Inspection on 17/11/09 for The Byre

This inspection was carried out on 17th November 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Byre 30/03/10

The Byre 10/12/08

The Byre 17/01/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

Key inspection report Care homes for adults (18-65 years) Name: Address: The Byre Allaston Court Farm The Byre Lydney Gloucester GL15 5SR     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Paul Chapman     Date: 2 5 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. 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. Care Homes for Adults (18-65 years) Page 2 of 42 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 42 Information about the care home Name of care home: Address: The Byre Allaston Court Farm The Byre Lydney Gloucester GL15 5SR 01594844244 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Footsteps Medical Care Limited care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who may be accommodated is 4. The registerd person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home The Byre was registered in July 2007 as a new service for adults with a learning disability. It is located in a residential area on the outskirts of Lydney. The property is a bungalow which has been fully redeveloped in order to meet the relevant National Minimum Standards. All bedrooms have en-suite facilities. There is also a spacious shared bathroom with adaptations, a lounge and a kitchen-dining area. Prospective residents and their representatives are provided with information about the home including the Service Users Guide. Fee levels are negotiated on an individual basis. 1 0 1 2 2 0 0 8 4 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 42 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: Before completing the site visits to this service we sent an AQAA (Annual Quality Assurance Assessment) for the registerd provider to complete. The registered provider failed to return this document to us, it is a legal requirement that the provider completes this document and the CQC are considering what actions will be taken as a result. This inspection site visit was completed over 3 visits to the service. The 1st inspection site visit was unannounced on Tuesday 17th November and on our arrival we were met by the acting manager. During this site visit we spent time examining the care management plans for all of the people in the home including assessments to manage potential risks, finanicial management, food prepared in the home and the activities they complete. In addition to this we spoke to 2 staff on duty, examined rotas and the procedures to protect people in the home. We also completed a tour of the premises with the acting manager. This first site visit raised serious concerns about the service and as a result we left 2 immediate requirements for the registered provider to address and contacted the funding authority for people in the home to discuss our Care Homes for Adults (18-65 years) Page 5 of 42 concerns. The immediate requirements related to the records of income and expenditure for people who are unable to manage their own finances and risk assessments to minimise potential risks to people while they go about their day to day lives. After this site visit we arranged to meet the registered provider at the home in the following week on Wednesday 25th November. We looked at evidence that confirmed the immediate requirements had been met. At this meeting we discussed our concerns about the service and examined records for staff training and recruitment, we also spoke to 5 staff on duty during the day. At this site visit it came to our attention that untrained staff were administering medication to people in the home, as a result we left an immediate requirement that this practice ceased immediately. Due to the significant risks identified in the previous site visits 2 inspectors returned to the home on Thursday 3rd December and seized documents under PACE (Police and Criminal Evidence Act) Code B. A range of documents were copied and removed as evidence of where the registered provider may have committed an offence against the Care Homes Regulations 2001. Whilst at the home we examined the medication administration since our last visit and this showed that only trained people are now administering medication. Care Homes for Adults (18-65 years) Page 6 of 42 What the care home does well: What has improved since the last inspection? What they could do better: None of the people living in the home has a signed statement of terms and conditions detaling each parties expectations whilst the person is living in the home. The Service Users Guide and Statement of Purpose should be produced in an easy read format to enable people with communication difficulties to understand them more easily. All of the people in the home must have care plans in place that detail their assessed needs and provide staff with sufficient detail to meet those needs. Risk assessments are now in place that identify a range of risks for each person but they require further development and regular review to ensure that peoples changing needs are identified. It is difficult to identify where people are able to make choices in their day to day lives and the registered provider must ensure that they document this in the future. Activities completed by people from day to day must be thoroughly documented including the choices given to people. There appears to be little choice about the food provided to people in the home and its nutritional value. The registered provider must ensure that all of the people get the choice of a range of wholesome and nutritional food. Medication administration was seen to be poor putting people in the home at an unacceptable level of risk. People living in the home require support to mobilise and there was limited information available to support staff with this practice. This puts people at risk of injury and receiving inconsistent approaches by staff. 