Inspection on 04/11/08 for The Alton Centre

This inspection was carried out on 4th November 2008.

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

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

Other inspections for this house

The Alton Centre 08/10/08

The Alton Centre 08/10/07

The Alton Centre 20/06/07

The Alton Centre 07/06/06

The Alton Centre 12/12/05

The Alton Centre 05/05/05

The Alton Centre 16/11/04

The Alton Centre 14/07/04

The Alton Centre 25/05/04

The Alton Centre 13/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: The Alton Centre Irchester Road Knuston Spinney Wellingborough Northants NN29 7EY     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Louise Bushell     Date: 0 4 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 52 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 52 Information about the care home Name of care home: Address: The Alton Centre Irchester Road Knuston Spinney Wellingborough Northants NN29 7EY 01933413646 01933413664 altoncentre@activecarepartnerships.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Active Care Partnerships Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 40 Number of places (if applicable): Under 65 Over 65 0 physical disability Additional conditions: 40 But Lisa Lovett would attend the home two days per week for six months. That Active Care Partnership employs Ms Cunningham forthwith as the manager of the home, with that appointment to last with the requirement that Active Care Partnership be required to submit an application for registration for Ms Cunningham forthwith, with the position thereafter to be discussed with CSCI. That Mr White will attend the home two days per week for six months. That the division catering manager will attend the home every fortnight for six months: and That the resident number will not increase beyond 19 for six months, but any increase or any variation will be discussed with CSCI. The group quality assurance Manager will attend the home once a months for six months. The maximum number of service users who can be accommodated is: 40 The registered person may provide the following category of service only: Care home Care Homes for Adults (18-65 years) Page 4 of 52 with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Physical disability - Code PD There will be five care staff on the day shift and four on the night shift for six months. There will be two registered general nurses on duty at all times for six months Date of last inspection Brief description of the care home The home currently provides care for 19 physically disabled adults between the ages of 18 and 65 years. The home is situated in a small village, close to two local towns and their amenities. Transport is provided in the form of two mini-buses. Accommodation for the client group with Physical Disabilities is mainly provided over three floors and is in single rooms with ensuite facilities. Adaptations such as ceiling hoists and mobility aids are provided according to assessed needs. Inspection reports are available from the home or from the Commission for Social Care Inspection website. Information is available in the main entrance hallway in The Alton Centre. Care Homes for Adults (18-65 years) Page 5 of 52 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 peterchart Poor Adequate Good Excellent How we did our inspection: A key inspection was conducted at the Alton Centre on the 4th November 2008. The inspection was conducted by two inspectors and an expert by experience to seek the views and experiences of the people who use the service. Prior to this statutory inspection, a period of eight hours was spent in preparation. This comprised of reviewing the Annual Quality Assurance Assessment, a document sent to us by the provider, the last key inspection report dated 10th October 2007, a further four random inspection reports, the service history and concerns, complaints and allegations made about this service since the last key inspection and comments cards for staff and people who use the service. No relative or representative comment cards were received. Care Homes for Adults (18-65 years) Page 6 of 52 On the 16th July 2008 we received a complaint about the service which raised concerns for the health safety and wellbeing of the people who use the service. A series of strategy meetings were held involving the Police, Northamptonshire County Council Social Services, the Primary Care Trust and the Commission. As a result a team of inspectors conducted a random inspection on the 6th and 7th August. Serious shortfalls were identified in care planning processes, risk management, dietary needs and support with feeding, management of diabetes, management of wound care, failure to obtain medical intervention, record keeping, management of catheter care, medication practices, safeguarding, staff supervision, ineffective management of the service and staff training. The outcomes for the people who use the service were poor. Two deaths had occurred at the service during this time. The first death was recorded as natural causes by the coroner following the post mortem. The second death occurred at the service on the 7th August 2008 following the inspection conducted on the 6th August 2008. Inspectors noted on the 6th August 2008 that one individual was seen to have breathing difficulties which indicated a serious chest infection. Inspectors were advised that antibiotics had been prescribed although these had been ineffective to date. The Registered Manager stated that she would call the General Practitioner and that he would visit tomorrow. She then stated that she would call the out of hours medical support services after six O Clock the same day. One the 7th August 2008 the individuals plan of care was reviewed and the inspectors were advised that the individual had died during the early hours of the morning. The Registered Manager confirmed that the person was not seen by the out of hours medical support services. Records confirmed that staff did not call the out of hours medical support services to visit the individual and that the person had died alone and without medical attention. Nineteen requirements were made as a result of this inspection. Four requirements relating to the inspection conducted on the 10th October 2007 were carried forward as unmet. The Manager was registered with the Commission on the 15th October 2007 and was served with an urgent cancellation of registration notice on the 7th August 2008 and was suspended from duty pending investigation into her professional competence. The Commission applied to the Magistrates Court for an urgent cancellation of registration for the Alton Centre on the 7th August 2008. This application was granted and Northamptonshire County Council, the Primary Care Trust (PCT) and Northamptonshire County Council (NCC) took over the management of the service. All people using the service were reassessed by the PCT. As a result three people were admitted to hospital for treatment. An application of appeal was submitted by the company to the Care Standards Tribunal. This application was granted and registration was reinstated on the 5th September 2008 with the following imposed conditions of registration. Active Care Partnership (ACP) employs Mrs. Cunningham forthwith for the manager of the home, for that appointment to last with the requirement that ACP be required to submit an application for registration for Mrs. Cunningham forthwith with the position thereafter to be discussed with the Commission for Social Care Inspection (CSCI). It is stipulated that at least two registered nurses must be on duty at all times for six months (in addition to manager). it is stipulated that 5 carers are on duty during day hours and 4 at night for six months. That the resident number will not increase beyond 19 for six months but any increase or variation will be discussed with CSCI. The organisations Training Manager, Lisa Lovett is to spend two days per week at the service. The organisations Clinical Lead, Stewart Whyte is to spend at least two days per week at the service for six months. The organisations Catering Manager is to attend once a fortnight for six months. The organisations Quality Manager is to attend at least once a month for six months. On the 24th September 2008 we conducted a random inspection to monitor compliance with the imposed conditions of registration as set by the Care Standards Tribunal and the outstanding requirements made. A further seven requirements were made as a result of this inspection. On the 8th of October 2008 a further random inspection was conducted to monitor compliance with the imposed conditions of registration as set by the Care Standards Tribunal and the outstanding requirements made. Compliance had been achieved with fifteen requirements made within the set time scales. On the 20th October 2008 a further random inspection was conducted to monitor compliance with the imposed conditions of registration as set by the Care Standards Tribunal and the outstanding requirements made. Compliance had been achieved with fourteen of the remaining fifteen requirements made within the set time scales. One requirement was not complied with in full. Following the key inspection of the 10th October 2007 there has been one concern relating to the loss and removal of property, one complaint regarding safe storage of money. There have been twelve Safeguarding Adults allegations about this service, these have been subject to independent investigation under the Local Authority Guidelines for the Safeguarding of Adults. The outcome for six of these are as yet unknown. The Commission have a focus on Equality and Diversity and issues relating to this are also included in the main body of the report. This site visit to the home was conducted over a period of seven and a half hours during which the inspectors made observations and spoke to the people who use the service and staff. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of two people who use the service were selected and all aspects of their care and experiences were reviewed, including individual plans of care and associated documentation. The service specialises in the care of people who have physical disabilities, some of whom have limited communication abilities and as such were unable to recollect or to fully express Care Homes for Adults (18-65 years) Page 8 of 52 their views about this service. In these circumstances observations are used to inform the inspection activity. The current fee range for this service is 596.19 pounds to 901.94 pounds per week. Additional charges are made for news papers, hairdressing and other personal items. Care Homes for Adults (18-65 years) Page 9 of 52 What the care home does well: What has improved since the last inspection? What they could do better: A total of seven additional requirements and eight recommendations have been made as a result of this inspection. A requirement has been made in relation to the services Statement of Purpose. This document is to be reviewed to ensure that it is up to date and reflects the current changes that have been made as a result of the imposed conditions of registration. Information has been gathered as part of the inspection process in relation to the rights of the individuals residing at the service. The service must demonstrate that risk assessments have been conducted where the rights of the individual may be in conflict with current best practices. It was found that medicines were not being stored under the appropriate environmental conditions and that temperatures of the storage room were to high. Records were being maintained and showed that they were being stored at 31 degree Celsius, this is 6 degree above the recommended storage temperature. The failure to store medicines at the appropriate temperature could result in people receiving a treatment that is ineffective. The storage of controlled drugs medication did not have the correct hinges and was not secured to an external building wall. During the inspection it was observed that a number of bedrooms did not have privacy locks on the en suite bathroom doors or the bedroom doors and therefore did not comply with the fixtures and fittings as specified in Standard 26. In addition to this requirements were made in relation to the management of Care Homes for Adults (18-65 years) Page 10 of 52 individuals finances and recruitment practices. A number of recommendations have been made and the service should consider these as good practice recommendations. 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 11 of 52 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 12 of 52 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. Appropriate assessments are undertaken however this information was not consistently transferred to the Individual Plans of care and working practice therefore the service failed to meet the individual needs of the people who use the service. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been met in this outcome area. Shortfalls have been identified. A requirement was made on the 10th October 2007 at the previous key inspection. Care must be taken to ensure that all service users welfare needs are transferred to the care plan from admission and assessment documentation to ensure that their needs are met. This requirement was complied with during the inspection conducted on the 20th October 2008. Evidence obtained at the random inspections dated the 6th and 7th August 2008 Care Homes for Adults (18-65 years) Page 13 of 52 Evidence: determined that for one person the nutritional assessment identified the level of support required and this was not reflected in the individual plan of care or in the practises observed. The out come was that this persons meal was removed with out the person being able to eat it. Assistance with the dessert was only provided once inspectors had intervened. The service has a Statement of Purpose which complies with the criteria specified in Schedule 1 of the National Minimum Standards. However this was last updated prior to the proposed cancellation of the Registered Managers registration and the imposed conditions of registration and this needs to be addressed to ensure that the people who use the service have access to up to date information. The Expert by Experience reviewed the Service User Guide, her findings included that information was not available in a format suitable to meet the diverse needs of the people who use the service. It also did not contain information about how to contact local social services and health care authorities, key contract terms and the qualifications of staff. The last inspection report was not included in the Service User Guide however was available in the entrance of the building. There have been no recent admissions to the Alton Centre. This is in compliance with the imposed conditions of registration specified by the Care Standards Tribunal on the 5th September 2008. We reviewed the admissions procedure for the service and found it to be satisfactory. Pre admission assessments are conducted by senior nursing staff and these assessments are now being used to form the basis of the individual plans of care. Recognised assessment tools are used to assess the specific risks of individuals. In general people who use the service confirmed that they had enough information to make choices about whether they would like to live at the Alton Centre. The contracts for both of the people case tracked were reviewed. It was found that one of these had not been accurately completed as it had the persons next of kin listed as the person using the service. It did not specify the room number and was not signed by any persons involved. Care Homes for Adults (18-65 years) Page 14 of 52 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have control over their lives within the scope of their ability, however documentation does not consistently support a person centred approach and reflect their changing needs. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been met in this outcome area. Shortfalls have been identified. Two requirements were made on the 6th and 7th August 2008. Care plans must be regularly reviewed and guidance in them implemented to ensure the health and welfare of the people living at the home. This was reviewed on the 20th October 2008 and there was evidence that all existing individuals had been reassessed and had care Care Homes for Adults (18-65 years) Page 15 of 52 Evidence: plans developed according to their assessed needs. A requirement was made at the random inspection on the 24th September 2008. Manual handling risk assessment must be in place, be reviewed active and current. One identified person did not have a manual handling risk assessment in place however required manually handling. This means that the staff do not have the right information available to them in order to ensure that people are cared for appropriately. All people who use the service have had recent reviews of their care plans based on assessed needs. In general these now provide the right information for staff. However some of the documentation is not dated and care plans were last reviewed on the 21st September 2008. On the 4th November 2008 the care plans had not been reviewed and there was no evidence that a review was scheduled. Some risk assessments had not been reviewed monthly as stated on the services paper work. Accident records indicated that one of the people case tracked had fallen in their bedroom on two occasions. The risk assessment had not been amended to reflect the increase risk. A requirement was made on the 10th October 2007. Risk assessments must be undertaken by staff who are fully trained and competent to complete this task. This was reviewed on the 20th October 2008. Currently Mrs D Cunningham is reviewing all risk assessments and has attended a Health and Safety training course which includes risk management. The current arrangements for reviewing care plans is that they are being completed by the proposed registered manager. There is little written evidence that the people who use the service or their representatives are involved in the care planning process. The care plan is task focused and is not person centred or user friendly. The manager confirmed that she will be developing this in the future. Individual plans of care now demonstrate that peoples specialist needs are documented and that any restrictions are in the persons best interest and are supported by a risk assessment. Where appropriate care plans are in place for the management of behaviours that may challenge. The Expert by Experience spoke with a number of people who use the service and has confirmed that people are involved in their care plans and feel satisfied about the way their care needs are met. Surveys received determined that people are satisfied with their care. All individuals have key workers. One person told the Expert by Experience that her key worker works night duty and that she is less accessible as a result. The service caters for people with a diverse range of needs and some were able to confirm that they were able to influence their life styles and daily routines. Individuals confirmed that they have regular contact with the proposed manager. Care Homes for Adults (18-65 years) Page 16 of 52 Evidence: The Expert by Experience spoke with people about the availability of advocacy services. There was no information available at the service for the individuals concerning advocacy services. However some individuals did confirm that they felt able to talk to certain staff members as they knew that they would be listened to. People are supported to maximise their independence. A number of individuals access the local community independently and manage aspects of their own health care needs. For example dental services and pharmaceutical services. People are also able to manage their own finances. People who use the service told us that they are able to vote and confirmed that they receive their personal mail. It was determined that each person was provided with this support suitable to meet their needs. People are supported to experience risk based on their wishes and abilities. People confirmed that they access the community independently and attend college and work placements. One person owns a mobility car and has commented possibly about accessing the local area. The service respond appropriately when unexplained absences occur. Care Homes for Adults (18-65 years) Page 17 of 52 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples social and recreational interest are effectively promoted, however there were serious shortfalls in the promotion of peoples religious observances. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been adequately met in this outcome area. Shortfalls have been identified. A requirement was made on the 6th and 7th August 2008. The registered person must ensure that a choice of food is provided for the identified service users that takes into account his dietary needs arising from his religion. Care Homes for Adults (18-65 years) Page 18 of 52 Evidence: At the inspection conducted on the 8th October 2008 the above requirement was fully met. Personalised menus were in place for this individual to ensure that his cultural and religious needs were being fully met. New menus had also been devised for all people who use the service to ensure that their preferences had been taken into account. The menus displayed the nutritional values showing recommended daily allowances in each food group. Records of food consumed were being maintained. The individual commented that he enjoyed his cultural food choices. An individuals care plan was case tracked on the 24th September regarding their specific dietary needs. It was found that the choices of the individual were not consistent with the information provided by the dietitian as recorded in the care plan. Whilst individual choices must be supported the service did not have any risk assessments in place to balance personal choice with a diet designed to support the persons health and wellbeing. People who use the service have opportunities for educational and occupational activity appropriate to there individual needs. People confirmed attendance at local colleges and access to the local community. Others confirmed arrangements to attend their local church of their choice and that they are supported to exercise their political right to vote. Through discussion with people who use the service it was determined that they visit local restaurants, shopping centres and access local community based activities and are supported by staff to do this. Some individuals attend gardening, craft, cooking and wood work and undertake card games, bingo and dominos. One individual said that they would like to go to Blackpool and although she has not been to date she has been to on day trips, shopping and out for meals. She commented that she likes to attend cooking classes. The Expert by Experience commented that it was excellent that the home has invested in staff time and resources to undertake social activities and that there is approximately 54 hours of activity worker hours per week spanning over 6 days. However the Expert by Experience also commented that people who use the service should be enabled to become more involved in making decisions about the running of the home. People who use the service are supported to maintain links with family and friends. Visiting times are flexible to meet the wishes of the individual. People are able to receive visitors in the communal or private areas. Daily routines are flexible within the constraints of peoples planned activities. However in one of the individuals care plans Care Homes for Adults (18-65 years) Page 19 of 52 Evidence: there was a discrepancy between the assessment and the plan of care in relation to the preferred times for rising and retiring to bed. The individual plan of care for one of the people case tracked showed that they were Sikh and did not eat beef or pork. When the lunch time period was observed the choices available were beef steak or gammon which this one individual is unable to eat. A cheese sandwich was the only alternative provided. Care Homes for Adults (18-65 years) Page 20 of 52 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. The management of personal health care and support has serious shortfalls and fails to protect the people who use the service. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been met in this outcome area. Shortfalls have been identified. The findings of the random inspection conducted on the 6th and 7th August 2008 raised serious concerns about the personal health care and support. In particular the prevention and management of pressure ulcers for at least two people who use the service, both requiring hospital treatment. For example one of the care plans, failed to reflect the deterioration of pressure ulcers over the previous two years and the care plan was not reviewed or adjusted to reflect Care Homes for Adults (18-65 years) Page 21 of 52 Evidence: any changes in need. It was found that in only the evaluation records that it was identified that a named person has a pressure ulcer on his bottom and left heel. There was evidence of considerable deterioration and the eventual outcome was that the person required hospital treatment. The evidence showed that there was a significant delay in the identification and subsequent recording and treatment of the pressure ulcer which resulted in a serious infection. From entries within the care records it was not clear whether medical advise had been sought. An immediate requirement was issued at the inspection of the 6th August 2008 which stated that wound care must be carried out as detailed in the relevant and up to date care plan that actually reflects the needs. Entries of monitoring and assessment must be accurate and deterioration and development of any wound must be acted upon. On the 24th September 2008 we reviewed compliance with this immediate requirement and found that care plans had been reviewed and now contain accurate information including photographic detail to monitor the state of pressure ulcers. Care plans provided appropriate detailed instructions to staff about the care and treatment of pressure ulcers. There was evidence that the people who use the service had appropriate risk assessments and pressure relieving equipment in place. The findings of the random inspection conducted on the 6th and 7th August 2008 raised serious concerns about the personal health care and support. In particular concerns about the management of people who use the service with unstable insulin dependant diabetes. One of the care plans was examined on the 6th of August 2008. The care plan did not state the optimum level of this persons blood sugar levels, neither did it state the action staff should take if the levels were out side of this range. There was confusion amongst the nursing staff regarding the blood sugar monitoring, when insulin should be given and when the person should eat their meals and what action should be taken in action should be taken when a person is hypoglycemic. Records in the persons file indicated that they had not had a diabetic health review for the last eighteen months. Medication Administration Records (MAR) indicated that there were fifteen occasions within a three week period where insulin had not been given as prescribed. One of the nurses spoken to stated that we just use our discretion, if its below 5 we dont give insulin as she goes hypo. She added that the manager had told her that she needed to give the person food after the insulin had been administered but had not seen the new care plan. She also stated that she had not received training in diabetic care. Care Homes for Adults (18-65 years) Page 22 of 52 Evidence: Four immediate requirements were made on the 6th of August 2008 as a result of the findings, the first of which stated, the registered person must ensure that the time the unidentified service users blood sugar is taken is recorded accurately, this is to ensure the consistent monitoring and management of the service users diabetes. The requirement was reviewed on the 24th September 2008 and there was evidence found that blood sugars were being monitored and recorded accurately. The second immediate requirement stated that the registered person must ensure the time when the unidentified service user eats her meals is recorded. This is to ensure the consistent monitoring and management of the service users diabetes. This requirement was reviewed on the 24th September 2008 and there was sufficient evidence to ensure compliance. The third immediate requirement stated that the registered person must ensure that the identified service user is assisted to eat her meal promptly when her insulin has been administered. This is to ensure consistent management of the service users diabetes. This requirement was reviewed on the 24th September 2008. Deirdre Cunningham confirmed that new care plans had been developed following a diabetic review. These showed that they provide staff with clear instructions regarding the sequence of eating, checking blood sugars and the administration of the insulin. The final immediate requirement stated that the registered person must ensure that the optimum range for the blood sugar levels of the identified person is recorded together with the actions nurses should take if the level falls out side of this range. This is to ensure consistent monitoring and management of the service users diabetes. This requirement was reviewed on the 24th September 2008 and it was established that subsequent to the previous review, the person had been admitted to hospital due to the instability of her diabetes. There was evidence that the care plans had been re written and now provides appropriate information. However the care plan combined the routines for both day and night insulin administration. Subsequently