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Care Home: British Home and Hospital for Incurables

  • Crown Lane Streatham London SW16 3JB
  • Tel: 02086708261
  • Fax: 02087666084

The British Home & Hospital for Incurables (BHHI) is a voluntary care home for 127 people. It is a registered charity with a Board of Management. BHHI provides purpose built accommodation for people who are chronically sick and physically disabled. The aim of the home, highlighted in the statement of purpose is: ` to provide high quality nursing care with high levels of clinical and recreational support thereby assisting each resident to achieve maximum possible independence`. BHHI is 5 minutes from local shops and near to all the local transport facilities. It is close to Streatham Common and a short drive from all the amenities in Streatham. This a large Victorian building, which has a distinctive presence in the area. It is maintained to a high standard and an 15012009 extension, which was built in 1996, is in keeping with the existing building. There are two units on each floor known as East and West Wing. The newer wing created 48 single rooms all en suite. A kitchen was completely rebuilt in 2001 where the food is cooked and brought to each floor in portable Bain Maries. The Home has a physiotherapy department with two full-time physiotherapist and two full-time physiotherapy assistants who see all people who use the service.

  • Latitude: 51.423000335693
    Longitude: -0.1089999973774
  • Manager: Christine Lilian Morland
  • Price p/w: -
  • UK
  • Total Capacity: 127
  • Type: Care home with nursing
  • Provider: British Home and Hospital for Incurables
  • Ownership: Voluntary
  • Care Home ID: 3488
Residents Needs:
Physical disability

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for British Home and Hospital for Incurables.

Key inspection report Care homes for adults (18-65 years) Name: Address: British Home and Hospital for Incurables Crown Lane Streatham London SW16 3JB     The quality rating for this care home is:   one star adequate 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: Sonia McKay     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 38 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 38 Information about the care home Name of care home: Address: British Home and Hospital for Incurables Crown Lane Streatham London SW16 3JB 02086708261 02087666084 chris.morland@britishhome.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: British Home and Hospital for Incurables care home 127 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: The maximum number of service users who can be accommodated is: 127 The registered person may provide the following category of service only: Care home 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 categories: Physical disability - Code PD Date of last inspection Brief description of the care home The British Home & Hospital for Incurables (BHHI) is a voluntary care home for 127 people. It is a registered charity with a Board of Management. BHHI provides purpose built accommodation for people who are chronically sick and physically disabled. The aim of the home, highlighted in the statement of purpose is: to provide high quality nursing care with high levels of clinical and recreational support thereby assisting each resident to achieve maximum possible independence. BHHI is 5 minutes from local shops and near to all the local transport facilities. It is close to Streatham Common and a short drive from all the amenities in Streatham. This a large Victorian building, which has a distinctive presence in the area. It is maintained to a high standard and an Care Homes for Adults (18-65 years) Page 4 of 38 Over 65 0 127 1 5 0 1 2 0 0 9 Brief description of the care home extension, which was built in 1996, is in keeping with the existing building. There are two units on each floor known as East and West Wing. The newer wing created 48 single rooms all en suite. A kitchen was completely rebuilt in 2001 where the food is cooked and brought to each floor in portable Bain Maries. The Home has a physiotherapy department with two full-time physiotherapist and two full-time physiotherapy assistants who see all people who use the service. Care Homes for Adults (18-65 years) Page 5 of 38 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: one star adequate 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: This inspection was carried out by three inspectors over two days, including a night visit. A pharmacy inspector visited on the first day of the inspection. We had a tour of the premises and looked at records relating to the environment. We looked at records of how people were being cared for and we spoke with residents and relatives. We spoke with the manager and staff on duty. We looked at records about complaints. We looked at information supplied to us by the manager in an annual quality assurance audit. Care Homes for Adults (18-65 years) Page 6 of 38 We looked at things the home has notified us about since the last inspection. We looked at activities going on in the home and we joined staff for lunch. We contacted health and social care professionals by telephone and by sending out surveys. We sent surveys to the home for staff to complete and send back to us. Care Homes for Adults (18-65 years) Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: The health needs of prospective residents are assessed before they are admitted to the home. Staffing levels and the need for any additional staffing should also be part of the assessment. It is important that there are enough suitably trained staff to meet the assessed needs of any resident admitted to the home. The home must also write to prospective residents about the outcome of their assessment and whether their assessed needs can be met. Care Homes for Adults (18-65 years) Page 8 of 38 Care is delivered to residents in accordance with care plans although the documentation has shortfalls; this has the potential to mislead on all the necessary actions needed to support residents. Record keeping is not always available to demonstrate that appropriate action is taken to follow guidelines from health and social care professionals, or a true reflection of the progress of residents. More could be done to ensure that staff act on or record the verbal complaints made by relatives and residents, as some feel as though the issues they raise are not looked at. Staff should have a better understanding of the Deprivation of Liberty safeguards. The home benefits from the stability of a staff team that are dedicated and skilled. Although there is some indication that staffing numbers are not appropriate to the needs of some of the residents, especially those with highly complex health conditions who need close monitoring. 