1 person has a plan for daily physio therapy but we were unable to find any records of staff completing this. The registered provider must ensure that all peoples medical needs are appropriately addressed. Care Homes for Adults (18-65 years) Page 7 of 42 All of the people in the home require support with their personal care but care plans we examined did not provide us with sufficient detail as to meet peoples needs consistently. People in the home can present behaviours seen as challenging. None of the staff have received training to meet these needs and there is limited information available to staff in the form of guidelines to meet these needs. This is putting both people in the home and staff at serious risk. Some of the comments made by staff raised serious concerns about practices adopted by some of the staff. Staff training is poor with the majority of staff receiving no specialist training to meet peoples needs. The registered provider must ensure that all staff receive the appriopriate training to meet the needs of people in the home. The staffing rota showed a number of occasions where the home was staffed by inexperienced and unqualified staff which puts people at unacceptable levels of risk. The home has not had a registered manager since November 2008 and the registered provider must ensure that they employ an appropriately qualified and experienced person that must apply for registration with the CQC. The registered provider must ensure that all incidents that must be reported to the CQC under Regulation 37 of the Care Homes Regulations 2001 are reported. The registered provider has designed a quality assurance procedure for the home but it has not been implemented. The registered provider must implement quality assurance and be able to provide evidence of people opinions being sought and shortfalls/corrective action being taken. The registered provider must ensure that the homes fire safety procedures meet criteria of the relevant Fire regulations and we recommended they speak to the local fire service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 42 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 9 of 42 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an up to date Statement of Purpose and a Service Users Guide which will give potential service users accurate information about the service provided. The service obtains assessments for people that wish to move into the service and this enables the provider to make an informed decision about whether the service can meet their needs. People do not have signed statements of terms and conditions detailing the responsibilities of each party. Evidence: A requirement of the previous inspection report was that the services Statement of Purpose and Service Users Guide must be updated. This has been completed but we recommend that both documents are dated and the Service Users Guide should be created in an easy read format. A requirement of the previous inspection report was when people are admitted to the service a completed assessment is obtained from the funding authority. Examining the information available for the last admission to the service we found an assessment/care plan from the funding authority. Care Homes for Adults (18-65 years) Page 10 of 42 Evidence: A requirement of the previous inspection report was for each person living in the service to have a statement of terms and conditions. This requirement has not been achieved and the CQC will be considering what action to take. Care Homes for Adults (18-65 years) Page 11 of 42 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning for people in the home is poor making difficult to identify peoples needs and the steps taken by staff to meet them. Record keeping in the home meeds to significantly improve to make it possible to confirm that peoples needs are being met consistently by staff. Choices for people living in the home are poorly documented. Until recently all of the people in the home were being put at unacceptable risks to due to the poor risk management in the home. Evidence: At our 1st site visit we examined the documents evidencing care for all of the people living in the home. At the time of this visit only 1 person had an up-to-date care plan in place and this had been written in the week before this site visit. Another person had moved into the service for an assessment over a 4-month period. Looking in their file we were only able to find the care plan created by the funding authority before entering the home. No care plans had been created by staff in the home to address the persons needs. The only records seen to evidence their time in the service was the daily notes kept by staff and a basic routine detailing their morning routine. The Care Homes for Adults (18-65 years) Page 12 of 42 Evidence: files for the other 2 people in the home provided a similar picture where we were unable to find care plans to show what peoples needs were and how staff addressed them. At our 2nd site visit the acting manager had made some progress with developing another persons care documents although there were still no care plans in place. The registered provider explained that when they had realised that peoples care plans were not in place they had aimed to address this and commented that if our site visit had been a couple of weeks later all of these plans would have been in place. At this site visit the registered provider showed us PCPs for the other 2 people. These had been created after their admission to the service 2 years ago. Looking at them they provided information across a wide range of topics, unfortunately none of these documents had been reviewed in the past 18 to 24 months. This makes it impossible to confirm that they accurately reflect peoples current needs. The CQC recognise that the home have created a new care plan for 1 person in the home which will hopefully improve the quality of this persons care. This is difficult to judge as the care plan has been introduced so recently. Speaking to the registered provider we stressed the importance that care plans provide the reader with sufficient detail to meet peoples needs consistently and enable an accurate review of peoples needs. The care plans created in the week before this site visit did not provide the reader with sufficient detail, and must be reviewed. It becomes a requirement of this report that all of the people in the home have care plans in place that accurately reflect their needs and provide staff with enough detail to enable them to meet those needs consistently. These care plans must then be reviewed at regular intervals to ensure they remain accurate. 