is so they can contribute to their reviews and care records. We saw easy read person centred care photographic and pictorial plans that had been produced with the individuals. However, staff should carefully consider the language used in these for example in one it stated you have been warned. We observed a positive piece of pictorial planning for one person in stable cottage who has not tolerated or has destroyed items in their bedroom. The individual had worked with one of the care team co-ordinators to make a plan and collage of the items they would like in their bedroom. This was displayed behind perspex in the main lounge. This is the individuals pictorial plan and should be displayed behind perspex in their bedroom if they will tolerate it. One person had a communication passport. However, this was in the unit office and was not with the person. The registered provider has advised that this document has been provided for staff to understand the resident better and is not designed to be carried with the individual. There is very little personal life history information in peoples plans. Life story works have photographs and items in them that show what the person has been doing in their lives. Staff should develop life story books/works where appropriate and in formats that suit each individual with the people living at the home, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. This means that people can be actively involved in the monthly reviews of their plans and goals. Life history works should be developed where appropriate that include details and photographs of their history such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. There are new staff working at the home so it is important that this information is available to assist staff in getting know the people who live at the home. There are limitations and restrictions placed on some people who live at the home. It was not clear whether some of these people are still subject to aftercare under the mental health act. There was no evidence of best interest assessments under the mental capacity act or whether any deprivation of liberty assessments or applications had been Care Homes for Adults (18-65 years) Page 27 of 63 Evidence: made for these individuals who are subject to restrictions. There are unit or house meetings taking place so some people have an opportunity to make their views known. The registered provider has told us that the frequency of these is intermittent but they aim to make these more frequent and regular. On several occasions during the inspection we heard breaches of confidentiality by staff whilst using the walky talkies. All staff carry a walky talky for safety due to the size of the site and to call for assistance when required. We heard personal information being shared about individuals who live at the home. We found records relating to five people in one communal file. We found records relating to two people in one person’s individual care record. We identified at the Random Inspection in May 2009 that we had found records for another person in someone elses care records. Care Homes for Adults (18-65 years) Page 28 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people participate in a range of social, leisure, and educational and occupational opportunities. Those people who do not have planned or organised opportunities may not be having meaningful, stimulating or fulfilled lives. Evidence: For people who live in East and West wing there is very little opportunity for them to participate or develop daily living skills. There is a central kitchen and laundry for the two units. There is a small training kitchen attached to the activity centre. Five people have the opportunity to shop, cook and prepare a meal on a Friday as a planned activity. One person chooses to do their own laundry in the training kitchen. There is an activity centre at the home. There are planned sessions that people can participate in. Examples of these sessions are library, swimming, arts and crafts, bus trip, horse riding, rambling and an outdoor activity centre. They are for between four and thirteen people depending on the activity. Care Homes for Adults (18-65 years) Page 29 of 63 Evidence: Some people told us that they go to Gateway in Wareham on a Thursday evening and the Glow Club in Wimborne on a Tuesday evening. There is also a Disco at the home once a month. There are plans to develop a kitchenette, small laundry area in the east wing in the next 12 months. Surveys from people told us that they always(4), usually (3) or sometimes (1) can make decisions about what they do each day. One person has identified that they would like to be in paid employment. They are currently working with the animals at the home one hour a day. This is part of the employment scheme run by the home. Within the AQAA the manager told us that: We arrange for Dorset Advocacy to support the residents group. We arrange for people to take part in life skills learning and training both with the Activities Centre and local colleges. We have positive links with the community so residents can enjoy full access appropriately supported. We have four vehicles, in addition residents benefit from accessing public transport. At least two people who live in Stable cottage have their own laptops and access to the internet. One person in East wing has internet access. From their care records and care plan we established that there had been an undue delay in getting them internet access. The registered provider has advised us that there were a number of difficulties in establishing this, and that they assist people to have internet access. We did not fully explore how people are supported to fulfill their spiritual needs. However, one person who has lived at the home for a long time told us that they like going to church for communion but had not been in a long time. They said its like talking to a brick wall. The registered provider has advised us that individuals are provided with opportunities to meet their spiritual needs, but that this is not always recorded. The people and staff from Garden Cottage plan, shop and cook their food each week. We found two trays of out of date eggs in the kitchen. One of the trays had a label on showing that it had been started after the expiry date. We left an immediate requirement that the out of date eggs must be removed. The registered provider has confirmed that action was taken immediately to address this. Page 30 of 63 Care Homes for Adults (18-65 years) Evidence: The staff and people in Stable Cottage also shop for their food each week. The menus seen showed all lot of mince based dishes. The