information in the care plan was separated to provide clear and unambiguous information to staff. In addition to this a requirement was made that stated that, the registered person must ensure that the information contained in the identified service users care plan regarding the management of her diabetes is communicated early to all nursing staff who are responsible for her daily care. This is to ensure consistent monitoring and management of the service users diabetes. Care Homes for Adults (18-65 years) Page 23 of 52 Evidence: This requirement was reviewed during the random inspection dated the 24th September 2008, at this time the individual was in hospital. However discussion with management confirmed that staff been instructed about the management of this persons diabetes. This requirement was further reviewed on the 8th October 2008 and there was evidence that staff had been issued with individual laminated reference guides and have signed to confirm their understanding and compliance. A second requirement was made that stated that the registered person must ensure that staff implement the care plan in place for the management of the identified service users diabetes. this is to ensure the consistent management and monitoring of the service users diabetes. This requirement was reviewed during the random inspection dated the 24th September 2008, at this time the individual was in hospital. However discussion with management and staff confirmed that instruction had been given regarding the management of this persons diabetes. This requirement was further reviewed on the 8th October 2008 and individual plans of care and other records. For example the blood sugar monitoring record identified that the care was being given as specified in the individual plan of care. A third requirement states that the registered person must ensure that the identified service user receives her insulin at the times prescribed by her medical practitioner. This is to ensure consistent management of the service users diabetes. This requirement was reviewed on the 24th September 2008. A sample of medication was reviewed and determined that medicines were being administered, stored and recorded as required. This requirement was further reviewed on the 8th October 2008 and this specific individuals MAR was reviewed and showed that her insulin was being administered as prescribed and was consistent with the individual plan of care. A fourth requirement was made and states that the registered person must ensure that the times when the identified service users receives her insulin are recorded accurately on the MAR. This is to ensure consistent monitoring and management of the service users diabetes. This requirement was reviewed on the 24th September 2008. A sample of medication was reviewed and determined that medicines were being administered, stored and recorded as required. This requirement was further reviewed on the 8th October 2008 and this specific individuals MAR was reviewed as showed that her insulin was being administered as prescribed and was consistent with the individual plan of care. Care Homes for Adults (18-65 years) Page 24 of 52 Evidence: At the random inspection conducted on the 6th and 7th August 2008, serious concerns were identified regarding a person who was at risk of weight loss and said to be receiving meal supplements. The pressure area care plan assessment stated that he should receive appropriate fluid and food take and stated that he required assistance. It also stated that he required 6 to 8 cups of fluid in a 24 hour period. Lunch time service was viewed on the 6th August 2008 and it was observed that the person was sitting at the table with cheese sandwiches. The person did not attempt to eat the sandwichs but drank the juice from his cup. The chef confirmed that there were two cooked choices on the menu of the day which were gammon and beef steak. The person could not eat either due to his religion. No care staff offered assistance to eat the sandwiches. Despite the attempts of this person to attract staff members, there was no response until tinned pears and ice cream were placed in front of the person. This had not been cut up and was impossible for the person to eat in this state. When prompted the staff then cut up the pear which then allowed the person to eat the desert. The sandwiches were removed with out the person being asked if they had finished. None of the sandwich had been eaten. The person was still trying to eat their dessert when the care staff pulled the table cloth out from under his dish and cleared the table. He continued to hold his cup but no one asked if he would like any more drink. This was eventually cleared along with the dish. It was clear from this observation that the care plan for this person was not being followed as he was not being supported to eat, attention was not being paid to his fluid intake and that he was not being offered choices or being allowed to eat in a relaxed way. This indicates that the person was not receiving adequate nutrition identified as necessary to ensure weight maintenance and the prevention of pressure sores. Two immediate requirements were made on the 6th of August 2008. The first of which stated that the registered person must must ensure that the identified service user is given support to eat his meals as identified in his care plan. This is to ensure that he eats sufficient food of good nutritional quality to maintain his health and well being. Through observation at the random inspection dated the 24th September 2008 it was established that this person was now in receipt of appropriate support to eat his meals. This person was also able to confirm that he was now satisfied with the support that he received. A second immediate requirement was made that the registered person must ensure that what the identified service user has eaten is accurately recorded. This is to enable his diet to be monitored to ensure that he eats sufficient food of good nutritional Care Homes for Adults (18-65 years) Page 25 of 52 Evidence: quality to maintain his health and well being. This requirement was reviewed on the 24th September 2008 and food records identified that this person was now in receipt of an appropriate balanced diet that was sensitive to his religious beliefs. During the inspection conducted on the 6th and 7th August 2008, serious concerns were also identified about the failure of management to ensure that people who use the service receive timely medical attention. One person was seen to have breathing difficulties which indicated a serious chest infection. Inspectors were advised that antibiotics had been prescribed although these had been ineffective to date. The registered manager stated that she had called the general general practitioner and that he would visit tomorrow. She then stated that she would call the out of hours medical support services after six oclock the same day. Due to concerns identified during the inspection of the 6th August 2008 and the risk to peoples health and well being, it was concluded that a further inspection should be conducted on the 7th August 2008 to consider whether the needs of the people at the service were being met. The individual plan of care of this person was reviewed and inspectors were advised that this person died during the early hours of the morning. The registered manager confirmed that the person was not seen by a general practitioner, neither did she call or delegate the task to call for the out of hours medical service. Records confirmed that staff did not call the out of hours medical services to visit the individual and that the person had unnecessarily died alone and with out medical treatment. A requirement was made which stated that action must be taken to assure medical attention when a person requires this. Reasons why this did not happen for one named person when the manager said they would must be recorded under the Northamptonshire County Council Safeguarding Adults Team. Since these serious concerns have been identified both the Commission and Northamptonshire County Council are working in partnership to ensure the safety of the people who use the service. An urgent application was made to the Magistrates Court for urgent cancellation of the service and the registered managers registration. The random inspection conducted on the 6th and 7th August 2008 identified serious concerns regarding the management of medication. Issues identified determined that there was no evidence that medication was being managed safely. There were significant gaps in the MAR indicating that these had not been given, further investigation evidenced that the prescribed medication had been out of stock for a two week period. Care Homes for Adults (18-65 years) Page 26 of 52 Evidence: A requirement was made that stated an effective system for ordering medication must be in place to ensure that there are sufficient quantities of medication so that people receive their prescribed medication and prevent the risk of deterioration in their health. This requirement was reviewed on the 24th September 2008, a system of ordering was in place and sufficient stocks were available supplied through a high street chemist. A further requirement was made that stated that the systems must be sufficient to identify when errors in recording have been made and action taken on this. Audits must be undertaken to identify the inaccuracies identified at this inspection when medication stock did not reconcile with medication records. This requirement was reviewed on the 24th September 2008, standardised MAR systems are in place and seen to be in good order. There was sufficient evidence and information to enable checks on stock control and monitoring of safe administration. We have also received evidence of audits conducted by Active Care Partnership. A further requirement was made that stated that care should be taken to ensure that directions on service users medication is unambiguous. This requirement was