3 of the 4 people living in this service have communication difficulties. This makes it difficult for staff to empower people to make choices. At the 2nd site visit the registered provider showed us communication care plans that had been created 2 years ago. These provided examples of how people communicate they are happy/sad and make choices. Staff commented that sometimes people are asked what they would like to do and they could communicate whether that was what they wished. An area that should be reviewed is the meals provided to people in the home. The menu is written by staff, and although there are 2 choices staff decide what will be cooked. We spoke to the only person able to communicate verbally about the food. We asked them whether they were able to choose what they liked to eat? they replied no, I eat what is put in front of me. We checked this comment with staff who agreed that this person rarely gets a choice. The registered provider must ensure people living in the home are empowered to have choices and that these are documented. This becomes a requirment of this report. Care Homes for Adults (18-65 years) Page 13 of 42 Evidence: We looked at risk assessments for all of the people in the home. 1 person had risk assessments created with their care plans in the week before the 1st site visit. These assessments covered a good range of potential risks and identified what steps could be taken to address them. Risk assessments for the other 3 people in the home were very poor with a limited number in place, and these had not been reviewed regularly. We felt this put people at an unacceptable risk and as a result we issued an immediate requirement at the 1st visit giving the provider 7 days to ensure that where required, risk assessments were in place for each person. At our 2nd site visit each person had a range of risk assessments in place. We feel this is a starting point but stressed to the provider that the risk assessments need continual review and development as new risks become apparent. This is becomes a requirement of this inspection report. Care Homes for Adults (18-65 years) Page 14 of 42 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People take part in a number of activities in and outside the home but we are concerned that the attitude of some staff affect the quality of life of people in the home. From examining records and speaking to staff we are concerned that people have little or no choice about what they eat and the range of meals are not wholesome and nutritious. Evidence: To identify the activities people take part in we looked at a sample of 3 peoples daily notes and spoke to staff about the activities they support people with. We also spoke to 1 of the people in the home who was able to communicate with us verbally. There are a range of regular activities that take place on a weekly basis, these include; 2 people attending day services, 3 people attending hydrotherapy and everyone attending a local social club 1 evening a week. Staff are also supporting 1 Care Homes for Adults (18-65 years) Page 15 of 42 Evidence: person to visit a local golf club to use the driving range. We spoke to the person about this who confirmed this happens regularly and they enjoyed it. We saw evidence of activities that take place in the home with staff supporting people to use the homes sensory room and 1 example of a person being supported to make cakes. Other activities that were noted included people listening to music, watching TV and dancing. Whilst we were completing the site visits we saw staff spending time with people listening to music and watching TV. Other activities recorded in daily notes included trips to Gloucester shopping, and rides on the homes vehicle. Speaking to staff about activities they confirmed these activities take place but made other comments that concerned us. More than 1 member of staff commented that recently people were completing less activities, we put this to the provider, they stated that due to the winter some activities were no longer happening. A member of staff made a comment that was of concern, they explained that they like to take people out and when they had arrived 1 day they had said to another staff member they should take people out, the other member of staff replied I cant be bothered, as a result they were unable to take any of the people out. This is a poor attitude and although we appreciate it may be an isolated incident the registered provider must monitor this to ensure that people in the home are not being stopped from completing activities due to the attitude of staff. Records we sampled showed peoples families visit regularly. We examined a menu for the home and spoke to staff about how the meals are chosen. Speaking to the senior support worker they explained they are responsible for creating the menu. They explained that the menu provides 3 choices for breakfast and 2 choices for lunch, this was confirmed from looking at the menu. Our sample of peoples daily notes showed people eating the following; various cereals, toast and jam, fish and mash, roast turkey, pizza, pie and mash, chips and beans, chicken curry, liver and sausage, spaghetti bolognese, stew, sausage and mash, faggots and a take away. We spoke to staff about how people are empowered to choose what they would like to eat, a staff member stated that 1 person sometimes gets a choice. It was the opinion of the other 5 staff we spoke with that people do not get a choice about what they eat, staff stated they are told what meals they will prepare for tea/lunch, they also stated there is usually no fresh fruit or vegetables in the home and food is usually frozen. The daily notes we examined provided little evidence of fresh fruit and vegetables being used in meals. We spoke to 1 of the people living in the home about the food, we asked what they thought of the food and whether they were able to choose what they ate; they replied, I have never been asked what I would like to eat, the meals are just served up each Care Homes for Adults (18-65 years) Page 16 of 42 Evidence: day. The food is nice. We are very concerned that people do not appear to be getting any choice about what they eat, and that their diets consist of a range of frozen, rather than fresh products. People in the home have communication difficulties but from the information made available to us they are able to communicate if they are happy/unhappy with things. It becomes a requirement of this report that people living in the home are empowered to have a choice about the meals and food they eat and there is a range of wholesome, nutritious ingredients available to prepare these meals. Care Homes for Adults (18-65 years) Page 17 of 42 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. Peoples personal care needs are not accurately reflected in their current care plans and this presents a risk of their needs not being met consistently. Where required health professionals are involved in peoples care and records are available to support this. People have been put at significant risk due to untrained staff administering medication. Evidence: We examined the care plans for peoples personal care. The acting manager had written a care plan for 1 person in the week before the 1st site visit. Examining this care plan showed that it provided some detail about the persons personal care needs but not enough to meet their needs consistently. We spoke to the registered provider and the acting manager about this explaining why a greater level of detail was needed. 2 other people also had care plans that detailed their personal care needs, unfortunately neither document had been reviewed in the previous 18 to 24 months, again the level of detail was poor and did not accurately reflect each persons needs. The 4th person did not have a care plan to address their personal care needs (there was a brief morning routine document)and the acting manager and registered provider stated that they would be creating one in the near future. It is a requirement Care Homes for Adults (18-65 years) Page 18 of 42 Evidence: of this inspection report that the registered provider ensures that each person has a care plan that is person centred and identifies their personal care in such detail that enables staff to meet their needs consistently. We saw training records that showed new staff complete moving and handling training. 3 people require the staff to use hoists when moving them. When examining the care plans supporting peoples care we were unable to find any care plans to address peoples moving and handling needs. We spoke to the registered provider about this and explained that these plans should be in place. This becomes a requirement of this inspection report. When examining 1 persons care there was a list of physio exercises for staff to complete with them on a daily basis. We spoke to the acting manager who stated staff should record in the persons daily notes when they do this. We examined daily notes and were unable to find any evidence of these exercises being completed. We were assured these exercises have been completed, just not recorded. the registered person must ensure the exercises are taking place and that staff record when they have copmpleted them. This becomes a requirement of this report. 1 person in the home relies on PEG feeding for their nourishment. When examining staff training records we were unable to find evidence that staff had completed training. The provider stated that when the person left hospital the nursing staff had provided training to staff. New staff have then been given training by the established staff. We recommend to ensure best practice is stillbeing followed that the provider should arrange for all staff to complete refresher training in this subject. Whilst examining peoples files we saw a range of records showing the input of other healthcare professionals. This was also confirmed through our conversations with other healthcare professionals. As part of the acting managers strategy to review peoples care they have started to re-organise peoples files making it easier for the reader. They must be mindful of some of the information being kept in peoples files as even in the file re-organised by the acting manager there were still some document that appeared to be out of date. We found hospital assessments in place for 2 people in the home. Both had been completed, 1 was dated as completed the day before the 2nd site visit. A requirement of the previous inspection report related to the registered person reporting information to the CQC via Regulation 37 notifications. When speaking to the registered provider it was their understanding that we had been notified of incidents. We found 1 incident whilst completing the site visit that should have been reported to Care Homes for Adults (18-65 years) Page 19 of 42 Evidence: us, and we have not received any notifications since the previous inspection was completed. This is an offence under these regulations and the CQC will be taking enforcement action as a result. We examined the medication administration in the home. 1 of the senior members of staff has the responsibility for overseeing medication. Storage of medication is secure in a recognised medication cupboard sited in the laundry. Records of medication administration showed that it is audited on entry to the home. All of the medication sheets we examined were hand written by the 1 staff member, this is poor practice and puts people at risk of a medication error. If a medicaton sheet is being hand written it should be cheked by another person to ensure it is correct. This becomes a requirement of this inspection report. In addition to the requirement we makes the following recommendations; the provider should implement a sheet of sample initials/signatures for the administration, they should also create a file of information identifying the contraindications of the medication administered to people in the home. The most serious concern we identified with medication practice is staff not trained in the safe handling of medication administering medication to people in the home. In some cases we saw this had been happening for the past 5 months. This is a clear breach of the regulations and due to the seriousness of our concerns we left an immediate