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 9 of 38 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 10 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health needs of prospective residents are assessed before they are admitted to the home. Staffing levels and the need for any additional staffing should also be part of the assessment because there must be enough suitably trained staff to meet the assessed needs of any resident admitted to the home. The home must also write to prospective residents about the outcome of their assessment and whether their assessed needs can be met. Evidence: We looked at how a new resident was admitted to the home. There is an application form and the nursing staff had obtained relevant needs assessments and hospital reports. This gives them appropriate information about the nursing care needs of the person referred and enables them to write a set of initial care plans. Records show that he visited with a relative before making a decision to move in. We spoke with residents and relatives. A relative said that she have visited the home before she agreed for her mother to be placed there. Residents themselves are not always given a chance to visit before moving in, although there is written information Care Homes for Adults (18-65 years) Page 11 of 38 Evidence: they can look at. We note that all placing authorities are charged a fixed rate for placing a person, irrespective of that persons individual nursing care needs or whether they need two people to provide nursing or personal care or one to one support to help them to communicate and engage in activities. The assessment does not take into account the time that will be needed for any additional observations or health monitoring required. There is also a need to send prospective residents a letter at the end of the assessment. The letter must confirm whether the home can meet the persons assessed needs, as this is not done at present. Care Homes for Adults (18-65 years) Page 12 of 38 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. This area was judged to be adequate. Care is delivered to residents in accordance with care plans. The documentation has shortfalls; this has the potential to mislead on all the necessary actions needed to support residents. Areas of good practice were experienced in relation to decision making, and everyday choices. Evidence: Visiting health and social care professionals consider care planning documentation to be poor and an area that needs improvement. Nurses we spoke with during the two days of this inspection said that they are too busy providing care to keep up with the paperwork. They do not have sufficient time to complete and update care plans in a meaningful way. We note that care plans are generally limited to health care needs and identified problems. They could be more person centred and should cover planning for a wider range of health and social care need. Care Homes for Adults (18-65 years) Page 13 of 38 Evidence: We sampled a selection of care plans and case tracked how the service is delivered and the outcomes for individuals. The documentation in the home varies greatly in detail and content. On the whole it needs to be improved and a consistent approach to be adopted throughout the home. On some floors there is evidence of more attention to detail and more consideration given to a person centred approach. We looked at plans for one person whose admission we had looked at. A general assessment of need had been completed within two weeks of admission and this had resulted in initial care plans which were signed by the resident. We looked at these plans and they did correspond with information given in daily notes and by staff. For example a personal care plan says that the resident has a bed wash, but records and staff say that he has a bath occasionally. Staff said that this takes two members of staff and use of a hoist. This information is not on the personal care plan at all. On the second floor we selected three residents and evaluated the care delivery. One resident has quite complex needs. He is a young adult that remains in a vegetative state. His care plan is based on the needs assessment. The care plan contained all the basic details on the help and support required. The resident was unable to communicate, he appeared well cared for. Staff spoken to were knowledgeable on the medical condition diagnosed, also on the support the person required. The records of daily progress were brief; there were records of the night care other than position change and nutrition intake. During our visit he was seated comfortably in a wheelchair. The records of assessments highlighted all the risks associated with his medical condition, also the risk of developing pressure sores. He is unable to swallow and a PEG feed is used for nutrition. Nutritional screening takes place with regular weight records in place. A positioning chart was in place recording periods out of bed, and the position change when in bed. This regime according to the records seen has successfully promoted good tissue viability. Another resident selected is in the older resident, has been resident for some time at the home. She told us of the care delivered in the home and how it helps her. The care plan describes the support needs accurately. The previous day she attended an appointment at the hospital out patients. Carers and nurses she finds attentive, they deliver good care she finds. As part of the care plan we found that this person requires support to manage diabetes which is insulin dependent. It is advised that regular Care Homes for Adults (18-65 years) Page 14 of 38 Evidence: blood sugar monitoring takes place twice a day. We found that all these records were up to date; also that staff take appropriate action when dealing with notable variations. The resident is aware of her care plan and finds that staff consult with her. She too is identified as at