Care Home: Combe House

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What the care home does well The home was clean and comfortable and well-maintained. It provides twenty-four hour care and support to an all male group of young adults who in addition to their primary condition of learning disabilities also have complex needs and behaviours associated with autism and epilepsy. The planned structure of the home`s operation supports a lifestyle that the people using this service appeared to be comfortable with. A person centred approach to care planning was demonstrated. This means the planning starts with the individual and not services, taking account of, as far as possible, the wishes and aspirations of people who live in the home. Consistent programmes of care and support were evident, promoting personal control and independence within individual levels of capacity. Whilst wishes and interests are accommodated in daily routines,ensuring predictability and stability, programmes for managing compulsive behaviours are in place for individuals, to help them lead fulfilling lives. Staff assist and support the progression of communication skills, enabling and encouraging people using services to express themselves and make choices. Opportunities for social inclusion and for developing socialisation skills are made available and most people using services regularly access community resources. Staff works collaboratively with multi-agency professionals involved in the care and support of each person, to ensure their wellbeing and safety. Robust risk assessments and working protocols ensure people using this service have the level and quality of support they need to promote their health and wellbeing. What has improved since the last inspection? The one requirement made at the time of the last inspection had been met. This was for a risk assessment to be carried out specific to steps leading from the patio and radiators not fitted with covers. It was positive to note the home has been accredited by the National Autistic Society since the last inspection. Since the acquisition of this home and another home in Woking in September 2008 by this organisation, there has been significant improvement in the environment. This has been achieved through an ongoing redecoration and refurbishment programme. Five bedrooms have been redecorated and refurbished and people using services involved in choosing the colour schemes and new furniture for their rooms. Communal areas have also been redecorated and floor covering replaced in the office and laundry. Becoming part of a corporate organisation specialising in the care of people with learning disabilities has had positive benefits. These include a robust, external management structure which has increased support available to staff and made provision of a dedicated admission assessment team. Financial procedures have improved and staff recruitment initiatives are gradually filling staff vacancies. A new, detailed staff induction programme has been developed. More leisure activities have been introduced both outside and inside of the home affording increased choice of activities for people using services. What the care home could do better: A new manager has recently taken up post and was stated to be preparing to apply for registration. She has carried out a service review and has a clear action plan for service development and improvement. The inspection visit identified shortfalls in practice and record keeping specific to administration of controlled drugs. Whilst recognising inspection visits carried out by regional operations managers sometimes include medication audits it is recommended these are carried out more regularly by the home`s management. It is noted the new manager has stated her intention to ensure a more robust quality monitoring system. The need to ensure pre-admission assessment records are at all times available for inspection was also identified. Also for some care plans to be updated to ensure these reflect current needs. It is recognised this is work in progress. The need to ensure we receive notifications in accordance with guidance on our website was also highlighted. Key inspection report Care homes for adults (18-65 years) Name: Address: Combe House Castle Road Horsell Woking Surrey GU21 4ET     The quality rating for this care home is:   two star good 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: Patricia Collins     Date: 1 6 0 6 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 31 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 31 Information about the care home Name of care home: Address: Combe House Castle Road Horsell Woking Surrey GU21 4ET 01483755997 01483773681 val.coomber@brookhurstcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Aitch Care Homes (Woking) Ltd The registered provider is responsible for running the service care home 7 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 7. The registered person may provide the following category of service only:Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Learning disability - LD Date of last inspection Brief description of the care home Combe House is a care home providing personal care for adults with a learning disability as their primary condition, on admission. The gender of the current user group is male. Most people are within the autistic spectrum and individuals have complex needs and behaviours that can challenge services. The home was accredited by the National Autistic Society in 2008. Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 7 Brief description of the care home Situated in a private road in a quiet residential area of Horsell Village, the home is a short distance from Woking town centre. It is a modern, detached, two-storey building set in its own grounds and blends in well with surrounding properties. Car parking facilities are at the front of the premises. Bedroom accommodation is arranged on the ground and first floor, providing seven en-suite bedrooms for single occupancy. Assisted communal bathing and toilet facilities are near to all bedrooms. There is no lift access to the first floor. Communal areas are on the ground floor comprise of two dining areas, a conservatory and separate sitting room, spacious kitchen and laundry room. The dining room, kitchen and conservatory have doors leading directly onto a large terrace and medium sized secure back garden. The home is operated by an organisation specialising in care services for adults with learning disabilities. Core fee charges are 1249.45 pounds per week which includes some one to one support. Additional charges of 10.50 per hour apply for people who need more one to one than is factored into the core fee. Other additional charges are for toiletries and hairdressing. Care Homes for Adults (18-65 years) Page 5 of 31 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: two star good 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: Date of last Key Inspection: 3rd July 2007. This