requirement stating this practice must cease immediately. We spoke to the provider about this who appeared shocked to find this practice was happening and they gave their assurances the practice would cease. Before leaving the home the provider stated that a number of the untrained staff will be completing medication training in December. The previous report made a requirement that the registered provider must ensure that where medication is being administered in food there are clear protocols in place and the persons consent is recorded. The senior carer stated that no one has any medication administered in food, therefore this protocol is no longer required. One person is prescribed Buccal Medazolam. For staff to administer this medication they must receive specialist training. From speaking to the health professional responsible for administering this training and from examining training records there are currently 3 staff trained to administer this medication. We spoke to the senior care staff about the steps they when the person requires the medication. They explained that if none of the staff on duty are trained to administer the medication they call an ambulance. Reading the risk assessment and procedure that support this situation the registered provider must ensure that these documents accurately reflect the actions Care Homes for Adults (18-65 years) Page 20 of 42 Evidence: taken and the level of risk presented. From speaking to the registered provider and the health care professional responsible for delivering this training we acknowledge that 3 more staff will be completing this training in the next month, Care Homes for Adults (18-65 years) Page 21 of 42 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. People are being put at unnecessary risks due to staff not receiving safeguarding adults and behaviour management training. Accounts detailing the income and expenditure of people in the home have been poor and caused an unacceptable level of risk to people. Behaviour management is inconsistent by staff and this puts people at risk. Evidence: The home has a complaints procedure, speaking to 1 of the people in the home they stated, I didnt know there was a complaints procedure. A requirement of the previous inspection report was that the registered provider must ensure that complaints are fully investigated and responded to in 28 days. Speaking with the provider about complaints they stated they had not received any complaints but had recently addressed a concern brought to their attention by a parent. The CQC recently received a complaint about the home and has asked the provider to investigate. We are awaiting the providers response. The home has a whistle-blowing policy and this was inspected as part of a previous site visit. Speaking with the provider they confirmed that they had not received any complaints from staff via the whistle-blowing policy. Training records showed that new members of staff have not completed any training in safeguarding adults. Speaking with 3 of the new staff they confirmed they had not received this training. It becomes a requirement of this inspection that where staff Care Homes for Adults (18-65 years) Page 22 of 42 Evidence: have not completed this training in the past 3 years they must now be enrolled on a course. All of the people in this home present behaviours that can be challenging. None of the people have care plans/guidelines in place that provide sufficient detail to address these issues and speaking with staff we found limited knowledge of supporting people when they become anxious. When people become anxious staff write notes detailing what led to the incident and the actions taken to address them. In a lot of cases there were notes detailing these incidents, but from speaking with staff we also found a number of incidents had not been recorded. Some of the other comments made by staff about their approach to managing behaviour were of great concern to us and further investigations are in progress to confirm this information. A requirement of this inspection report is that there must be guidelines implemented for each person that explain what actions staff must take when people become anxious. In addition to this all staff must complete training in behaviour management. At the first site visit we found a major shortfall with the accounting of peoples monies. The registered provider should keep accounts for all of the income and expenditure for people in the home whose money they hold. At our first site visit we found that none of the accounts had been completed since July/August 2009. As a result of these findings we left an immediate requirement that these accounts must be up to date within 7 days. At our 2nd site visit the registered provider had addressed this. We recommend that the provider audits these records as part of their monthly Regulation 26 visits to ensure that this does not happen in the future. Care Homes for Adults (18-65 years) Page 23 of 42 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a property that is homely, comfortable and that meets their current needs. Evidence: We completed a tour of the premises with the acting manager during our first site visit. The property is a bungalow that provides people with a range of bedrooms, bathrooms, toilets and communal rooms all on the same level. In addition to these rooms there is also a sensory room that is very popular with people, this is fitted with soft mats, lights and a a sound system. In this room is an armchair that belongs to 1 of the people in the home. It was noted that there is a hole in the covering showing the foam. This may cause an unecessary risk to infection control and the registered provider must address this. The property was decorated to a good standard throughout. There is a range of specialist equipment fitted in the home and we saw records to show that where it required regular servcing it had been completed. The property was clean, tidy and there were no offensive odours on either of the Care Homes for Adults (18-65 years) Page 24 of 42 Evidence: occasions we visited. Care Homes for Adults (18-65 years) Page 25 of 42 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 practices followed for the