risk of developing pressure sores. The risk assessment highlights this risk. For another resident that moves to the home regularly for respite we had discussions with the placing social worker. The social worker told us of the many positives experienced by this young person with learning disabilities. She and the relatives look forward to her breaks at the home, we heard that staff are great, and that they have a great understanding of this persons needs. When we completed our night visit the young person had moved in earlier in the evening. We recognised the sense of belonging experienced by resident. Staff were delighted to receive the resident in for respite and were making sure that she was settled for the night. Review records were seen for each of the residents where relevant, however it was not clear if the care plans were reviewed or that it was a paper exercise. We heard from staff members that some residents have not had statutory reviews for a number of years. It is recommended that referrals are made for residents where no reviews have taken place for over twelve months. We noted that the personal care plans of two of the people were inaccurate and did not reflect the personal care currently provided by staff. There is no information about having a bath or shower. The plans relates to bed baths only. Daily records show that a bath or shower are also provided on occasion. Care Homes for Adults (18-65 years) Page 15 of 38 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are a wide range of activities provided within the home to interest and stimulate residents in the activities area but not all residents are able to attend them or they may not be appropriate because of their disability. They are supported to maintain contact with their family and friends and to be a part of the local community. The meals provided are varied and nutritious. Evidence: The home has a large activities area on the lower ground floor of the home where there is a kitchen that residents use to develop their daily living skills in catering for themselves. We were shown the general activities program that is bi weekly. This is discussed and agreed at the residents meetings. There is a large computer suite where they can develop their computer skills that are well used but not open every day. Some residents shop on line but most get families to shop for them or they can purchase toiletries, drinks, cigarettes and other small items from the shop that is open Care Homes for Adults (18-65 years) Page 16 of 38 Evidence: each day. Sometimes the home has a visiting clothing outlet that comes in to the home and residents are able to choose and buy clothes. Some residents are able to visit local shops, restaurants and pubs and this is encouraged. The home has its own mini bus and the local off duty police come in to drive the residents on shopping trips or organized outings. The school children next to the home link up with the home to have joint events. We were told the next event they were doing was a Christmas Fair. We saw residents were making a paper chain to link the two establishments so people could follow it between the home and school. The children come into the home from time to time, for example at Christmas to do carol singing and put on their nativity play. Many residents would not be able to get to the activities area of their own accord and need to be taken. We saw porters taking residents down to activities. A number of residents are bed bound or the group activities would not be suitable for them. On the files we inspected we did not see they were assessed for any activities or any record of anything they were involved in. We were told the home put on special events days and evenings when they have meal and ask family and friends to join them. There is large art room that is well used. The activities coordinator said they had a number of exhibitions and fairs where residents could sell or auction their art work. This means they are doing something constructive and possibly profitable for themselves. Because of the size of the home some of the daily routines are flexible but others are not. For example meal times are set and most residents go to have them at the time they are served. We were told the residents could have their meals kept for them if they were out. On the day of the inspection residents were seen to be freely coming and going around the home from the unit they lived in. Because of their disabilities most residents are in wheel chairs. These are either motorized or propelled by themselves or a carer. Some residents we spoke to said they felt safer being in the home and had more freedom than if they lived in the community where they would be frightened to go out alone. We were given the results of a recent survey about music and entertainment. The residents within the home have very definite views of how they wish to spend their time. Most thought being in a group was not considered in important and engaging in traditional nursing home activities for example singing was not popular overall. Watching sports events is popular with both the men and the women, but a diverse range of sporting activities is evident. There was a request for SKY sports made by some of the residents which residents thought should be considered especially Care Homes for Adults (18-65 years) Page 17 of 38 Evidence: considering the arrival of digital television. They thought other channels such as the movie channels, UK Gold and nature programmers would be good to have. We saw that residents who did not complete the questionnaire will be approached again as their numbers are significant. The home has a large chapel that is well used. Residents spiritual needs are met. There are regular visits from church representatives from all denominations. On the day of the inspection there had just been a church service. Some residents are able to attend churches outside the home. We were told that when new residents first come in they go and sit and talk with them to see if they have any particular interests. This is not recorded in the main care plan but in the activities folder that is kept in the activities area. We met the hairdresser and the lady who does manicure and nail care. The hairdresser said she does whatever the residents wanted, such as perms, colouring and highlights. We saw throughout the inspection that staff