care team co-ordinator told us that these are going to be changed in consultation with the people who live at the house. We did not fully assess the meal provision with people that live in West and East wings as the floor was being relaid and the main kitchen was out of use. During the inspection people had take away meals, microwave meals or went out for their main meal. Staff told us that people are given a choice of the menu at the start of the day. This is in a written format. It is not clear how the people who communicate differently and do not use speech choose their meals. There is not any pictorial/photographic menus or sufficient staff who are fluent in BSL (British Sign Language) which is the first language of one person. People living in east wing use brightly coloured plastic crockery and cutlery. From discussion with the manager there is only one person who occasional presents a risk from throwing crockery. It appears that just because one person occasionally presents a risk that everyone else who lives there has to use plastic cutlery and crockery. The manager told us that cutlery was now on order. The provision of crockery and cutlery in this unit should be reviewed to ensure people can enjoy meals in a dignified manner. In stable cottage the people who live there have to use plastic beakers and mugs but the staff have crockery mugs. This practice should be reviewed to promote ordinary lifestyles. Care Homes for Adults (18-65 years) Page 31 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not supported in a way that maintains or respects their privacy and dignity. Some peoples physical, mental and emotional health needs are not identified or met. This means they are potentially at risk of neglect, abuse and ill physical or mental health. Evidence: In the main there were positive relationships and interactions observed between staff and the people who live at the home. Staff present as caring and told us that they want to support people in the best possible way they can. Surveys from people told us that staff always(7) or sometimes (2) treat them well. We are concerned that there times when peoples privacy and dignity is compromised. We observed one person who requires support from staff to promote their privacy. We discretely raised this with a staff member. Another staff member informed us that, the staff member who spoke with the service user had advised them that we had seen them displaying sexualised behaviour and the service user was extremely embarrassed. Staff need to support people in a more discrete way and give the guidance and support as to safe and appropriate locations. From incident reports for one individual they are observed at times when they should be Care Homes for Adults (18-65 years) Page 32 of 63 Evidence: given privacy as they are in a safe place. The registered provider has advised that this strategy is part of a plan agreed by multidisciplinary professionals. However, the homes care plan does not provide sufficient detail on how they maintain this individual’s privacy during these episodes that can last up to seven hours. There has been no analysis of these incidents to identify whether different strategies or earlier intervention may have worked. Staff have not been provided with training on how to safely support and guide people with personal and intimate relationships and expressing their sexuality. Peoples preference of gender of staff is not actively sought or recorded in peoples assessments or plans. Gender of staff is only specified is specific risk assessed circumstances. For two people we case tracked they are to be supported by male staff at times identified in their plans. However, for one person who has a recorded preference for female staff there are times when they are supported by lone male staff at night. This person requires personal care support and support to change their incontinence wear. Care records did not demonstrate whether this had been risk assessed and whether male staff do actually support this individual with personal and intimate care. The staff on duty were not clear as to what happened with the individuals personal care during the night. Some elements of peoples health records and care plans showed that their right to goodquality health care is being promoted. For example one person had been supported and guided through a number of hospital procedures by staff. However, there are also serious shortfalls in maintaining peoples physical and mental health. As previously identified none of the staff at the home have received training in mental health. Care plans do not accurately reflect the signs and symptoms of people becoming unwell. This means that staff may not recognise and understand the early indicators that someones mental health is deteriorating. Six people at the home have epilepsy. The registered provider has advised us that there are four qualified nurses working at the home. No further staff have had epilepsy awareness training from the organisation. We looked at the plans for two people with epilepsy. One person has been prescribed rectal diazepam and their plan has been in place since October 2008. The manager told us that as there have not been any staff who can administer rectal diazepam they have just called for an ambulance after 4 minutes. He said there is now one member of staff who can administer rectal diazepam. Staff are being trained in November in the use of Buccal Midazolam and this will then be prescribed. The plan states that if there are staff who can administer they need to administer rectal diazepam after 4 minutes. This means that the individual has been placed at risk and it could be at least 10 minutes following a Care Homes for Adults (18-65 years) Page 33 of 63 Evidence: seizure before paramedics attend due to the rural location. The registered provider has advised us that the plan has been agreed with healthcare professionals. However, CQC would expect staff to be trained in the administration of prescribed medications that are used to treat peoples health conditions. One persons epilepsy was just referred to in their care plan and risk assessments and stated that a listening device was to be used at night. There was no description of the individuals seizures and no specific epilepsy management plan in place. One person has diabetes and is diet controlled. The individual had a review at the diabetic clinic and was advised to change their diet by not eating biscuits, cakes or puddings. Records show that this person is still eating cakes and puddings and continues to gain weight since this appointment. The registered provider has advised us that the individual is