recruitment of new staff is inconsistent at puts people living in the home at unnecessary risks. The staffing of the home has put people at unacceptable risks due to staff not being appropriately trained to meet peoples needs. Staff training for new and established staff is poor and putting both staff and people in the home at unnecessary levels of risk. Evidence: A requirement of the previous inspection report was where staff had been employed by a care provider previously the registered provider must record the reason for the person leaving that employment. We examined the records for the past 4 people employed in the home since the previous inspection and none had been employed with a care provider previously. Examining the records for staff employed since the previous inspection showed that of 4 staff 50 had complete recruitment records while the other records were incomplete with a reference and gap in employment history identified. It becomes a requirement of this inspection report that the registered provider ensures that the regulations are met when recruiting new staff. All of the staff we spoke with confirmed that the majority of shifts are covered by 3 Care Homes for Adults (18-65 years) Page 26 of 42 Evidence: staff. Whilst examining the staffing rota for October we found 2 occasions that appeared to show only 2 staff on duty. When speaking to staff we asked them how the significant reduction in the size of the team had affected them. Staff were in agreement that it had meant them working more long days and staff spoke about working 10 or 11 days in a row and feeling exhausted. 2 of the staff we spoke to during our site visits explained they were leaving over the following 4 weeks. A serious concern identified on the rota was with new staff working together. We found an occasion where 3 new staff worked a shift together after working in the home after only 2 to 4 weeks. None of these staff had completed training in medication or epilepsy and were all new to working in a care environment. This is poor practice showing a disregard for the safety of people in the home. The registered provider must ensure that on every shift there are appropriately experienced and qualified staff so people living in the home are not put at unnecessary risks. We spoke to the new staff about their induction at the home and from their comments it was clear they felt it was poor. Records showed that they had received training in health and safety, moving and handling, fire safety and in 2 cases food hygiene. None of the new staff had completed the Common Induction Standards for Care. It becomes a requirement that these staff complete these standards and any future staff also complete this training. The staff files we sampled for new staff showed that training certificates are kept when staff complete training courses. We examined the latest training records for staff supplied by the registered provider. The training records were confusing as a number of training courses recorded on the document were the same courses with different titles. The registered provider was aware of this and gave their assurance they would address it. Looking at the training records and speaking to the registered provider and staff we are concerned that staff have not completed specialist training to meet peoples needs. An example of this is 1 persons funding authority had arranged training for the staff team but due to staffing issues none of the staff had attended the training. The funding authority had then provided some information on this persons condition to the home, speaking to staff 1 person stated they had seen this information and done some other research, but other staff we discussed this with stated they had not seen any information on this persons condition. Another example of this is the staffs training in Epilepsy where a not all of the staff have received even basic training in Epilepsy, this is now being addressed. It becomes a requirement of this inspection report that the registered provider ensures that all staff receive the appropriate specialist training to meet the needs of people in the home. When speaking to the registered provider they explained that they had cancelled a number of training courses during the summer due to a funding issue for 1 person in the home and swine flu. It becomes a recommendation of this inspection report that the Care Homes for Adults (18-65 years) Page 27 of 42 Evidence: registered provider develops a training plan for the staff team to achieve over the next 12 months. Speaking to 2 staff about the frequency of supervision they stated that these happened infrequently. 1 person stated that they had received 2 supervision sessions in the past 2 years. These standards clearly state that it is good practice that staff receive recorded supervision at least 6 a year. It becomes a recommendation of this inspection report that the registered provider ensures this is done. Care Homes for Adults (18-65 years) Page 28 of 42 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. The service is poorly managed and this is reflected in the poor administration in the service and the outcomes for people living there. Quality assurance in the service is not monitored and from the evidence gathered as part of this inspection it is clear that peoples needs are not being met. Steps are taken to reduce potential health and safety risks but these are inconsistent and potential risks remain. Evidence: At the time of this site visit there was no registered manager in post. The last registered manager resigned from the home in November 2008. The provider promoted a member of the staff team to the position of manager in February this year. It was our understanding this person would apply with registration with the CQC. This member of staff resigned in October without applying for registration. Speaking to the provider they were unclear about this believing that the acting manager had submitted their application. The CQC have no record of any application being received. It is the registered providers responsibility to ensure that the CQC receive an application for a manager to become registered with the CQC. Care Homes for Adults (18-65 years) Page 29 of 42 Evidence: At the time