respected their rights, for example by knocking before entering their rooms. Their post is not opened unless they have given permission and they are able to receive visitors as they wish. The staff that we saw and spoke with seemed to have a good relationship with residents who all spoke very highly of them. We met with the general manager who said they met new residents and introduced the catering staff and catering staff responsible for that floor. The catering supervisor visits the resident and goes through their dietary likes and needs as well as eating patterns. This will pick up any food intolerances or allergies. This is placed on the pantry notice board to keep staff informed of residents likes and needs. They have devised a residential meal tracking sheet and this looks at what the individual resident is eating and are they providing food choices for all. We were able to speak to five residents who were in the activities area. They said they were happy with the choice they were being given. They end out a full survey once a year and so far they have had a good response. All of those residents that we spoke with told us that the food was very good and that there were always alternative choices available. We were told there was always a cultural dish associated with nationalities other than British are also served regularly. The general manager always attended residents meetings and gives feed back on anything to do with the food and One concern came through a person who visits in a professional capacity who said concerns have been expressed about the limited opportunities residents have to go out of the home. There is also a light that residents can turn on that tells people they do not want to be disturbed in their bedrooms. This gives them more privacy. Care Homes for Adults (18-65 years) Page 18 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are knowledgeable and skilled, they work hard in promoting and managing the health and personal care of residents. Staff capacity is stretched by low staffing numbers. This results in shortfalls in documentation. Record keeping is not always available to demonstrate that appropriate action is taken to follow guidelines from health and social care professionals, or a true reflection of the progress of residents. There is also a need for consultation with a wider range of health professionals to enable staff to better meet the complex needs of some of the residents. Medication administration is adequate although there are areas in need of improvement. Evidence: Individual residents receive support that respects privacy and dignity although it is not always as flexible as it should be. Times for getting up are restricted for some as day staff feel they can only assist when it is within their capacity. Despite the presence of dedicated and skilled care residents may wait longer than is acceptable periods at night for toileting and personal care. Care Homes for Adults (18-65 years) Page 19 of 38 Evidence: Records show that some people do not have a weekly bath or shower, in addition to regular bed washing. Personal care plans are inaccurate in some cases and must be updated to reflect current personal care, for example one persons plan says he has just a bed wash but his daily records show that he has the occasional bath as well. We found that the home accepts people with high support needs. According to information on the AQAA the majority, one hundred people, need help with personal care. A high percentage of these according to eighteen of the staff we spoke to require two staff to carry out personal care tasks. We observed this on our visits both day time and night time. Staff were polite and pleasant as they assisted residents. We heard from a visitor as he left the building, he said that staff are great, they work very hard and always have a smile for everyone. At night time residents require frequent help with personal care and toileting. We observed that on our night visit 25th November only three staff were on duty on first and second floors, four were on duty on the ground floor. Due to medical conditions and disabilities the majority need two staff for the personal care tasks. Two carers continued with the personal care delivery as the nurse attended to medication procedures. We observed that staff were concerned that some residents waited longer to get attention as they were unable to attend to call bells as promptly as they wished to. We spoke to staff on duty on all floors. We found that staff are coping with the demands and needs of the residents but recognise they feel that residents would be better cared for if the staffing levels represented the needs of residents. Some residents we spoke to complimented staff on their dedication, they told of times they experience slow response as staff are busy with others. We sampled ten care files associated records to look at progress reports. Daily progress notes are too brief, there is a lack of evidence available to confirm the welfare and well being of each resident at night. This also hinders the review of individual needs and how successful care plans are in addressing individual needs. We are concerned about the lack of daily progress notes in relation to response to prescribed nursing and medical care. Records must be maintained of the nursing provided to each resident included a record of his condition. Care Homes for Adults (18-65 years) Page 20 of 38 Evidence: We heard of residents not receiving bathing as frequently as they require, this too was related to insufficient staffing levels. We saw records that show that some residents have had only two baths in a month, making do with a daily bed bath from staff instead. Residents we met appeared well cared for, were groomed according to individual choice. Physiotherapy is available for residents. We observed that a resident on the top floor was recommended to have frequent physiotherapy at the home as it was not available at the hospital. Changes took place in August this year when a new GP practice took over the medical care of residents. The change was well received by residents and staff. The GP visits the home five days a week. We found that on care plans there is some evidence that health care is promoted. We viewed records of hospital appointments. Residents spoken to also confirmed this. A resident on a PEG feed on the top floor had