encouraged to adopt a healthy lifestyle. The placing social worker has confirmed that they are satisfied with the support provided. We looked at the medication systems for East Wing, Garden Cottage and Stable Cottage. The medication for three people who live at Garden Cottage is stored in East wing and is administered by East wing staff. This involves them leaving west wing and walking to Garden Cottage with medication up to four times a day, possibly more if people are prescribed PRN (as needed medication). Alternative storage and administration arrangements must be made that do not include staff walking with medication and leaving another unit without a member of staff. We found a stock of Naloxine Hydrochloride injection in Stable Cottages medication cabinet. The staff on duty were not clear when and in what circumstances it was to be administered. There was information on the box that stated it was to be administered by paramedics. As the staff were not able to locate any procedure or protocol for this medication we made an immediate requirement that; A medication protocol and procedure must be developed for the use of Naloxine Hydrochloride injection by emergency services. A number of people have as required medication prescribed. There must be PRN (as needed) medication plans in place. These plans need to include under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. These should be agreed with the prescribing practitioners or learning disability health practitioners where possible. It is recommended that these plans be kept with the administration records so that staff can easily refer to them. The training matrix tells us that only fourteen of the staff have received medication training and only one staff has had their competency assessed within the last year. The registered provider has told us they plan to increase the number of staff trained in the Care Homes for Adults (18-65 years) Page 34 of 63 Evidence: administration of medication. . Care Homes for Adults (18-65 years) Page 35 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The shortfalls in the complaints procedures and investigations means that people cannot always be confident that their concerns are taken seriously. The serious shortfalls in the managers and staffs knowledge and understanding of adult protection means that allegations are not all reported to the relevant authorities and or investigated and people are at risk of harm or abuse. Evidence: The complaint procedure is included in the service users guide. The guide is supported by pictures and photographs. However, there is not a separate easy read version of the complaints procedure that is supported by pictures and photographs. As some people who live at the home communicate in complex ways written and or pictorial information is not necessarily accessible to them. There should be descriptions in peoples plans as to how they let people know when they are unhappy and unsettled. Further consideration should be given to developing ways of each individual having accessible information about how they can complain or let staff know they are unhappy. Surveys from people told us that they know who they can talk to if they are unhappy and know how to complain. The surveys from health and social care professional told us that the service usually or sometimes responds appropriately to them if a person using the service or another person have raised concerns. Care Homes for Adults (18-65 years) Page 36 of 63 Evidence: We looked at the complaints records at the home. There have been three complaints received in the last year. One from a social work student, one from someone who lives at the home and one from a relative. There were records of the complaints. However, there were not clear records of the investigations and a copy of the written outcome to the complainant for two of the complaints. The complaints records did not include any of the allegations that people made about staff or other people at the home that were not investigated by the local authority. The manager provided us with an electronic spreadsheet that details of the incidents recorded at the home. There is not a separate paper record for adult protection safeguarding referrals. There is no analysis of referrals by the manager or management team and what actions can be taken to prevent recurrence of incidents. The staff involved at the time do complete good detailed records of the incidents. For example a safeguarding referral was made for an incident where one person absconded after another person had thrown crockery at them. This happened during staff handover. The manager told us that one of these people have had one to one support since July of this year. We are concerned that this incident could have been prevented but as there was no analysis of the incident there is no record of what has been put in place to prevent any recurrence. From this spreadsheet we identified that there were a number of incidents that were not reported to us or the local authority under safeguarding procedures. We made an immediate requirement that two safeguarding referrals be made. One was were one person had injured another and where an individual made an allegation that they had been grabbed by staff during a physical intervention. From information provided by the manager in the AQAA there have been 11 physical interventions or restraints this year. We have not been notified of a majority of these restraints. The manager told us that only two people have physical intervention plans. The spreadsheet tells us that a total of five people have been subject to physical intervention by staff in the last year. Physical intervention plans must be place for people and these must be agreed by a multidisciplinary team and to be in their best interests. Where the home has reported allegations to the local authority and they have decided not to investigate there has been no investigation by the home. When the local authority has investigated and asked the organisation to undertake further investigation or action this has not been fed back to the local authority or us. We had to request at the inspection that we be informed of the outcome of one investigation and disciplinary action taken under regulation 37. This is poor practice. Adult protection concerns must be taken seriously and be followed up. Not all staff have received adult protection safeguarding training. The training matrix Care Homes for Adults (18-65 years) Page 37 of 63 Evidence: refers to refresher training every two years. This home should review the frequency of safeguarding training due to the complex needs of the people that staff support. We