of this site visit another member of the staff team was acting as manager. The provider explained they have asked an employment agency to find an appropriately qualified person to become manager of the service and apply to be registered with the CQC. Before we completed this site visit we wrote to the service provider requesting that they complete the AQAA (Annual Quality Assurance Assessment) for the service. This document asks the provider to provide evidence of what the service does well and their planned improvements. It is a legal requirement that a registered provider submits this document. The provider has failed to submit this document and we spoke to them about this at our 2nd visit. As a result of not receiving this document from the registered provider the CQC will be considering what action to take. The management of this service is poor. There appears to be little direction given to the staff team and comments made by the majority of the staff team that we spoke with raised serious concerns about working practices. As a result of these statements we have informed the appropriate authorities with the responsibilities for safeguarding adults in social care. A requirement of the previous inspection report was for the provider to create a quality assurance system and evaluate the service. At this site visit the provider showed us a document they had created, unfortunately it had not been used. As a result of this the provider has not met this requirement and is subject to enforcement action the CQC. A requirement of the previous inspection report was the provider must ensure they complete monthly visits to the service and compile a report of their findings. Reports written by the provider shows they have been completing these visits each month over the past 6 months. We are concerned that although these visits were being completed monthly the registered provider was unaware of the shortfalls identified around peoples care and the management of their monies. We recommended that as part of any future visits they should audit/check the finances for people whose money is managed by the home. We examined the procedures to minimise potential risks to people living in the service; Fridge and freezer temperatures were being monitored but the recording was inconsistent. It is recommended the registered provider ensures these temperatures are recorded regularly. Care Homes for Adults (18-65 years) Page 30 of 42 Evidence: Hot water outlets are monitored each month by the provider, they must ensure that all outlets that are used are tested. Cleaning products - We saw a small number of COSHH sheets that did not appear to have been updated since 10/01/08. The provider stated that these are in the process of being updated at present and they will be in a similar format to the risk assessments. Fire safety - Examining the records available to us showed that the fire risk assessment had been completed in July 2008 and had not been reviewed. This must now be done. Other records showed that staff and engineers were testing the alarm system as required. We did find 2 shortfalls, the emergency lighting was not being tested at regular intervals and there was no record any fire evacuations taking place in the past 12 months. The provider must ensure that both of these areas are addressed. Training records examined during the site visit showed that new staff complete a health and safety course as part of their induction. It is recommended that where other staff have not completed this course in 3 years they should be enrolled on refresher training. Care Homes for Adults (18-65 years) Page 31 of 42 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 5 5 Each person must have a statement of terms and conditions in place which provides information about any additional costs which are to be paid. This is to make sure that people have access to information about the costs of the service they are to receive. 26/02/2009 2 19 37 The registered person must inform the Commission of any incidents affecting the well being of people living in the home. This is in respect of an emergency admission to hospital. This is to make sure that we can monitor the support people are receiving. 26/02/2009 3 22 22 The registered person must provide evidence that complaints are fully investigated and responded to within 28 days. This is to make sure that the home processes complaints in line with its policies and procedures. 26/02/2009 4 37 8 The registered provider must 27/02/2009 appoint a manager who must Page 32 of 42 Care Homes for Adults (18-65 years) 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 apply to become registered with us. This is to make sure that the home is managed in line with current legislation. 5 39 24 The registered person must put a quality assurance system in place to evaluate the service provided. This is so that the quality of the service provided can be monitored and reviewed. 26/02/2009 Care Homes for Adults (18-65 years) Page 33 of 42 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 1 20 13 The registered person shall 25/11/2009 ensure that all medication is not administered by staff that have not been trained in the safe handling of medication. Failure to ensure that staff are trained in the safe handling of medication puts people at unecessary and unacceptable risk. 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 5 5 Each person must have a Statement of terms and conditions in place which provides information about any additional costs which are to be paid. This is to ensure that people have access to information about the costs of the service they are to receive. 01/01/2010 2 6 15 The registered person must ensure that all of the people in the home comprehensive care plans in place that identify their needs and the 01/01/2010 Care Homes for Adults (18-65 years) Page 34 of 42 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 steps staff must take to meet those needs. Failure to implement these care plans will put people at risk of their needs not being met. 3 7 16 The registered person must ensure that people in the home are empowered to make choices and these must be recorded. Empowering people to have a choice and recording these occasions will provide good evidence that the service is led by the needs and wishes of people living in the home. 4 9 13 The registered person must ensure that risk assessments are continually reviewed and new assessments must be implemented as required. Failure to do this puts people at unacceptable risks. 