reviewed on the 20th of October 2008. This showed that the service has changed to a monitored dose system supplied by a high street chemist. Medication Administration Records provide clear instruction to staff and are well maintained. The Individual plans of care for the specific person relevant to this requirement, shows that there is clear instructions for staff about the management of this persons medication. In addition to this, reference guides have been issued to individual staff. Other records show that the care is being provided as specified in the medication records and the individual plans of care. The random inspection conducted on the 6th and 7th August 2008 identified serious concerns regarding the management of continence. One person residing at the Alton Centre had an indwelling catheter with a drainage bag attached. This was left hanging from the side of their bed and laying on the floor. The catheter bag was full of urine. A requirement was made that stated that when people have a catheter the care provided must be based on good practise and clinical guidance so that people are not at risk of discomfort from the catheter bags left handing at the side of the bed laying on the floor. Care Homes for Adults (18-65 years) Page 27 of 52 Evidence: The compliance date for this requirement was the 20th of October 2008, however there has been no evidence of this poor practise observed following the inspections conducted on the 6th and 7th August 2008. The random inspection conducted on the 6th and 7th August 2008 identified serious concerns regarding the care planning process and the impact on the provision of care. Care planning documentation reviewed determined that for one person the nutritional assessment identified the level of support required and this was not reflected in the individual plan of care or in the practises observed. The out come was that this persons meal was removed with out the person being able to eat it. Assistance with the dessert was only provided once inspectors had intervened. A requirement was made that stated that care must be taken to ensure that all service users welfare needs are transferred from the care plan, admission and assessment documentation to ensure that their care needs are met. This requirement was reviewed on the 20th October 2008. There have been no new admissions to the Alton Centre since the conditions of registration were imposed by the Care Standards Tribunal. However the management confirmed that all of the existing people who use the service have now been reassessed to identify their current health care needs. The individual plans of care have also been reviewed and now provide information to staff about how those health care needs are to be met. A sample of individual plans of care were reviewed these showed that the proposed manager has sought further information about the individuals health care needs from the appropriate health care professionals, these needs are clearly documented and there is also evidence that the provision of health care has been changed as a result. Where information has been found to be lacking there is evidence that further information is currently being sought. People who use the service told us their needs are being met and that they have noticed an increase in the staffing levels. One person who uses the service stated that its good to know you can have the support if you need it, its comforting. Staff told us that they feel they have the skills and competence to meet the needs of the service. The random inspection conducted on the 24th September 2008 identified serious concerns regarding the fluid intake of vulnerable people. The records of two individuals who were selected for case tracking showed that they had received an inadequate Care Homes for Adults (18-65 years) Page 28 of 52 Evidence: volume of fluid in the previous 24 hours. On further enquiry it was established that additional fluids had been given and not recorded. Two requirements were made on the 24th September 2008 as a result of the serious concerns identified. The first requirement states that the people who use the service must be offered adequate and regular fluids within a 24 hour period. The first requirement was reviewed on the 20th of October 2008. Evidence showed that improvements had been made to the record keeping process and that people who use the service are now offered regular fluids. The second requirement states that management must monitor and ensure that the adequate fluid input and output for vulnerable people for people who use the service. The second requirement was reviewed on the 20th of October 2008. There was no evidence to demonstrate that management had monitored the fluid input and output of the vulnerable people. This requirement was carried forward, to be reviewed again at the key inspection conducted on the 4th of November 2008 and records were then found to be adequately monitored by the management of the service. The random inspection conducted on the 24th September 2008 identified concerns regarding the management of risk. Some examples of risk assessments viewed specified the risk but failed to provide sufficient information about how the risks would be reduced and managed. One requirement was made which stated that risk assessments must be in place and sufficiently identify control measures to reduce the risks. To ensure that people who use the service are supported and protected at all times. This requirement was reviewed on 20th of October 2008. It was evidenced that additional information had been included in the care planning process to further support the risk assessment in place to reduce and manage the risk. However accident records indicated that one person had had two falls and the care plan and risk assessment had not been reviewed to take this increased risk into account. A further requirement has been made. The random inspection conducted on the 8th October 2008 identified serious concerns regarding the management of risks associated with peoples rights to choose conflicting with recommended guidance, for example one of the care plans details that a dietitian Care Homes for Adults (18-65 years) Page 29 of 52 Evidence: had recommended a specific diet, however the food records demonstrated that this had not been adhered to. Through discussions with the management of the service it was established that the recommended food was offered and available but the individual had chosen a consistently unhealthy option. In addition to this a further example of a persons right to choose conflicting with recommended guidance is regarding the management of catheterisation and the purchase and use of homely remedies within a care home setting. These issues have been referred to the Northamptonshire County Council Safeguarding Team for consideration. At present the outcome of this is unknown and will reviewed at the next inspection. Two people were cased tracked as part of the inspection conducted on the 4th November 2008. This showed that the findings of the their recent reassessment were reflected in the care planning and the care provided. For example the documentation explored individual preferences for personal care, such as care being provided by staff of the same gender, expression of personal identity such as clothing and appearance and sexuality. One person using the service told us that in the past, with staff support, she has been able to direct the management of her own continence. Following a change in the management of the service historical practices have been found to be non compliant with current best practise. However the impact of this means that her Independence and choices are limited. This issue has been referred to the Northamptonshire County Council Social Services Safeguarding Adult Team. At present the outcome of this is unknown and will reviewed at the next inspection. One person using the service told us that, following changes to the management of the service she is now unable to purchase over the counter medication for the service to administer. However the existing management says that this contravenes the medication polices set out by Active Care Partnership. The impact of this means that her Independence and choices are limited. This issue has been referred to the Northamptonshire County Council Social Services Safeguarding Adult Team. At present the outcome of this is unknown and will reviewed at the next inspection. The Expert by Experience spent time with a number of people who use the service. They confirmed that they have access to appropriate aids and equipment and that staff assist them as required. The people who use the service confirmed that they receive personal support in the way that they prefer and that their physical and health needs are met. The Expert by Experience also determined through discussions that people retain, administer and control their own medication where appropriate. Individual plans of care showed that peoples preferred routines were recorded and that Care Homes for Adults (18-65 years) Page 30 of 52 Evidence: they were reasonably flexible within the constraints of their planned activities. People who use the service have access to a range of health care professionals including general practitioners, speech and language therapists, dietitians and an on site physiotherapist. The manager confirmed that the people who use the service are now being supported to attend routine annual health checks. Medication systems were also reviewed at the key unannounced inspection conducted on the 4th November 2008. People who use the service have access to lockable facilities within their own rooms for the safe storage of medication if this is required. The MAR were seen to be in good order and there were adequate stocks of medication available. The monitored dosage system in use demonstrated a clear audit trail which identified that medication is being given as prescribed. In general medication supplied in loose containers such as liquid medication is dated at the time