did not assess how the home supports or manages peoples finances during this inspection. The manager is appointee for some people at the home. Care Homes for Adults (18-65 years) Page 38 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not live in a personalised, homely, clean, odour free and well maintained home. There are parts of the environment that are unsafe in terms of windows, infection control and fire safety. This places people at significant risk of harm. Evidence: We were accompanied by two fire safety officers on the first day of inspection. This was because there have been two fires at the home this year. The fire service is responsible for compliance with fire safety regulations and left a notice of deficiencies with the person in charge at the end of their visit. The shortfalls identified were: Some fire doors in a poor state of repair, do not close properly and seals not intact, the fire risk assessment is not considered sufficient and the sensory room fire door needs a viewing panel. We also identified that one person had removed the intumescent strips and cold smoke seals from their bedroom door. This persons behaviours present a significant fire risk. This bedroom door must be checked on a daily basis to ensure the safety of people living at working at the home. There are not individual fire risk assessments for each building. The personal evacuation procedures in garden cottage did not include all of the people who live there and included Care Homes for Adults (18-65 years) Page 39 of 63 Evidence: somebody who had recently moved out. The fire procedure displayed needs clarifying as it could be interpreted that staff are to return to the fire once everyone evacuated, it states that staff should return to affected area. Staff have now all been trained in the revised fire procedures and there is now an identified shift leader who is responsible for calling the fire brigade. Staff and people safely evacuated one of the cottages during the inspection following a false alarm. There are windows in East Wing and Stable Cottage that are not safe and pose risks to individuals. Some did not have restrictors and some sash windows were either very stiff and hard to open or dropped suddenly and had bolts to keep them open. We made an immediate requirement that the provider must make safe all windows in East Wing and Stable Cottage. We spent time in all of the living units/houses. The lounge within West Wing has recently been refurbished and provides homely accomodation. Both East and West wing corridors appear institutional and impersonal. There is no personalisation of the shared areas in the east and west wings, except for a noticeboard with photos on in East wing. We only saw two bedrooms in west wing. One was highly personalised and one had waterproof poly safe safety flooring, a broken armchair, no bedding and no curtains or blinds. The individual has not had curtains or any blinds for over six months and the room is on the ground floor and visible from the garden. We saw all of the bedrooms in east wing. They were all personalised and most were carpeted, except one room that just had a bed in it. Staff told us that the individual does not like things in their bedroom and that there are no plans to try and introduce anything. Two people showed us their bedrooms in garden cottage they were personalised and were carpeted. We saw all of the bedrooms in Stable cottage. Most of them had waterproof poly safe safety flooring regardless of whether the individual had issues with incontinence. One person was lying on their bed asleep with no sheets or quilt. One bedroom had bare walls, a tiled floor, some of which were cracked and a wooden fixed bed base. There was no mattress and we were told that the individual sleeps on a thick quilt on top of the bed base. We made an immediate requirement that a mattress was to be provided. The room also smelt of urine and the windows were screwed shut so there was no ventilation. There were bolts protruding from the toilet bowls where the toilet seat had been removed. We gave an immediate requirement that these should be removed. Page 40 of 63 Care Homes for Adults (18-65 years) Evidence: Bedrooms doors in the East wing and Stable cottage are kept locked. Staff in east wing told us that people had keys to their rooms, however, we observed most people seeking staff out to open their doors or waiting for staff to open their doors for them. No-one in stable cottage has independent access to their bedrooms and are reliant on staff due to the behaviours of one person. However, the bedroom doors are not opened when this person is not in or is downstairs. There were uncovered radiators in east and west wings that were uncovered and were very hot to touch. This was identified at the last key inspection. The doors in Stable cottage constantly bang shut. They are very loud and this means that there is not a calm and relaxed atmosphere, which is important for people with autism who are likely to heightened senses. There were a number of toilets throughout the home that did not have any toilet roll or hand wash available. The registered provider has advised us that they plan to install suitable toilet roll dispensers. At the start of the inspection there was an open wardrobe with cleaning chemicals in it in the first floor bathroom in west wing. The kitchen in Stable Cottage is in need of replacement, the work surfaces are damaged and the formica broken in places, peeling and cracked. The tiling around the sink area is also cracked and broken. We asked the manager if there is a plan to refurbish this kitchen and we were told there is but as yet no timescale to do the work. This kitchen presents an infection control risk and must be replaced. There is a programme of refurbishment and the carpets in the corridors in West wing were being replaced with wood effect lino during the inspection. There are plans to develop a kitchenette, small laundry area and staff toilet in the east wing in the next 12 months. We made a requirement at the last two key inspections that The registered provider must ensure all parts of the home are kept clean, hygienic and free from offensive odours. This requirement still has not been met. Examples are; Cobwebs in peoples bedrooms and in one had a swarm of ladybirds. One bedroom in east wing had soiled tissues on the floor and had an unpleasant smell. One bedroom in stable cottage smelt strongly of urine. Some Ensuite toilet cisterns in stable cottage where either made of unsealed wood or secured with unsealed wood. Ensuite bathrooms and toilets were dirty and some stained. Care Homes for Adults (18-65 years) Page 