appropriate fluid intake chart records maintained. He was seen by the specialist nurses from the HEN team. According to the records examined staff are following all the recommendations made. Both nurses spoken to are trained and competent in this field. Also see were records that frequent position changes take place. On our night visit we found that a resident with many complex health needs was cared for by two competent nurses. Both are experienced in tracheotomy care, and PEG feed regimes. For a resident with diabetes we examined records of blood sugar recordings, also of the insulin given. The resident feels safe in the home, she finds staff reliable and competent. We found from records too that staff responded promptly and appropriately if there were concerns about the readings. We found that the home is good at making sure that tissue viability is promoted. Other care plans seen included evidence of pressure sores on arrive at the home, these are now healed. The home specialises in supporting people with physical disabilities, a large number have mobility difficulties. Essential pressure relieving equipment is supplied to prevent the development of pressure sores. The home provides care to people approaching the end of life. The manager informed Care Homes for Adults (18-65 years) Page 21 of 38 Evidence: us that they plan to commence the Gold Standard Framework in 2010. The current arrangements are not as good as they could be. We heard of hospital admissions that may not always be necessary if staffing levels were more appropriate. We heard of occasions in the past when there were not enough trained staff on duty. In the absence of trained nurses at night for some floors nurses told us of interruptions in medication procedures to assist carers on other floors when a residents condition deteriorates as they approach the end of life. The changing needs of residents with deteriorating conditions must be considered, arrangements should be in place for appropriate staff to be present to deal with this with sensitivity and respect. We contacted the homes GP and he is satisfied with the care provided. Feedback from health professionals tells us that the home could do better by contacting specialist community health teams for more advice about the care of individual residents with complex needs. Health care plans are in place but often do not cover some basic health care needs, for example, dental care. There is a plan for what is described as optional health care. Staff routinely cover dental, chiropody, opticians and hairdressing on this plan. Referral to psychologists may be of use to some people, whose needs present a challenge at times. There is also concern about bowel management and the use of regular enemas for some people. We also contacted a specialist feeding team. They are satisfied with the care of those people who are fed by a tube. We note that the staff do not keep records of feeding in some cases and this must be done to ensure accurate records are kept. We note that in some cases there is little external input for residents, some of whom have a cognitive impairment and challenging behavior. A care plans written about the challenging needs of one person just say to put her to bed and put up her cot sides. A referral to a psychologist may help staff to provide better support when this person is upset. The safe handling of medicines was assessed by a Commission pharmacist inspector as 5 requirements on various aspects of medicines handling were made at the last inspection in January 2009. They looked at medication records, medication supplies and storage areas, and care Care Homes for Adults (18-65 years) Page 22 of 38 Evidence: plans for a selection of people at the home. They also observed people being given their medicines by the nursing staff. When we visited in January 2009 we found that when medicines were given to people, there were gaps in the records where medicines had been given but staff had not signed for giving them. At this inspection we did not find any gaps in the records. In January 2009 some medicines were being stored above the recommended temperature of 25C. Cooling systems have now been installed, and medicines storage areas are now within range. In January 2009 there were some dressings out of date, and food supplements were not labeled with residents names. These issues have been addressed, no out of date medicines were found, and all medicines were labeled. In January 2009 records of disposal of medicines were also incomplete, these are now in place, which provide an audit trail, so that all medicines received, used and destroyed can be accounted for. All medicines were in stock, all medicines are being stored securely, including controlled drugs, and residents are receiving their medicines as prescribed in the majority of cases except the instances listed below. Regular medication audits are carried out, and these appear to be effective however there are still some issues with medicines handling which need to be addressed, most are good practice but still should be considered to improve medication handling to a good standard. There were 3 instances where instructions on the medicines chart was for twice daily usage however for the past month staff were using once a day only. Two were a mouthwash, and one a liquid medicine for constipation. One resident was prescribed a patch to be reapplied every seventy two hours, this was used correctly last month, however this month there was an error and if the chart had been followed, the resident would have received the patch every ninety six hours instead. There are a number of creams and external products such as shampoos and ointments where there are no clear instructions for use. It would be good practice to add the area of application and frequency of use onto the medicines record for all creams and Care Homes for Adults (18-65 years) Page 23 of 38 Evidence: ointments. There are some handwritten entries on medicines records, and some changes to the dose or frequency of a medicine which should have a robust check for accuracy, usually a second staff signing to confirm the details. It would be good practice to add the quantities of medicines brought forward from the previous month onto the current medicines record to enable stock checks to be carried out, and also to ensure medicines do not run out, as there were two instances