5 12 16 The registered provider 18/12/2009 must ensure that they promote the welfare of all of the people in the home and that staff support them to take part in a range of activities. 01/01/2010 22/01/2010 Care Homes for Adults (18-65 years) Page 35 of 42 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 Failure to do this will negatively affect the quality of life experienced by people in the home. 6 17 16 The registered provider 18/12/2009 must demonstrate how peope are given choices about the food they eat. The registered provider must also ensure that peoples diets are wholesome and nutritious. Failure to provide people with a wholesome and nutritious diet may cause health issues for people in the home. 7 18 17 The registered person must ensure that comprehensive records are kept to provide evidence that a persons health needs are being met. Failure to do this makes it impossible to confirm this persons physical needs are being addressed. 8 18 15 The registered person must 25/12/2009 ensure that where people require moving and handling by staff that plans are in place identifying how peoples needs are met. 11/12/2009 Care Homes for Adults (18-65 years) Page 36 of 42 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 Failure to do this puts people at unnecessary risk. 9 18 15 The registered person must 18/12/2009 ensure that peoples personal care needs are identified and that care plans are in place that detail the actions required by staff to meet those needs and wishes. Failure to implement these care plans put people at risk of their needs not being met. 10 19 37 The registered provider must inform the CQC of all events that are prescribed as part of this regulation. Failure to do this is a breach of the regulations. 11 20 13 The registered person must ensure that medication sheets are checked for accuracy by another member of staff. Failure to do this presents a greater risk of a medication error. 12 23 13 The registered person must 08/01/2010 ensure that guidelines are developed detailing the actions staff must take when 11/12/2009 11/12/2009 Care Homes for Adults (18-65 years) Page 37 of 42 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 people become anxious and present that challenges. Failure to do this puts people at risk of being treated inappropriately when they become anxious. 13 23 13 The registered person must ensure that all staff receive training that enables them to support people appropriately when their behaviour becomes challenging. Failure to do this presents a risk of people being treated inappropriately and inconsistently when they become anxious 14 32 18 The registered provider must ensure that staff are appropriately skilled and experienced to meet the needs of people in the home. Failure to do this puts people in the home at unnecessary risks. 15 33 18 The registered provider must ensure that there are appropriately experienced and skilled staff on each shift. 18/12/2009 29/01/2010 15/01/2010 Care Homes for Adults (18-65 years) Page 38 of 42 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 Failure to do this puts people in the home at unnecessary risks. 16 34 19 The registered provider must ensure that whenever new staff are recruited to the staff team that the regulations are adhered to at all times. Failure to do this puts people in the home at unnecessary risks. 17 35 18 The registered provider must ensure that all staff receive the appropriate training to meet needs of people in the home. Failure to do this puts people in the home at unnecessary risks. 18 37 8 The registered provider 15/01/2010 must appoint a manager to be responsible for the day to day management of the service. The manager must be appropriately qualified to manage the service and an application for registration with the CQC must be received without delay Failure to appoint an appropriately qualified manager will continue to put 19/02/2010 18/12/2009 Care Homes for Adults (18-65 years) Page 39 of 42 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 people living in the service at unnecessary levels of risk. 19 39 24 The registered provider must implement the quality assurance procedure. This makes sure that the registered provider is monitoring the service being provided. 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 15/01/2010 1 1 The Service Users Guide should be produced in an easy read format to ensure that all potential admissions to the home have access to the information they need. The Statement of Purpose and Service Users Guide should be dated to enable the reader to judge how up to date the information may be. It also enables the service to review the documents at regular intervals. The registered should ensure that staff receive training in administering PEG feeding. The registered person should compile information about the contraindications of the medication administered to people in the home. The registered person should create a sample signature/initials list making it easier to identify which staff have administered medication. The registered provider should ensure that all staff receive regular supervision as identified in the National Minimum Standards for this service. The registered provider should ensure that the homes fire safety risk assessment is reviewed and updated as Page 40 of 42 2 1 3 4 19 20 5 20 6 36 7 42 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations required. 8 9 42 42 The registered provider should ensure that a fire evacuation drill is completed. The registered provider should contact the fire service to ensure that fire equipment is checked by staff in line with the fire service guidelines. It is good practice that where staff have not completed health and safety training in the past 3 years that they complete refresher training. 10 42 Care Homes for Adults (18-65 years) Page 41 of 42 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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