of opening to ensure that medication is administered within in its shelf life. However one bottle of medication was not dated and it was therefore not possible to cross reference the amount of liquid remaining with the MAR or the ensure it was given within its specified expiry date. This bottle was disposed of during the inspection and a new bottle was dated and the amount recorded on the MAR to enable an accurate audit trail. Medication requiring refrigeration is stored in a locked refrigerator in the office, this medication was dated at the time of opening and records indicated that appropriate temperatures were being maintained. One of the medications identified was a bottle of penicillin which was not in use, it was established that this had not been given because the staff knew that this particular person using the service was allergic to penicillin. MAR identified that it had not been given and an alternative treatment had been prescribed. The penicillin was disposed of during the inspection. Medication is also stored on the second floor, although there was a fan in use in the room, the temperature cooling system was not in use. Records indicated that the room temperature was 31 degree Celsius, this is 6 degree above the recommended storage temperature. The failure to store medicines as the appropriate temperature could result in people receiving a treatment that is ineffective. The management of controlled drugs was reviewed and records were seen to be in good order, with an accurate audit trail. However the storage of controlled drugs did not have the correct hinges and was not secured to an external building wall for compliance with the Royal British Pharmaceutical Guidelines. Medication administration practices were reviewed at the key unannounced inspection on the 4th November 2008. Staff were seen to relate well to the people who use the Care Homes for Adults (18-65 years) Page 31 of 52 Evidence: service and to follow appropriate practices in the administration of medication. Care Homes for Adults (18-65 years) Page 32 of 52 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. A comprehensive complaints procedure is in place however care practices within the service have failed to ensure that people are protected. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been met in this outcome area. Shortfalls have been identified. The service has an up to date complaints procedure which is easily accessible to the people who use the service. The Expert by Experience spoke to a number of people who use the service. They told her that they would speak to their key worker and most said that they feel safe to complain. However the Expert by Experience also reviewed the service users guide and identified that it did not contain all of the information specified in standard one of the National Minimum Standards. The information included in the Commissions comment cards also determined that the people who use the service are able to raise their concerns and feel that they are being listened to. Care Homes for Adults (18-65 years) Page 33 of 52 Evidence: We have received one concern from a relative about missing items, communication systems and a lack of response to their concern. This was referred to the provider for investigation and reviewed at the key unannounced inspection conducted on the 4th November 2008. The complaints file was reviewed and this showed that a full investigation had been conducted. We also have also received evidence to show that the service has responded directly to the complainant. There was no evidence found to support the concerns raised, however an apology was offered for the initial lack of response. The service has received one complaint since the last inspection from a relative regarding the use of and storage of an individuals money. The complaints file showed that a thorough investigation had been conducted and the findings communicated to the complainant. Since the last inspection there have been eleven safeguarding adult allegations about this service. All of these safeguarding allegations relate to the management of health and personal care, specifically the management of risks, pressure sores and medication. The outcomes of these safeguarding allegation investigations are not as yet known. More recently one person was admitted to Hospital and required surgery because the service had failed to provide the appropriate care to this individual. During the same month we also received information that another person had died whilst eating and that the police were involved in the multi disciplinary investigations. A further person died of a chest infection following failure of the service to obtain appropriate medical treatment. Our review of the information resulted in the unannounced inspection focusing on wound care, nutrition, medication and management. A requirement was made on the 10th October 2007 stating, to properly protect service users staff must have a full understaing of and follow safeguarding proceedures promptly. This requirement was carried forward from the insection conducted on the 6th and 7th August 2008 and was reviewed at the unannounced random inspection conducted on the 20th October 2008. Through a review of the training records and discussion with staff it was established that this requirement has now been met. Subsequently staff have received training in safeguarding of adults and were able to confirm their understanding of types of abuse and any actions that would need to be taken as a result they were also able to confirm access to the local authority guidelines, internal policies and procedures including the whistle blowing policy. Care Homes for Adults (18-65 years) Page 34 of 52 Care Homes for Adults (18-65 years) Page 35 of 52 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment is adequate providing people who use the service with a comfortable place to live however it does not protect the privacy of the people who live there. Evidence: There were no outstanding requirements from the last key inspection dated the 10th October 2007. The premises is suitable for its stated purpose, all bedrooms are single and is there are dedicated communal and activity areas, with a large varied out door space available for all to access as required. The premises is accessible to wheelchair users, disability aids, adaptations and equipment are available in a variety of forms and supports peoples personal choices and preferences. Following the random inspection of the 6th and 7th August 2008 and the imposed conditions of registration the service has been subject to the increased involvement from the Responsible Individual and other senior representatives within the organisation. Care Homes for Adults (18-65 years) Page 36 of 52 Evidence: This has resulted in significant improvements to the environment. A significant number of bedrooms have been redecorated and re carpeted following consultation with the people who use the service. During the inspection conducted on the 4th November 2008 it was noted that some of the bedrooms did not comply with the fixtures and fittings as specified in Standard 26. For example it was observed that bedrooms did not have privacy locks on the en suite bathroom doors or the bedroom doors. During the inspection conducted on the 24th September 2008 an area was identified as being malodours. During the key unannounced inspection conducted on the 4th November 2008 the service was clean and hygienic following a deep clean and continuing maintenance works to improve the environment. A full electrical test has been conducted and action taken to correct any shortfalls identified. The environment appeared safe and no hazards were identified. Staff spoken to were able to confirm adequate supplies of hot water. Hot water was being tested and records viewed and showed that hot water was dispensed at safe temperatures. Staff confirmed that they had received recent training in infection control procedures. There were no outstanding requirements from the last key inspection dated the 10th October 2007. The premises is suitable for its stated purpose, all bedrooms are single and is there are dedicated communal and activity areas, with a large varied out door space available for all to access as required. Care Homes for Adults (18-65 years) Page 37 of 52 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. The lack of knowledge and poor practice exhibited by some nursing staff does not ensure that the people who use the service are protected and in safe hands at all times. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been adequately met in this outcome area. The imposed conditions of registration stipulated that; 1. At least two Registered Nurses must be on duty at all times for at least six months in addition to the manager. 2. At least five carers are on duty during the day hours and four at night for six months. 3. That the resident number will not increase beyond nineteen for six months and any variation or increase will be discussed with the Commission for Social Care Inspection. Care Homes for Adults (18-65 years) Page 38 of 52 Evidence: 4. The organisations Training Manager, Lisa Lovett is to spend two days per week at the Alton Centre. 5. The organisations Clinical Specialist, Stewart Whyte is to spend at least two days per week at the service for six months. 6. The organisations Catering Manager is to attend once a fortnight for six months. 