where residents had painkillers on their previous charts, and none on the current chart but no evidence on the medication record that these had been stopped by the prescriber. One resident is self administering medicines, he keeps them in his room, he does not have a locked drawer to store them but keeps the door locked when he is not in his room to ensure the safety of other residents and the security of his medicines. The home has carried out a risk assessment to confirm this is safe. Another resident is keeping some medicines in her room, which she takes herself, it was not clear from the chart that this was the case, or how many were in stock. One blood glucose testing kit is being used for more than one resident which increases the risk of cross infection. One person has a sedating medicine prescribed, which is to be given only when needed. The instructions were half a tablet when needed. The record did not state how many times a day it could be given. PRN protocols should be available for all medicines used on an as required basis, in particular sedating medicines. The absence of a PRN protocol could result in people being given medication that they do not need or more often than intended, but in this case the medicine had not been overused, and was used only four times in the past month. Care Homes for Adults (18-65 years) Page 24 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Formal complaints are properly addressed by the home manager but more could be done to ensure that staff act on or record the verbal complaints made by relatives and residents, as some feel as though the issues they raise are not looked at. The staff know what to do if they think that there are concerns about the safety of a residents but they should have a better understanding of the Deprivation of Liberty safeguards. Evidence: The registered manager has understanding of the local authority procedures to safeguard vulnerable adults and she makes referrals to the local authority team when she recognizes that an incident has safeguarding implications. We contacted the local authority and they confirmed that there have been a number of safeguarding investigations at the home, some of which are ongoing at this time. They find the manager works well with them to resolve these situations. Staff we spoke with knew about safeguarding procedures and when to report concerns. The manager said that all staff have attended training about this. Staff we spoke with were less knowledgeable about the new deprivation of liberty safeguards and the manager confirmed that further training is required. We looked at some of the records of complaints and compliments that the manager Care Homes for Adults (18-65 years) Page 25 of 38 Evidence: maintains in her office. We also looked at information suppled in the self audit sent to us by the manager. This tells us that there have been eight formal complaints. All eight were substantiated and all were resolved within 28 days. The manager also maintains a log of concerns and complaints and how they were resolved. This helps her to track complaint resolution and notice any trends. The board of trustees also look at complaints and how they are handled on a regular basis. We spoke with relatives about how the home handles concerns and complaints and found that staff could do more on each unit to record verbal concerns as some relatives felt that their verbal complaints are sometimes overlooked and not addressed. We spoke with residents during the two days of this inspection and generally people are satisfied with the home and they know how to complain if they need to. One resident was happy that she had raised an issue that had worried her, because the manager had acted quickly to resolve it and make her feel safer living in the home. Care Homes for Adults (18-65 years) Page 26 of 38 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home is generally hygienic and clean. The bedrooms we saw are were homely and comfortable and meet the residents assessed needs. Evidence: The home is a large home over four floors. It provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet residents needs. These are all services by the appropriate agencys and records are kept of these. We toured the building and found it well maintained and safe. We spoke to the service manager whose company has recently taken over the maintenance of the building. All the appropriate checks are in place. We spoke to one of the maintenance people and they told us they did a visual check of all potential hazards each day, including the fire doors. We were told there are regular weekly and monthly checks that are carried out and a record of this was seen. Each unit kept a book to report faults that have occurred and the maintenance man checks these each day too. On the day of the inspection we were told they were having a survey done of asbestosis and how this would be dealt with any that was found. This is risk assessed and the risk will Care Homes for Adults (18-65 years) Page 27 of 38 Evidence: determine how it is dealt with. We spoke to the general manager who manages the facilities of the home. The home is kept clean, hygienic and free from offensive odours throughout. All communal areas are cleaned each day. We were told there is a program of deep cleaning each bedroom that the domestic staff must follow. Four rooms on each floor are deep cleaned each day, Monday to Friday. These must be signed off by the supervisor when she has checked them and the unit each day. We found good systems are in place to control infection in accordance with relevant legislation and published professional guidance. Staff have had the appropriate training and this is recorded in their training file. 18 staff have NVQ level 2 in Multi Skill in Cleaning and 3 in NVQ level 3 Multi Skill in Cleaning . The kitchen is in a separate block across from the home. We saw there were clear guidelines and procedures in place to ensure all the food safety regulations were met. Inside the kitchen there are separate areas for food preparation. Dirty dishes that come back from the units are washed in the main building again with strict procedures in place to stop cross contamination. There is clear separation of laundry. All dirty linen from the beds is out sourced and this leaves the laundry free to only wash residents clothes. Care Homes for Adults (18-65 years) Page 