Inspection on 11/08/09 for Severn Cottage & Rose House

This inspection was carried out on 11th August 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Severn Cottage & Rose House 21/08/08

Severn Cottage & Rose House 23/08/07

Severn Cottage & Rose House 30/05/06

Severn Cottage & Rose House 05/12/05

Severn Cottage & Rose House 23/06/05

Severn Cottage & Rose House 29/11/04

Severn Cottage & Rose House 24/05/04

Severn Cottage & Rose House 18/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

Key inspection report CARE HOME ADULTS 18-65 Severn Cottage & Rose House 4 Forbes Close Ironbridge Telford Shropshire TF7 5LE Lead Inspector Deborah Sharman Key Unannounced Inspection 11th August 2009 09:30 Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Severn Cottage & Rose House Address 4 Forbes Close Ironbridge Telford Shropshire TF7 5LE 01952 433653 01952 432209 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.selfunlimited.co.uk Self Unlimited Manager post vacant Care Home 19 Category(ies) of Learning disability (19) registration, with number of places Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) 19 The maximum number of service users who can be accommodated is: 19 21st August 2008 Date of last inspection Brief Description of the Service: Severn Cottage and Rose House is part of a small complex providing care to adults with learning disabilities. The site comprises of 2 large houses both providing 15 places, a smaller bungalow providing 3 places (4 Forbes Close). 4 Forbes Close supports semi independent living with minimal staffing to reflect the support needs of the people living at the home. There are 3 bedrooms, a lounge/diner, and communal bathroom with toilet, a separate toilet and shared kitchen. The home is well placed for access to local services, and amenities, in Ironbridge and Madeley. The registered Manager is responsible for both Severn Cottage and Rose House and this is now reflected in the home’s registration with the Commission for Social Care Inspection. The current range of fees for service users was not available to us. Enquiries should be made directly with the service. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 0 star. This means the people who use this service experience POOR quality outcomes. Two Inspectors carried out this unannounced key inspection on 11 August 2009 from 9.30am to 7.00pm. No one knew we were going and they were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by us as key. These are the National Standards which significantly affect the experiences of care for people living at the home. Information about the performance of the home was sought and collated in a number of ways. Prior to the inspection we were provided with written information and data about the home in an annual return which is called an AQAA. We had sent surveys to people who live and work at Severn Cottage and Rose House and also to independent health professionals who have contact with the home. We did not receive any completed surveys back from people who either live or work at the service. We received one completed survey back from a health professional. The comment we received helped us to plan our inspection and has helped us to form a judgement about the quality of support provided. During the course of the inspection we used a variety of methods to make a judgement about how people are cared for. The newly appointed acting manager was unavailable on the day we inspected. A support worker who had been an acting assistant manager at the service supported the process of inspection throughout the day and two senior managers met with us at the end of the day to discuss the feedback from our findings. We looked at how three people are supported in detail using care documentation and by talking to the people. We also looked at steps the service had taken to assess the suitability of one person who has applied for a place in Severn Cottage. We read a variety of other documentation related to the management of the care home such as training, recruitment, accidents and complaints. We looked at how the environment meets the needs of those whose care we were assessing. We did this by looking at the communal and private areas used by these people in both Severn Cottage and Rose House. We also had the opportunity to talk to a visiting relative who described her and her son’s experiences of the service to us. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 6 All this information helped to determine a judgement about the quality of care the home provides. What the service does well: What has improved since the last inspection? The service obtained sufficient information about someone who has applied for a place in Severn cottage. This helps the service to know whether they can meet the persons needs before they offer a place. Fire safety in Rose cottage has been reassessed and steps taken to address issues believed to be at high risk. Hazards from chemicals on the premises have also been assessed and are managed safely. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that at the time of admission, 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. They are not however, provided with enough information about their rights and responsibilities, about how much they will pay and what the home provides for the money. EVIDENCE: The home has three vacancies and is in the process of considering applications. We looked at how one persons application for a place is being considered. Information from a range of sources has been obtained to help the service to decide if they could meet this persons needs. This has included visiting the person in his current accommodation and the person has been able to stay at the home for a five-day introductory stay. It was positive to see that guidance was in place for staff to refer to prior to his stay to help them to meet his needs and minimise any identified risks. We could see that he had enjoyed his Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 10 stay, that he appeared to have been kept active and busy and that staff had used the opportunity to evaluate his suitability for a place. Shortfalls remain in the provision of written information to new and existing residents to inform them about their rights and responsibilities. The Statement of Purpose which was dated January 2009 needs updating further to reflect current 2009 – 2010 fees (the copy we saw quotes fees for 2008 – 2009) and our new address. Also, the management arrangements for the home must be accurately explained. We found the previous acting manager described in the Statement of Purpose as the registered manager. This person was not registered and has since left the organisation’s employment. The Service User Guide has not been issued to people new to the home and those who already live there. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Performance against these standards is mixed. Systems to support people’s needs and minimise risks are partly developed. Lack of staffing, management and a period of instability over recent months following far reaching restructuring of the organisation has undermined progress. EVIDENCE: The outcomes that we found are mixed. People that we spoke to are happy living at Severn Cottage and Rose House and are happy with the support they receive. We found good examples of how peoples needs are being met. For example we saw one person wearing her hearing aid and she confirmed that Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 12 she had received particular support with her personal care following a recent operation. She also told us that steps described in her care plan to help relieve arthritis are acted upon. Following the operation, equipment needed to promote independence and safety was provided. Another person confirmed that in accordance with her care plan she prepares her own breakfast. This ensures that she is being supported to maintain and promote her skills and independence. Previous incidents considered under safeguarding procedures have concluded the need for staff supervision and training in order that peoples needs can be met whilst reducing any associated risk. We are concerned that current staffing levels compromise the level of supervision possible and the training recommended has not been provided. A complaint was received by the service describing how staff shortages were affecting a range of support needs. The complaint described how personal care had deteriorated and how staffing shortages had affected routines such as shopping and cooking. As a consequence food was being borrowed from other homes on site and people, instead of cooking and eating their meals independently in Rose House had to join people in Severn Cottage for communal meals. This has not promoted people’s life skills. Actions agreed as a consequence have not been fully implemented. For example, although staff responsible for the day to day management of the service was directed to improve staffing levels, they were not given the resources to do so but have done their best to resume shopping and cooking. People living in Rose House confirmed this. People that we spoke to were able to describe risks and demonstrate how they would avoid the risk. We looked at systems in place to support this and judge that little progress has been made to improve the quality or monitoring of the written risk assessments since we last inspected. For example, risk assessments continue to state actions that will be taken to reduce risk but don’t say whether these actions have been carried out. Risk assessments in relation to scalds from hot water for example, still state that people will be taught about the risk but the effectiveness of this for each person has not been evaluated as part of reviewing the level of risk. Therefore there is not always an individualised approach to assessing and controlling the level of risk. This combined with a lack of action in response to excessive water temperature is unacceptable. Some risk assessments have not been reviewed since 2007. Omissions in systems and the monitoring system provide the potential for harm. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16, 17. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can take part in activities that are appropriate to their age and culture, are part of their local community and are able to keep in touch with family. The need to support people to develop their skills and abilities is recognised but in practice has been compromised by staff shortages. Meals are not always healthy, fresh or nutritionally balanced. EVIDENCE: Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 14 Before we visited, in their AQAA, the service told us that: We ensure that service users have as much opportunity is possible to lead their lives as members of the local Ironbridge community and wider Telford community.’ It states people have employment opportunities and gives examples of people working in a local charity shop, a local nursery, at the cafe self unlimited runs and the possibility of full employment in the cafe bar self Unlimited is in the process of developing. In order to improve further the service is aware that they could better identify all service users interests and future aspirations and identifies the need to revise the staff rota so as a timetable staff working hours more flexibly. We looked at how the people whose care we were looking at in detail, spend their time. We could see that people have enjoyed visits to a variety of different places of interest within their local and extended community. One person whose care we looked at had been to the cinema, to Shrewsbury, to Cosford air museum, for walks locally, to local supermarkets, the barbers, McDonalds and to a community nightclub. Another person we spoke to confirmed taking part and enjoying all the activities listed in her plan of care. These include short walks, music nights, attending a weekly club and swimming. She told us that she feels fully occupied as there is enough going on. We could also see that people have regular contact with their family and friends. Everyone living in the home has been supported to plan a holiday this year. We could see that there has been a complaint made about staffing shortages affecting the homes routines and ability to support peoples independence with shopping and meals in Rose House. This has meant that people have not always been able to have their meals at a time and in a place to suit them. However, it appears that people living more independently in Rose House are now once again being supported to shop and take their meals independently of Severn cottage. There has also been a complaint made about the nutritional value of lunches in Severn Cottage following the closure of the main kitchen. Senior management acknowledged that staff require training in cooking and nutrition. It was acknowledged that staffing shortages have created a culture of using convenience foods. We could see for example, that although there was some fresh vegetables on the premises, the evening meal of toad in the hole and vegetables, was entirely composed of pre packed frozen ingredients. In addition by teatime, there were no fresh ingredients on the premises to prepare wholesome packed lunches for the following day. The complainant had alleged that jam sandwiches are offered. We could see a variety of jams available with no alternatives. Food records were sparse and were not able to evidence the suitability of food provided throughout the day. It is positive that menus for the evening meal are available and show that people are involved in choosing their evening meals. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 15 Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People currently living at Severn Cottage and Rose House do not have complex health needs and consequently their needs are being adequately met. It is important that systems are developed and monitored to ensure people do not miss health appointments and that health and medication is monitored and reviewed. EVIDENCE: People are satisfied with how their personal care is supported. One person told us that her key worker knows how she likes things to be. Everyone that we met throughout the day, presented as clean and well groomed. People are able Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 17 to choose whether they have a shower or a bath and specialist equipment has been provided to support one person following an operation. We could see that the health needs of the three people whose care we looked at are largely being met. For example, one person who is in good health had been to the dentist and following an opticians appointment had been taken to a follow up appointment with an ophthalmic consultant. For a second person, pre-and post-operative support was appropriate and advice was provided by the district nursing service. We pointed out to the service that one persons recall appointment for a specific health appointment had been missed. Also, we could see that two lots of medication had been discontinued. This could not be accounted for and we found evidence that the symptoms may not have been alleviated for the person indicating in these instances a lack of monitoring and review. Serious concerns have been raised about the management of one persons health and medication. These are currently being investigated independently by the local authority under safeguarding procedures. Other people living there are less dependent and are taking minimal medication which is accounted for in records appropriately. One person is being supported to take their own medication. We found that for this person, medicine which had been dispensed by the chemist was then being put into containers by staff for the person to take later. The dispensing chemist should be asked about this as the medication could be packaged differently to make the situation safer. Little medication is prescribed to be given as required. But we discussed this with staff who understood what it meant and records provided evidence of this. Medication training has been provided although competency based distance learning training has not been completed by most staff. A staff member told us that her competence to administer medication had been checked by her manager. We received a completed survey from one health professional who feels that the service always acts on advice to meet people’s health needs, manages medication correctly and respects people’s privacy and dignity. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 18 Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain. However, sufficient action is not always taken to put things right when people complain. Complaints and action taken are also not adequately recorded to show what actions have been taken to put things right for people. The care home takes action to follow up any allegations but additional staffing and or better management of staffing would protect people where there are known behaviours and risks. EVIDENCE: The service is not managing its complaints in an open and transparent, accountable way. The AQAA told us that there has been one complaint. Prior to and during the course of the inspection we became aware of a number of concerns and complaints. None of these were recorded in the complaints log. At inspection, we became aware of one complaint from a relative about staffing levels compromising the provision of personal care, shopping and meals. The complaint indicated that food was being borrowed from other houses as there was not sufficient time to go shopping. These are serious issues raised, Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 20 however the decision taken by a senior manager was to deal with them as concerns rather than as complaints with the consequence that the matters were not recorded in the complaints log. The lack of records makes it difficult to know whether the complaints were investigated and upheld. However an action plan sent for implementation to the acting assistant manager indicates that the complaints listed were upheld. Again it is not clear whether the complainant is satisfied with the outcome or whether feedback was given. The intention was to write to the complainant but we found out that this did not happen. Prior to lodging a formal complaint which is now being dealt with under safeguarding, a further relative has indicated to us that concerns had been previously raised with the company. Although we could see that copies of emails between the parties have been retained, there is no evidence to suggest that concerns raised have been identified and dealt with as complaints so that the service can take action, learn from and develop as a result of the feedback it receives. The service responds appropriately when an allegation is made and follows locally agreed procedures to report incidents to the local authority. Since we last inspected there have been four safeguarding referrals and investigations with one subject to ongoing consideration. There has not been a repeat of the concerns. In a risk assessment arising from the process, the need for staff to be provided with specific training was agreed as a way of controlling risk. This training has not been provided. Also, the need for staff to effectively supervise those at risk in two cases was concluded. Given the increased multifunctional nature of staff who are cleaning and now catering for a large group of residents, the service needs to demonstrate how it can adequately supervise people when there are two staff on duty in Severn Cottage. Staff that we spoke to, including a new staff member are aware of the risks and how to minimise them to protect people. Protection through adequate supervision however is compromised when staffing numbers are inadequate. All permanent staff have received safeguarding training with two bank staff needing this. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment has worn since the last inspection but we found improvements being made that people living there had been involved in choosing. People’s bedrooms meet their needs and lifestyles. EVIDENCE: On the day of inspection, five new carpets were being fitted to bedrooms. People were clearly very excited about this and told us that they had chosen the colours of the new carpets. Since we last inspected some aspects of the environment have deteriorated. For example staining to carpets and the cover Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 22 on the arm of the sofa in the lounge was completely ripped off. Positively a new sofa has been ordered and people were involved in choosing this. People like their bedrooms which are clean and personalised. Bathing facilities of choice are close by and we could see that specialist equipment had been provided to meet the needs of two people. We found that there was no soap for hand washing in a toilet in Severn Cottage or Rose House. Therefore, a system needs to be implemented to ensure that soap is regularly replenished in toilets to ensure that people can wash their hands thoroughly to avoid the risk of cross infection and illness. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can have confidence in the staff at the home because checks have been done to make sure that they are suitable. However, people’s support is compromised as there are not always enough staff on duty. Staff are provided with appropriate training but they are not being sufficiently supervised by their managers. EVIDENCE: Staff that we spoke to acknowledged that the last few months have been turbulent. However, they were confident that they are coming out of this period, that morale is good and that they have a good and effective staff team. They acknowledged that they have been short of staff but said that they have managed. They feel positive about the appointment of two new staff who have recently started in post and stated that more staff have been promised. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 24 Staff that we spoke to did not share our concern about staffing levels, with one staff member feeling that the problem arose from lack of management of staffing rather than a lack of staff. Managers acknowledged that staffing in Rose House has been under resourced. This was brought to our attention by a complaint received by the service. We discussed this with the acting assistant manager, senior managers and looked at the rotas and could see that Rose House is consistently 12 staffing hours short each week. Although as a result of the complaint the acting assistant manager had been told to rectify this, he was unclear how he was expected to and the matter had not been monitored and resolved. Discussion showed that it was not custom and practice to use agency staff in Rose House to cover the shortages and it appeared that this had not been considered. We received assurances at the end of the inspection from senior managers that the new acting manager is undertaking a review of staffing rotas to ensure that staffing works more effectively and flexibly for the benefit of the people who live there. We talked to 2 new staff both of whom confirmed that all the appropriate checks and references had been carried out before they started work. They confirmed being interviewed and having the opportunity to meet the people who live there prior to the interview. We looked at recruitment records and could see that all necessary steps to check the backgrounds of applicants have been carried out. This protects people from the risk of appointing someone who are unsuitable to work with vulnerable people. Staff continue to feel well-trained and this includes new staff who feel well supported throughout their induction period. Throughout the inspection day, although there was a combination of staff on duty including long term staff, new staff, bank staff and agency staff we could see that steps were taken to ensure that new staff were not left alone to supervise residents. Formal systems to support the performance and practice of staff need to be more fully developed and implemented. For example, staff told us that over the last few months they have not received formal supervision and staff meetings have rarely been organised. However, where concerns about staff performance have been identified, action has been taken. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A lengthy period of management instability has been compounded by a far reaching organisational restructure. There has been a lack of management and a lack of monitoring and leadership which has affected people’s experiences of living and working at Severn Cottage and Rose House. However people are confident that this is now improving. EVIDENCE: Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 26 When we last inspected Severn cottage and Rose House 12 months ago, we found many improvements had been made in a short period of time. Although overall we had judged that the home was providing an adequate service, we felt confident that they were on track with some minor adjustments to provide a good service. Since then, the organisation has undergone a major restructure in order to work towards providing more person centred care. This has led to changes to senior and operational managers and has had a destabilising effect. It is evident that the service has not continued to develop and make progress and has not been managed well through the period of change. There has not been a registered manager for 12 months. When the last acting manager left, the acting assistant manager who was new to the home was left to assume day-to-day responsibility for the service. He was unsure of his role, unclear where files were kept, did not receive an induction and has not had formal supervision although informal support networks were available to him. When we arrived to inspect, he was still unsure of his role as his contract as acting assistant manager had not been renewed. He should not have been on duty on the day of the inspection but had popped in to oversee the laying of new carpets and stayed in the absence of anyone else to support the inspection process throughout the whole day. The AQAA shows us that the service is aware of the ongoing need to