41 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always sufficient staff on duty to meet peoples needs safely. People who live at the home cannot have confidence in the staff because they are not supervised whilst waiting for checks have been done to make sure that they are suitable. Peoples needs are not consistently met and they are supported because staff do not get the right training, supervision and support they need from their managers. Evidence: We looked at four weeks rotas and the staffing is as follows; Duty manager working 9-5 and on call when not on site 5 waking staff on at night, 2 allocated to East wing, 1 in other units/houses. Garden Cottage ( 4 people) 1 staff from 7.30-10pm 1 staff 9-5 Stable Cottage (7 people) 3 staff 7.30- 10pm West Wing (15 people) 3 staff 7.30-10pm East Wing (8 people) 6 staff 7.30-2.30, 7 staff 2.15-10pm The manager told us that two people who live in east wing have 1 to 1 support during the waking day, two people have 20 hours per week funded and two people have a few hours each. There are also managers, an administrator, a gardener, decorator, cooks and other ancillary staff. We have concerns about the staffing levels for the following reasons. One staff from east Care Homes for Adults (18-65 years) Page 42 of 63 Evidence: wing has to leave the unit to go to garden cottage up to four times a day to administer medication. One staff from east wing has to support one individual from garden cottage when they need to spend time in west wing (this can between one to seven hours). There is only one staff on duty at night in stable cottage and there are two people who have epilepsy and are monitored by listening devices. There is only one member of night staff on duty in west wing and there is at least one individual who presents significant risks to other people. Incident reports have reflected that up to five staff can be involved in managing an incident. There has been a high turnover of staff in the last year. From information provided in the AQAA and the training matrix, 28 staff left and there have been 22 new staff employed who work directly with people in the last year. The registered provider has advised that the service has sought to increase overall staff numbers and that some staff newly employed staff have left within a short period of starting. The registered provider has stated that since the inspection they have introduced a new structure and staffing levels have increased throughout the home. We looked at the staff files for five staff including three of the most recently recruited staff. All of the staff files included 2 written references. However, one reflected poor attendance and one raised questions about their suitability to work with people who present challenges. There had been no follow up on these references. All staff had received a clear PoVA check. However, CRB checks had not yet been received for two of the staff. They were both working but did not have a named supervisor and one person had made a declaration of a conviction. There was no evidence that this had been risk assessed whilst they were awaiting CRB clearance and they were working on nights. The registered provider has advised us that a risk assessment had been completed, but was with the HR department and was not available at the home. As already identified some people living at the home have very complex needs and different ways of communicating. Staff present as caring and want to be able to support people well. However, as identified throughout the report the staff have not been provided with training to be able to meet the very complex needs of the people at the home. Where training has been identified as mandatory not all staff have completed it or has it been updated. The training matrix lists the mandatory training as; Proact SCIP (a physical intervention training based on defense and diffusion), emergency first aid, adult protection, health and safety and infection control. There is not any of these that all staff have completed. All staff have now completed fire training. The manager told us that staff have received a briefing on the mental capacity act and deprivation of liberties. Care Homes for Adults (18-65 years) Page 43 of 63 Evidence: Approximately half the staff group have attended autism awareness training. All staff must be trained in all of the mandatory areas and the following: medication, epilepsy, care of older people, mental health conditions, working with people with forensic histories, BSL, adult protection and assessing and understanding risks. There are regular unit/house staff meetings and group night staff supervisions. Some staff told us that they felt well supported and others felt that they would benefit from more support from managers. We sent out fifteen staff surveys but only had one returned. Under what could the home do better was the comment, talk to staff more. The survey told us that the manager sometimes gives them enough support. The staff do not all receive regular supervision from their line manager. Staff support people with complex needs and therefore need regular support and supervisions to ensure that they are able to safely meet their needs. Care Homes for Adults (18-65 years) Page 44 of 63 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home do not benefit from or live in a home that is well managed or that has effective monitoring systems. Evidence: The registered manager has worked at the home since 1995 and has been registered as the manager since March 2008. We undertook a random inspection in May 2009 following concerns identified during a safeguarding investigation by the local authority, a fire at the home and the number of incidents that resulted in safeguarding referrals. Action has been taken to meet four of the six requirements issued at that focused inspection. As identified throughout the report there are serious shortfalls in all outcome areas for people who live at the home. These shortfalls mean that people have been admitted into the home when staff do not have the skills and or knowledge to be able to meet their complex needs. People are at significant risk of their health, social, emotional and personal care needs not being met. They are also at risk of harm or abuse from other people that they live with. Whilst some people live in highly personalised accomodation, Care Homes for Adults (18-65 years) Page 45 of 63 Evidence: some people live in an environment that in areas is not clean and is not suited to individuals needs. Not everyones privacy and dignity is respected and it is not clear on what basis some people have restrictions placed on them. There have also been