7. The organisations Quality Manager is to attend one a month for six months. These imposed conditions have been reviewed during all regulatory activity dated the 24th September 2008, 8th October 2008, 20th October 2008 and the 4th November 2008. At each of these inspections there was evidence found to demonstrate that changes had been made by the organisation to cover annual leave and training commitments on two occasions. There was a delay in the proposed registered manager applying for her CRB. Following the inspection conducted on the 6th and 7th August 2008 four Registered Nurses including the Registered Manager have been suspended pending investigation into concerns about their professional knowledge and practice. These investigations have not been concluded. As a result of the random inspection conducted on the 6th and 7th August 2008, three requirements were made. Two of which were carried forward from the previous key unannounced inspection conducted on 10th October 2007. The first requirement stated to protect service users properly staff must have a full understanding of and follow safeguarding procedures promptly. This requirement was reviewed on the 20th October 2008. Staff spoken to confirmed that they had recently received training in the safeguarding of adults and were able to demonstrate knowledge of whistle blowing and reporting procedures in relation to safeguarding. This was also evidenced in the training records. The second states that risk assessments must be undertaken by staff who are fully trained and competent to complete this task. This requirement was reviewed on the 20th October 2008. The proposed Registered Manager of the service verbally confirmed that risk assessments are being completed by those who have suitable qualifications. The proposed manager confirmed that the staff completing the risk assessments had received training in an intermediate Health and Safety course which covers aspects of risk management. Care Homes for Adults (18-65 years) Page 39 of 52 Evidence: The third requirement made states that all staff must receive supervision to assess their level of competence at least six times a year to ensure that the people who use the service are in safe hands at all times. This requirement was reviewed on the 20th October 2008. Staff supervision records showed that supervision had now commenced. Staff were able to confirm that they had received supervision. At the inspection conducted on the 24th September 2008, management informed us of the proposed training programme for staff. However there was no formalised programme in place showing how this was to be managed or the time scales involved. A further requirement was made on the 24th September 2008 that states that a training plan must be in place to ensure that all staff are qualified and competent and able to provide the support and care as required by the people who use the service. This was reviewed at the random inspection conducted on the 20th October 2008. Evidence showed that a schedule of training had been devised for a four week period. Recruitment practises were reviewed at the key inspection conducted on the 4th November 2008. It was established that in general staff files contained the appropriate information including Criminal Records Bureau Checks and POVAFirst checks. Staff files also showed that appropriate references were obtained before staff commence employment. However one staff file only contained one professional reference and there was no evidence of a completed staff induction programme. The services application form does not state the relationship between the applicant and the referee. Contracts of employment are held for each individual. The Expert by Experience spoke to people who use the service and they commented that, in general they found staff to be polite and friendly. They also commented that staff work well together and that they can raise their concerns and that staff are responsive to their requests. As a result of the serious concerns raised and the findings of the random inspection dated the 6th and 7th August 2008, there has been increased in put from the Training Manager. All staff now have a new training programme in place and there is a rolling programme of mandatory training and training specific to the individuals needs. The training records show that First Aid, Fire Safety, Food Hygiene and Health and Safety, pressure care, nutrition, hydration and tissue viability and infection control have been provided. Care Homes for Adults (18-65 years) Page 40 of 52 Evidence: Arrangements are in place for staff to receive moving and handling training in the near future. Care Homes for Adults (18-65 years) Page 41 of 52 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. Serious shortfalls in the management of the service does not ensure that the people who use the service are kept safe at all times. Evidence: Due to the serious concerns raised at the random inspection of the 6th & 7th August 2008 and the subsequent enforcement action and the imposed conditions of registration set by the Care Standards Tribunal, the main outcome for the people who use the service is that their needs have not been met in this outcome area. Shortfalls have been identified. Following the last key unannounced inspection conducted on the 10th October 2008, Ms Jacqueline Curtis-Bates was registered on 15th October 2007 with the Commission for Social Care Inspection. However due to serious concerns raised through the safeguarding process about the care that two people had received at the Alton Centre, an unannounced inspection was conducted on the 6th and 7th August 2008 to review the management of nutrition, wound care, medication and management. Care Homes for Adults (18-65 years) Page 42 of 52 Evidence: As a result of serious concerns about their well being, three people were admitted to hospital for treatment. Two other people died at the Alton Centre, the first of these raised concerns about care practises in the service, however further information was made available that showed that this person died of natural causes. However during the inspection conducted on the 6th August 2008, it was identified that a person had a serious chest infection. This was reported to the manager who gave assurance that emergency medical attention would be obtained. On review during the 7th August 2008, we were informed that the individual had died alone in the early hours of the 7th August without medical attention having been sought. As a result the Registered Manager was served with an urgent cancellation of registration notice on the 7th August 2008 and was suspended from duty pending investigation into her professional competence. The Commission also applied to the Magistrates Court for an urgent cancellation of registration for the Alton Centre. This application was granted and Northamptonshire County Council, the Primary Care Trust (PCT) and Northamptonshire County Council (NCC) took over the management of the service. All people using the service were reassessed by the PCT and NCC. An application of appeal was submitted to the Care Standards Tribunal. This application was granted and registration was reinstated on the 5th September 2008 with the following imposed conditions of registration. These are as follow; Active Care Partnership (ACP) employs Mrs. Cunningham forthwith for the manager of the home, for that appointment to last with the requirement that ACP be required to submit an application for registration for Mrs. Cunningham forthwith with the position thereafter to be discussed with the Commission for Social Care Inspection (CSCI). It is stipulated that at least two registered nurses must be on duty at all times for six months, in addition to the manager. It is stipulated that 5 carers are on duty during day hours and 4 at night for six months. That the resident number will not increase beyond 19 for six months but any increase or variation will be discussed with CSCI. The organisations Training Manager, Lisa Lovett is to spend two days per week. The organisations Clinical Lead, Stewart Whyte is to spend at least two days per week at the service for six months. Care Homes for Adults (18-65 years) Page 43 of 52 Evidence: The organisations Catering Manager is to attend once a fortnight for six months. The organisations Quality Manager is to attend at least once a month for six months. The proposed Registered Manager has been in post since the Care Standards Tribunal and is in the process of gathering the information required to submit an application to become registered with the Commission for Social Care Inspection. To date this has not been recieved. On the 24th September 2008 we conducted a further random inspection to monitor compliance with the imposed conditions of registration as set by the Care Standards Tribunal and the outstanding requirements made on the 6th and 7th August 2008. A further seven requirements were made as a result of this inspection. On the 8th of October 2008 a further random inspection was conducted to monitor compliance with the imposed conditions of registration as set by the Care Standards Tribunal and the outstanding requirements made on the 6th and 7th August 2008. Compliance had been achieved with fifteen requirements made within the set time scales. On the 20th October 2008 a further random inspection was conducted to monitor compliance with the imposed conditions of registration as set by the Care Standards Tribunal and the outstanding requirements made. Compliance had been achieved with fourteen of the remaining fifteen requirements made within the set time scales. Following the inspection conducted on the 6th and 7th August 2008 two requirements were made, the first requirement stated that management of the home must be effective and sufficient to ensure that people receive the care and support required to stop serious risks to their health. This was reviewed on the 8th October 2008 and it was found that there is now a full time proposed Registered Manager in post as specified by the Care Standards Tribunal, although not yet registered. The proposed person is also a qualified Registered Nurse with previous experience of managing care services including the Alton Centre. The proposed person is supported by the Responsible Individual, a Clinical Specialist and the Operations Manager. The second requirement stated that training, support and monitoring of staff must be enough to ensure sufficient levels of competency is held by them to meet the assessed needs of the people living in the home. Monitoring must be able to identify to serious