implement quality assurance systems. Inspection showed us that progress has not been made since last year, with quality assurance frameworks remaining blank. There was little evidence of monthly regulation 26 visits by the provider, and evidence throughout the inspection day of a lack of monitoring and overseeing of the service. The AQAA did not tell us what had been done to make improvements we identified as needed at the last inspection. At this inspection we were not satisfied that enough had been done since the last inspection, to reduce the risk of scalds from hot water. We saw from records that hot water from a bath in a service user’s bedroom was too hot and sufficient action had not been taken to reduce the temperature. We requested that action be taken to make this safe before we left the home. We looked at how the home is being maintained. The previous maintenance person has left and has been replaced. We could see that repairs are requested and carried out to ensure that fixtures and fittings continue to work. We requested a range of service documentation and with the exception of Portable electrical appliances this was provided to show that enough is being done to ensure the safety of the premises and its facilities. Assessments of hazardous chemicals have been carried out and this is an improvement since last time. Also at the last inspection, the service was also not able to demonstrate enough had been done to address risks from fire in Rose House following a fire inspection in 2007. A further independently commissioned fire Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 27 risk assessment has since been carried out and action taken has been recorded to show how the high risk areas have been limited. Cold food storage temperatures are not being monitored with sufficient regularity. This risks food borne illness. We pointed this out within the last inspection report as did a senior manager following a recent regulation 26 visit. This continues to need improvement to ensure people’s health and safety. Staff need to be provided with training in new legislation relating to Deprivation of Liberty. One staff member we asked was not aware of the new legislation. The home has just recruited a permanent manager who is not yet registered with the Care Quality Commission. She was on leave on the day of inspection, but everyone we spoke to is confident that she will make the required improvements to the service for the benefit of the service users. In the meantime, in the time since we last inspected, there has been a lack of coherent leadership and oversight which has caused the service provided to people to deteriorate. We will be meeting with the organisation to discuss the outcomes of the inspection and our concerns about aspects of the service that have deteriorated and lack of progress. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X 1 X X 2 X Version 5.2 Page 29 Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA33 Regulation 18 (1)(a) Requirement The Organisation must take steps to review staffing levels to ensure that with regard to the size of the care home, the Statement of Purpose and the numbers and needs of service users, that at all times there are suitably qualified, competent and experienced persons working at the care home, in sufficient numbers as are appropriate for the health and welfare of service users. New requirement arising from this inspection August 2009. Arrangements must be made to review systems in place to support the provision of meals. This must ensure that suitable, wholesome and nutritious food which is varied and properly prepared is available in sufficient quantities and at such a time as may be reasonably required by service users. New requirement arising from this inspection August 2009. Timescale for action 30/09/09 2 YA17 16(2) (i) 30/09/09 Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 30 3 YA22 22 Documentation relating to 30/09/09 complaints received should include a full account of the nature of the complaint received, the investigation process, response to the complainant and outcome. All documentation relating to complaints should be available to the Manager and for inspection. This will assure people that their views and concerns are listened to and acted on and will demonstrate that systems are in place to learn from complaints and make improvements. Good practice recommendation arising from this inspection August 2007. Not met August 2008. Not met August 2009. New Requirement August 2009. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Steps should be taken to review with the pharmacist the current practice of double dispensing as this is not safe practice. New recommendation arising from this inspection August 2009. Fridge and freezer temperatures should be monitored and recorded at least daily and remedial action should be taken where temperatures do not comply with recognised safe ranges. New good practice recommendation arising from this Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 31 2. YA42 inspection August 2007. Not met for freezer temperatures August 2008. Not met August 2009. 3. YA1 The Statement of Purpose should be amended to reflect the change in manager since its last review. The weekly fee should be included in the Service User Guide. New good practice recommendation arising from this inspection August 2008. Not met August 2009. 4. YA18 Gender Care policy and practice should be reviewed to ensure staff and managers know what is expected at all times and service users preferences and welfare are promoted without compromising safety, dignity or care. New good practice recommendation arising from this inspection August 2008. Not assessed August 2009. 5. YA19 Where service users are not able to make informed decisions about health care / treatment, best interest meetings should be held to ensure their rights, interests are considered and promoted. New good practice recommendation arising from this inspection August 2008. Not assessed August 2009. 6. YA39 Effective quality assurance and quality monitoring systems, based on seeking the views of service users living at Severn Cottage should be implemented to measure success in achieving the aims of the home and to address any assessed shortfalls in service provision. New good practice recommendation arising from this inspection August 2008. Not met August 2009. Severn Cottage & Rose House DS0000020539.V377167.R01.S.doc Version 5.2 Page 32 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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