28 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home benefits from the stability of a staff team that are dedicated and skilled. There is some indication that staffing levels should be reviewed to ensure appropriate staffing levels are in place to meet the sometimes complex needs of all residents. Evidence: The home has a low turnover of staff. We examined personnel files for seven staff. Five of the files were for nursing staff. All had fully completed application forms. The records examined had all the required information present. We found that a new member of staff does not start employment unless they are fully vetted first. For the majority of staff three references are sought. A check is made that registration with NMC, if applicable, is current, and a CRB Enhanced disclosure with POVA check. Some good practice was observed too in relation to monitoring information and making sure that it is current for staff. To avoid staff working without relevant documentation human resources are alert to renewals of PIN numbers and immigration status. Copies of training certificates acquired prior to employment are held on individual files. Staff employed at the home demonstrate that they are skilled, experienced and committed. All the comments received from residents and visitors were positive on the kindness and dedication of staff. We viewed records of the training provision made for staff. The home makes sure that Care Homes for Adults (18-65 years) Page 29 of 38 Evidence: staff are kept up to date on the basic mandatory training. An internal trainer also leads on training for qualified nurses. A training matrix was provided. Staff receive specific training in relation to some conditions experienced by residents, for example Multiple Sclerosis, Parkinsons Disease. As a result of the shortfalls in record keeping, it is evident that there are some shortfalls in the training and development of staff, especially in relation to records of nursing care delivered. Staff should receive training and development to keep their skills and knowledge base up to date. The staff team work hard. Members of staff enjoy their roles, this is demonstrated in the way they respond to residents needs. We found that there is great teamwork within the staff team and that them help each other so that the residents are well cared for. This helps to keep morale high. Many staff raised concerns about the management style. Residents find staff to be approachable and to have a good attitude to their work. Comments received from residents during our visits include the following The nurses and carers are lovely, they make sure that I am comfortable and assisted to the toilet when I need to. Each day we are greeted with smiling faces, it makes us feel better. We had completed surveys from twenty four members of care staff and individual discussions with up to twenty care staff, half of these were nurses. All staff spoken to express the difficulties with current staffing levels and told us that that they are not appropriate for the needs and numbers of residents. This is mostly experienced at night. Feedback from the surveys indicates that many staff are concerned that staffing levels are too low at times. During the day each unit has an average of three or four carers plus a trained nurse. For nighttimes two units are combined on each floor. The number of staff available is two carers plus one nurse. We made a night visit to observe the number of staff on duty. The ground floor had four staff on duty covering two units. Staff told us that this often staffed by only three people. They explained the additional duties they are attending to. A member of staff said, We attend to night bells, ambulance calls and queries as well as attending to all residents in the two units. We observed the staffing numbers on the first and second floor. They did not appear appropriate. We asked staff for their views. One nurse said, the majority of residents have high care needs, need changing two to three times a night. As a result of the numbers of staff available some have to wait much longer for our service. Another nurse spoken to told of the pressures at night to get tasks completed, she said, I Care Homes for Adults (18-65 years) Page 30 of 38 Evidence: administer the medication, then I proceed alone to help with assisting people to bed, the other two carers are already busy attending to residents. It was evident that staff were working at great pace to attend to all the requests of residents. None of the residents made complaints about the service, but there were comments about the slow response to call bells because staff are busy. This reinforces the view of the lack of staff available at night. Given that we have seen evidence of poor care planning, poor record keeping and inadequate personal care and that staff say they do not have sufficient time to do their jobs properly there is evidence that there are is still not enough staff on duty to meet the needs of the current residents. Inadequate staffing levels were the subject of a requirement in the previous inspection report. We discussed this with the provider who consider staffing levels to be adequate given that there are a number of vacant placements meaning that the home is currently under occupied. Our findings during this inspection dictates that inadequate staffing levels may be a factor in a lack of evidence that residents with higher needs receive the care and support that they need. This requirement therefore remains unmet. The provider should therefore undertake a review of the current staffing levels and needs of the current residents so that they are able to demonstrate appropriate staffing levels. Staff are supervised by their line managers. We looked at records that show that most are supervised regularly, but frequency has lapsed for some on occasion. Because of the absence of some unit managers and the deputy manager it has not been done as frequently as required. Care Homes for Adults (18-65 years) Page 31 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is experienced and qualified. The home managment structure is under review and the service is planning to introduce further changes in how the service is run. Health and safety of the residents is promoted and protected by the actions and the policies and procedures in the home. Evidence: The manager is