failures in reporting incidents that effect the well being of people and staff disciplinary action to us. There have also been failings in reporting safeguarding referrals and outcomes of investigations to both us and the local authority. We issued seven immediate requirements at the end of the inspection. The manager told us on the third day of the inspection that he had already taken action to remove the chemicals from the open wardrobe in the west wing bathroom, so six are reflected in this report. We visited the home on 22nd October to monitor the action taken to address the immediate requirements. Action had been taken to meet these shortfalls. We are seriously concerned that both the immediate, further and repeated requirements had not been identified by the management and monitoring arrangements at the home. The service has a development plan. Since the inspection the registered provider has reviewed the staff structure and management arrangements in place to monitor and improve standards within the home. We acknowledge that the organisation has recently introduced clinical governance meetings as a quality assurance tool along side the regulation 26 visits and has appointed a temporary development manager for three days a week. This is so that the manager can focus on the day to day provision of care. Since the random inspection, the management team have been dropping into the home unannounced during the night to observe staff working at night. However, it is not clear how they are monitoring staff during the day, evening or in the community. There has been no review of incidents, accidents, physical interventions or safeguarding referrals to establish any trends or themes that mean that incidents could be reduced or minimised. Where shortfalls have been identified in regulation 26 reports it is not clear what action has been taken to address any shortfalls. There are house meetings that people can contribute to if they communicate verbally. It is not clear how people who communicate differently contribute or are consulted about their views of the home. Surveys from people included the following comments under the heading What the home does well; Take me out on trips, cooking food, morning words,supply disco/Halloween, support on trips out, good food, good choices, lots of people help me with my big laptop and Im well looked after. Under the heading What could the home do better the comments were; Buy a new TV, Care Homes for Adults (18-65 years) Page 46 of 63 Evidence: sometimes go out for a big take away to have to buy for Chinese and when a lot of big staff write very nasty things in the big book is to really upset me a lot. The surveys from health and social care professionals included the following comments under the heading What the home does well; manage people with complex needs, enthusiastic manager, provides a variety of outings/holidays, friendly, helpful staff team and encourage people to take part in different and new activities. Under the heading What could the service do better were the comments; employ regular staff to ensure clients needs are always met. Guidelines which are in place to be discussed with social services regularly and updated when required, Employ more staff who have had appropriate training and experience, and Staff mean well and are generally caring, however, the location /number of clients have increased therefore there is a need to employ more staff as manager/team leaders who have relevant training, provide in house training. From information provided in the AQAA we were unable to assess whether the following equipment has been serviced or maintained, as there was no review date completed for the fire detection and fighting equipment, heating system or gas appliances. The registered provider has advised us that this information was omitted in error and equipment has been serviced. We did not check the all of the health and safety and maintenance systems at the home. We have identified areas throughout the report where poor maintenance and health and safety have an impact on people who live at the home and in some instances place them at risk of harm. Care Homes for Adults (18-65 years) Page 47 of 63 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action 1 18 12 Care plans, risk and 01/01/2010 behaviour management plans must be followed for all individuals. This is to make sure that people are supported and cared for in line with their assessed needs and care plans. 2 30 16 (2) (k) The registered provider must 04/12/2009 ensure all parts of the home are kept clean, hygienic and free from offensive odours. This is an outstanding requirement from the last two key inspections. Care Homes for Adults (18-65 years) Page 48 of 63 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 Description Timescale for action 1 17 13 Remove out of date food from Garden Cottage 20/10/2009 This is to ensure the health and safety of people living in Garden Cottage. 2 20 13 A medication protocol and procedure must be developed for the use of Naloxine Hydrochloride injection by emergency services. 20/10/2009 This is to ensure that staff and emergency service know in what circumstances the medication is to be administered. 3 23 13 Safeguarding referrals must be made for the incidents and allegations relating to two named individuals 20/10/2009 This is to ensure that any allegations are appropriately investigated and actions taken to safeguard the people living at the home. 4 24 13 Make safe all windows in East Wing and Stable Cottage. 20/10/2009 Care Homes for Adults (18-65 years) Page 49 of 63 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 Description Timescale for action This is to ensure the safety of people and staff at the home. 5 24 13 Remove the metal bolts from 20/10/2009 the toilet bowl in one individuals ensuite toilet. This is to make sure that the individual does not get harmed whilst sitting on the toilet. 6 24 16 Provide a mattress for one named person. 20/10/2009 This is to ensure the comfort, warmth and well being of the individual whilst sleeping and in his bedroom 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 Description Timescale for action 1 2 14 People must be consulted and be involved in their own assessments and any decisions as to where and with whom they live. 01/01/2010 This is to make sure that people are involved about where and who lives with Care Homes for Adults (18-65 years) Page 50 of 63 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 Description Timescale for action them. 2 2 14 People must only be 01/01/2010 admitted to the home following an accurate full assessment that demonstrates that staff have the skills and knowledge to meet their needs. This is to make sure that people are placed at the right home, and that their needs can be met. 3 2 12 The current status of peoples residence at the home under the Mental Health Act must be clarified. 