shortfalls in competency then action must be taken to safeguard the people living at Care Homes for Adults (18-65 years) Page 44 of 52 Evidence: the home. This was reviewed on the 20th October 2008, three staff files were reviewed in order to establish what actions the service had taken with regards to the monitoring, support and disciplinary actions in relation to ensuring staff competence. Records indicated that a number of staff are being supported in their role, through increased monitoring and supervision. There is also evidence that the service is taking disciplinary action against four staff. Supervisions are being conducted and records are being maintained. Training is being undertaken by staff and a training plan has been produced. This shows the training scheduled until the 12th November 2008. A rolling programme is in place to ensure that all staff have attended mandatory training courses. Staff attendance is being documented. The rolling programme of training ensures that all staff are able to recieve this. Following the inspection conducted on the 24th September 2008 two requirements were made. The first requirement states that the Commission must be notified about all incidences that adversely effect the well being of the people who use the service. This requirement was made as a result of the service failing to notify us that two people had been admitted to hospital and that the lift was out of order. This was reviewed on the 20th October 2008 and it was found that appropriate notifications are now being submitted to the Commission. During the inspection conducted on the 24th September 2008 a review of a Regulation 26 template report was seen. There were several areas within the template that did not ensure all aspects of the regulation were included. This was brought to the attention of the Responsible Individual and the proposed Registered Manager, who stated that amendments would be made. The second requirement states that the format of the Regulation 26 visit reports must contain all of the information as specified under the regulation. This was reviewed on the 20th October 2008 and it was found that appropriate amendments had been made to ensure compliance with the regulation. The Responsible Individual also stated that corporate changes would occur to the style and format of the regulation 26 report to ensure that appropriate information is contained within the report. The Expert by Experience states that everyone whom she spoke to stated that they were happy with the way the care home was being managed. The Expert by Experience stated that they all seemed to be happy with the current management Care Homes for Adults (18-65 years) Page 45 of 52 Evidence: arrangements, felt listened to most of the time and that action has been taken as required. During the inspection conducted on the 4th November 2008 other key standards were reviewed including quality assurance and safe working practises. At the present time quality assurance activities include daily management audit, monthly manager audits, audit of service users money, environmental audits, catering audits and medication audits. Medication is also stored on the second floor, although there was a fan in use in the room, the temperature cooling system was not in use. Records indicated that the room temperature was 31 degree Celsius, this is 6 degree above the recommended storage temperature. The failure to store medicines as the appropriate temperature could result in people receiving a treatment that is ineffective. The management of controlled drugs was reviewed and records were seen to be in good order, with an accurate audit trail. However the storage of controlled drugs did not have the correct hinges and was not secured to an external building wall for compliance with the Royal British Pharmaceutical Guidelines. We have also been supplied with the results of audits undertaken by corporate staff. However there have been no recent surveys of the views of the people who use the service. We received a completed Annual Quality Assurance Assessment (AQAA) from the provider which details improvements that the service aims to achieve within the next twelve months. Some of these include the revision of the Statement of Purpose and the service User Guide, further development of the care plans with the involvement of the individual to achieve person centred care planning, increase user involvement, to provide service user focused activity programmes, the completion of Health Action Plans, the completion of full pre admission assessments to make sure that they are able to meet the physical, social and emotional care needs and wishes of the individual. In addition this is the Annual Quality Assurance determines that they have adequate information available to them on Whistle Blowing and safeguarding. It states that all staff receive full and comprehensive induction and that there is a robust recruitment procedure including all relevant pin and safety checks. The AQAA shows that improvements could be made through regular input from the staff training officer. It determines that health and safety is a high priority and that staff are trained. The Care Homes for Adults (18-65 years) Page 46 of 52 Evidence: service aims to improve by ensuring that matters requiring attention are actioned promptly, are recorded and actions shared and agreed with all, including the people who use the service. There is no evidence that any resident or staff meetings have been held, however a relatives meeting did occur and was recorded. A sample of polices and procedures were reviewed these were found to be dated June 2006 and there was not further evidence to show that these had since been reviewed. As part of the inspection a review of the management of individuals money was reviewed. It was found that the money belonging to the people who use the service was being pooled. This was stored in a locked, secure facility. Records indicated that the amount belonging to each person was recorded, however this was not on separate records. There is now evidence that staff are receiving training in mandatory subjects necessary to ensure the health and safety of the people who use the service. All records relating to Health and Safety were up to date and in order. Although risk assessments were in place for most activities, there was one example where an assessment had not been up dated following two falls. A record of accidents and incidents was in place. The proposed Registered Manager has now confirmed receipt of the revised certificate of registration specifying the conditions of registration. The certificate of insurance was displayed and in date. Care Homes for Adults (18-65 years) Page 47 of 52 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 48 of 52 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 The Statement of Purpose 01/01/2009 and service User Guide must be reviewed to ensure that it reflects the imposed conditions of registration. To ensure that people have accessible, accurate and up to date information. 2 19 12 Risk assessments must be conducted in situations where peoples rights to choose conflict with current best practice. To ensure that peoples rights are balanced with the potential risk and that action is taken to manage these risks. 01/01/2009 3 20 13 Medicines must be stored 01/01/2009 under appropraite environmental conditions in complaince with their product licience to mainatain their stability. Care Homes for Adults (18-65 years) Page 49 of 52 To ensure the quality of medications in use and to protect people in the service from harm. 4 20 13 The storage of controlled medication must be reviewed to ensure that the arrangements are in compliance with the guidance issued by the Royal British Pharmaceutical Society. To ensure the safe storage of controlled medication. 5 24 23 Action must be taken to ensure that appropriate fixtures and fittings are provided in the individuals accommodation. To ensure that a persons privacy and dignity is respected at all times. 6 34 19 Recruitment practices must demonstrate compliance with Schedule 2 of the National Minimum Standards. To ensure that the people who use the service are in safe hands at all times. 7 39 13 The arrangements for 01/01/2009 storing and recording money stored for the people who use the service must be reviewed to ensure that it complies with the guidance issued with the Commission for Social care Inspection 10/12/2008 01/01/2009 01/01/2009 Care Homes for Adults (18-65 years) Page 50 of 52 Managing money for people who use services. To ensure that people who use the service are protected from abuse. 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 5 Contracts should be reviewed to ensure that they contain the criteria listed in Standard 5 of the National Minimum Standards. People who use the service and or their representatives should be involved in the care planning and review process to ensure that acre plans are individual and person centred. People who use the service and or their representatives should be informed and supported to access advocacy services if they wish to do so. Information gathered during the assessment process should be reflected in the current care plan to ensure that people are supported to achieve their personal preferences. The application form should reference the relationship of the referee to the applicant. Staff files should evidence that a comprehensive induction training programme has been provided to new employees. Formal processes should be developed to ensure that people who use the service are able to voice their opinions and become involved in the running of the service. Policies and procedures should be reviewed on an annual basis to ensure that they comply with current best practice and are applicable to the needs of the people who use the service. 2 6 3 7 4 16 5 6 7 34 35 39 8 42 Care Homes for Adults (18-65 years) Page 51 of 52 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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