registered, experienced and is a qualified nurse. The provider told us that they are considering changes to the management structure and they have a new post for a deputy manager vacant at this time. There are also vacancies at ward manager level. The home was not subject to inspection or Regulation prior to 2002. This has resulted in a transitional period during which the Provider has sought to meet current standards. Social care and health professionals still regard the home as somewhat institutional indicating there is still work to be done in this regard. Care Homes for Adults (18-65 years) Page 32 of 38 Evidence: Feedback from staff during this inspection indicates that many staff are concerned that staffing levels are too low and may not always be sufficient to meet the needs of the residents; with routines that are task driven rather than person centred. The service is not recognising the importance of individualised person centred support and sees personal care needs as the limit of support needed. A review of staffing levels should consider the views of staff who are delivering the care also. There are systems for quality assurance in place. There are regular audits of all areas of home life and this includes regular surveys to find out the views of the residents. There are also regular visits from members of the board of trustees who conduct monthly inspections of the service and send their reports to the home manager. We toured the building and found it well maintained and safe. We spoke to the service manager whose company has recently taken over the maintenance of the building. All the appropriate checks are in place. We spoke to one of the maintenance people and they told us they did a visual check of all potential hazards each day, including the fire doors. We were told there are weekly and monthly checks that are carried out and a record of these were seen. Each unit kept a book to report faults that have occurred and the maintenance man checks these each day too. On the day of the inspection we were told they were having a survey done of asbestos and how this would be dealt with any that was found. This is risk assessed and the risk will determine how it is dealt with. PAT testing is carried out by the maintenance team and they have had the training to do this. We were told by the registered manager that they had recently commissioned a full health and safety audit. On the day of the inspection they had planned to meet with the general manager maintenance manager and the chief executive to go through the report to discuss what actions are to be taken. Care Homes for Adults (18-65 years) Page 33 of 38 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 33 18 There must be sufficient staff 13/02/2009 on duty at all times To meet the assessed needs of people who use the service. Care Homes for Adults (18-65 years) Page 34 of 38 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 2 14 The home must confirm that 28/02/2010 it can meet the needs of any prospective resident by sending them a letter indicating the outcome of the pre-admissions assessment. To maintain a professional relationship with resident and to advise them of the outcome of the assessment of their needs. 2 6 15 Each area of care and 01/02/2010 support must be detailed in a written plan. The plans must be revised when needs change. This must be done in consultation with each resident, where possible and must include the changing needs of residents with deteriorating conditions and arrangements to be in place for appropriate staff to be present to sensitively deal with end of life care. Page 35 of 38 Care Homes for Adults (18-65 years) 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 Care plans do not reflect current care arrangements in some cases. 3 12 16 The registered person must ensure the residents social needs are be fully assessed and appropriate activities offered. Some resident were not being offered appropriate activities. 4 19 17 Staff must maintain records of food and fluid intake. To ensure that residents are fed correctly. 5 19 17 Records must be maintained 28/02/2010 of the nursing provided to each resident included a record of his condition To ensure that appropriate records are kept about each persons health and welfare. 6 20 13 The Registered Provider must ensure that all medicines are used as prescribed To ensure that residents receive appropriate medical care. 31/12/2009 31/01/2010 15/01/2010 Care Homes for Adults (18-65 years) Page 36 of 38 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 The admissions procedure should include consideration of any additional staffing needed to deliver the care and support identified as needed. It is recommended that referrals are made for residents where no statutory placement reviews have taken place for over twelve months. Care plans should be more person centred and should be developed for all areas of care and support, including cultural needs. Residents should be consulted about their personal care needs and they should be given appropriate personal care, for example, regular baths or showers if they wish. There should be better records of medicines that residents are administering themselves. PRN protocols should be available for all medicines used on an as required basis, in particular sedating medicines. There are some handwritten entries on medicines records, and some changes to the dose or frequency of a medicine which should have a robust check for accuracy, usually a second staff signing to confirm the details. It would be good practice to add the quantities of medicines brought forward from the previous month onto the current medicines record to enable stock checks to be carried out, and also to ensure medicines do not run out. It would be good practice to add the area of application and frequency of use onto the medicines record for all creams and ointments. The home should do more to address verbal complaints and concerns. Staff should be trained in the Deprivation of Liberty Safeguards Staff should receive training and development to keep their skills and knowledge base up to date. The registered provider should undertake a review of staffing levels. 2 6 3 6 4 18 5 6 7 20 20 20 8 20 9 20 10 11 12 13 22 23 32 33 Care Homes for Adults (18-65 years) Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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