01/01/2010 This is so people are clear about their status at the home and their rights under the Mental Health Act. 4 6 12 People must be provided with 05/02/2010 suitable communication support to make their views and wishes known in their care plans. This is so people can contribute to their plans and their views are recorded. Care Homes for Adults (18-65 years) Page 51 of 63 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 Description Timescale for action 5 6 15 Peoples care plans must be 01/01/2010 reviewed, kept up to date, and include all the individuals needs identified in their assessments and their wishes and aspirations. This is so staff know what care and support people require to make sure that all their needs are met and they are well cared for. 6 7 12 Where people have 01/01/2010 restrictions or limitations placed on them this must be based and evidenced in their best interests by their own agreement or under the Mental Capacity Act or where necessary by a Deprivation of Liberty application. This so people are protected and any restrictions are made in their best interests. 7 9 13 Any areas of risk identified for an individual must be assessed and these assessments must include individual behaviours, self harm or harm to other people, medical conditions such as epilepsy. They must include descriptions of how staff are to support them. 27/11/2009 Care Homes for Adults (18-65 years) Page 52 of 63 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 Description Timescale for action This is is that any risks are minimised and staff know what action to take to keep people safe. 8 10 12 01/01/2010 Personal information must not be shared over the walky talkies. Peoples personal records must be kept in their own care records. This is to make sure that peoples right to confidentially is maintained. 9 11 12 People must be provided with 01/03/2010 opportunities to develop their social, emotional, educational, communication and independent living skills. This is to ensure that people have a good quality of life and well being. 10 17 12 People must be provided with 01/01/2010 ordinary crockery and cutlery to eat with, unless their individual risk assessment restricts this for safety reasons. This is so people can eat and drink in a dignified way. 11 17 12 People must be given a choice of food that is in an accessible format. 01/01/2010 Care Homes for Adults (18-65 years) Page 53 of 63 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 Description Timescale for action This is so people can choose their food each day. 12 18 12 Peoples privacy and dignity 27/11/2009 must be maintained at all times. Care plans must detail how staff are to support people in situations where their privacy and dignity may be compromised. This is to ensure the safety, privacy and dignity of people living at the home. 13 19 13 Where an individual is prescribed medication that can be administered by staff at the home. The staff must be trained to do so. 01/01/2010 This is to make sure that people receive prescribed medication. 14 19 13 Directions from health professionals must be followed. This is to ensure that people are cared for in line with health professionals assessments and recommendations. 15 20 13 There must be PRN (as needed) medication plans in place. These plans need to include under what 01/01/2010 01/01/2010 Care Homes for Adults (18-65 years) Page 54 of 63 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 Description Timescale for action circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. This is to make sure that staff know in what circumstances to administer as needed medications and the maximum dosage people can safely be given at any time. 16 20 13 Suitable medication storage 04/12/2009 must be established in Garden Cottage. The practice of staff transferring medication from East Wing must cease. This is to ensure the prompt and safe administration of medication. 17 22 22 There must be a record of any complaints, the investigation, the action taken and the response to the complaint. 01/01/2010 This is to make sure that complaints are investigated and acted on. 18 23 13 Incidents where people are physically aggressive and harm other people at the home, individuals abscond 01/12/2009 Care Homes for Adults (18-65 years) Page 55 of 63 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 Description Timescale for action or significantly self harm must be reported to the commission under regulation 37 and to the local authority under adult protection safeguarding procedures. This is to make sure that any allegations are appropriately investigated and actions taken to safeguard the people living at the home. 19 23 13 All staff must be provided with adult protection training. 05/03/2010 This is to make sure that staff recognise and know how to report any allegations of abuse. 20 23 13 04/12/2009 There must be records of restraints or physical interventions. Physical intervention plans must be in place for people and these must be agreed by a multidisciplinary team and to be in their best interests. Any physical interventions must be reported under regulation 37. This is to make sure that accurate records are kept and that physical interventions are only used Care Homes for Adults (18-65 years) Page 56 of 63 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 Description Timescale for action in exceptional circumstances to safeguard the individual and others. 21 24 13 The kitchen in Stable Cottage 05/03/2010 must be replaced. This is because it is an infection control risk. 22 24 23 The requirements detailed in 01/02/2010 the notice of deficiencies from the fire service must be met. This is to ensure the fire safety of all people at the home. 23 24 23 People should be provided 05/02/2010 with adequate furniture, bedding and other furnishings including curtains and floor coverings. This is to make sure that people live in a comfortable environment and can maintain their privacy. 24 30 13 The wooden toilet cistern lids 01/02/2010 and brackets must be replaced or sealed. This is because they are an infection control risk. 25 33 18 Staffing levels provided at the home must be based 01/01/2010 Care Homes for Adults (18-65 years) Page 57 of 63 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 Description Timescale for action upon the individual needs of the people who live there. This is to make sure that there is sufficient staff to meet the personal, physical, social and psychological care and support needs of the people at the home. 26 34 19 Staff waiting for CRB clearance must be supervised by a named member of staff. Any declarations of convictions must be risk assessed. This is to make sure that whilst the suitability of staff is verified they do not work unsupervised. 27 35 18 All staff must be trained in all 03/05/2010 of the mandatory areas and specialist training such as medication, epilepsy, care of older people, mental health conditions, working with people with forensic histories, BSL, adult protection and assessing and understanding risks. 16/11/2009 This is to make sure that staff have the skills and knowledge to be able to meet peoples needs. 28 36 18 Staff must be appropriately supervised. 01/02/2010 Care Homes for Adults (18-65 years) Page 58 of 63 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 Description Timescale for action This is to make sure that staff have the right support and guidance and their performance is managed. 29 39 24 The management at the 01/01/2010 home must develop ways of monitoring and observing the practices of staff working directly with individuals. This is to ensure that that staff are following procedures and guidelines. 30 39 24 The overall management of the home must improve, and develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. 01/02/2010 31 41 37 Regulation 37 notifications must be made for all events that effect the well being of people living at the home and staff disciplinary action. This is to ensure that the home is effectively monitoring and reporting 16/11/2009 Care Homes for Adults (18-65 years) Page 59 of 63 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 Description Timescale for action incidents in the home. 32 42 13 The health and safety and maintenance at the home must improve. 01/02/2010 This is to make sure that people live in a safe and well maintained home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 Assessments should include and explore peoples cultural and faith, preference of gender of staff, sexuality and important personal relationships, their finances and their communication needs. This is to make sure that that the home can meet all of peoples needs. Independent advocacy should be sought for people who need to support to make decisions about where and with whom they live or if they need to move to alternative accommodation because their needs have changed. People who are already living at the home should be consulted about any new people who may wish to move in. Life history works should also be developed that include details and photographs of their history such as family, friends, where they have lived, pets, work etc where appropriate. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. It is recommended that the monthly reviews collate all of the information recorded about individuals. This is so there Page 60 of 63 2 2 3 4 4 6 5 6 Care Homes for Adults (18-65 years) 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 is a clear monthly summary that gives a picture of how people have been and how they have spent their time. 6 6 Individual ways of including people in their reviews and their care plans should be developed. This should include investigating different recording mediums such as photographs, communication in print, DVDs, audio and the computer. This is so people are involved with the records kept about them and have this information in a format or medium that is accessible to them. Goals or actions should be identified in peoples care plans to show how their wishes and aspirations are to be achieved. People should be supported to worship and fulfill their spiritual needs. People should be provided with internet access if they want it and regular checks should be made to make sure that it is working. Peoples preference of gender of staff should be actively sought and recorded in peoples assessments or plans. Staff should be provided with training on how to safely support and guide people with personal and intimate relationships and expressing their sexuality. The competency of staff who administer medication should be periodically assessed. There should be a separate easy read complaints procedure for people. For those people who this information is not accessible there should be descriptions in peoples plans as to how they let people know when they are unhappy and unsettled. Safeguarding information should be made available to the people who live at the home in a format that is accessible to each individual. This is so that they know who they can communicate with if they dont feel safe or they are worried about abuse. A risk assessments should be completed in relation to any 7 6 8 9 13 14 10 11 18 18 12 13 20 22 14 23 15 24 Care Homes for Adults (18-65 years) Page 61 of 63 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 hot radiators and any necessary action taken. 16 17 18 24 24 24 There should be toilet rolls in toilets and hand wash in bathrooms. Ways of reducing the noise of slamming doors in stable cottage should be investigated. People should have free access to their bedrooms. Ways of reducing the impact that other peoples behaviours have on individuals free movement in their own home should be investigated rather than locking doors. People should be supported to personalise the communal areas of the home and their bedroom doors if they choose to. Unless there is an assessed need for an individual the hospital type floor covering or floor tiles, these should be replaced with less institutional floor coverings. The bedroom door of one individual should be checked on a daily basis to ensure the fire safety of all people living at working at the home. The fire procedure displayed should be clarified as it could be interpreted that staff are to return to the fire once everyone evacuated, it states that staff should return to affected area. The way staff are deployed should be reviewed, particularly the arrangements where staff from other buildings leave their allocated house to support people from other houses. References should be followed up and verified by telephone. Incidents, accidents, physical interventions or safeguarding referrals should be reviewed and or further investigated to establish any trends or themes that mean that incidents could be reduced or minimised. 19 24 20 24 21 24 22 24 23 33 24 25 34 39 Care Homes for Adults (18-65 years) Page 62 of 63 Helpline: Telephone: 03000 616161 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 © (2010) 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. 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