unannounced inspection visit formed part of the key inspection process using the Inspecting for Better Lives (IBL) methodology. It was carried out by one inspector over almost five hours. The report will say what we found as it is written on behalf of the Care Quality Commission (CQC). key inspections are a major evaluation of the quality of a service and any risks it might present. We always focus on outcomes for people using services. All key National Minimum Standards for Adults (NMS) are reported on as evidence of outcomes. In carrying out this inspection all available information has been taken into account when forming judgments about how well the home is meeting the NMS. This includes accumulated evidence and our knowledge and experience of the home since its last key inspection. Though we posted survey questionnaires for distribution by management to Care Homes for Adults (18-65 years) Page 6 of 31 people using services, staff and professionals in order to obtain their views about the home, these were not delivered. Each year providers registered with the CQC must complete a self assessment called an Annual Quality Assurance Assessment (AQAA) and send this to the CQC. It provides quantitative information about their service, requiring assessment of the service against the NMS outcome areas, demonstrating both areas of strength and where improvements can be made. The homes AQAA was received on time and its content was clear, of good quality and validated by evidence. The content informed our judgments about this service. The inspection process incorporated discussions with three people using the homes services. We sampled two bedrooms and looked at all communal areas including the garden. We spoke with all staff on duty on the early shift and the homes regional operations manager who was present for part of the visit. Direct and indirect practice observations were carried out and records sampled. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: A new manager has recently taken up post and was stated to be preparing to apply for registration. She has carried out a service review and has a clear action plan for service development and improvement. The inspection visit identified shortfalls in practice and record keeping specific to administration of controlled drugs. Whilst recognising inspection visits carried out by regional operations managers sometimes Care Homes for Adults (18-65 years) Page 8 of 31 include medication audits it is recommended these are carried out more regularly by the homes management. It is noted the new manager has stated her intention to ensure a more robust quality monitoring system. The need to ensure pre-admission assessment records are at all times available for inspection was also identified. Also for some care plans to be updated to ensure these reflect current needs. It is recognised this is work in progress. The need to ensure we receive notifications in accordance with guidance on our website was also highlighted. 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 31 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 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service and their representatives have clear information to help choose a service that meets their needs. Needs and aspirations are assessed prior to admission to ensure these can be met. Evidence: The home has a comprehensive statement of purpose and service users guide specific to the group of people who use this service. The service users guide is written in easy read language using pictorial images, symbols and photographs to make this information accessible to people for who the home is intended. A personal copy had been issued to each individual and was kept on the files sampled. Though reviewed and updated since the last inspection further amendments are necessary, as discussed. The guide is a comprehensive document, detailing the services provided and informing prospective people considering using this service and their representatives what they can expect. It also incorporates information about the complaint and admission procedures. Since the last key inspection one person had been admitted. Pre-admission Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: assessment information and the care management assessment for this individual was not on this persons files or files of others sampled.The need to ensure this information is available for future for inspections was discussed. In the absence of these records, to enable an informed judgment about the quality of the pre-admission assessment process, we looked at recent assessments and other records for a person recently referred. These records were incomplete however and did not evidence the assessment tools used or contain a copy of a care management assessment stated to have been obtained. The homes Annual Quality Assurance Assessment (AQAA) informed us that an initial assessment is completed by a manager and the companys assessment manager and that the assessment process was inclusive of the staff team. Discussions with staff and observations of the assessment documents that were available for this referral, indicated good practice procedures had been followed. Some of the staff on duty had worked with this individual in his own home as part of the assessment process. At the time of the last inspection the pre-admission assessments and supporting documentation viewed provided a good overview of personal, health and social care needs. It was also evidenced at that time the process included obtaining assessments from external professionals. Care Homes for Adults (18-65 years) Page 12 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessed and changing needs and personal goals are mostly reflected in individual care plans. Staff are in the process of updating the same. People using services have opportunity to make decisions in their lives and to take risks as part of an independent lifestyle. Evidence: The home operates a key worker system. We looked at three files of people using services. These contained care plans covering all aspects of daily living including support needs for personal and health care, communication, mobility and orientation. Strategies and guidelines were in place for the management of compulsive or challenging behaviours. A person centred approach to care planning was evidenced by all available information, including feedback from people using services and staff. Care plans and other care records were of a good quality and in accessible formats, however not all reflected current needs. It was stated that reviews are carried out annually, which does not meet the NMS of six monthly. We found however that one Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: support plan had not been reviewed for seventeen months. Choices are offered within a structure as the people living in Combe House are within the autistic spectrum. Some experience difficulty in making choices and decisions whilst others focus on their obsessions when choice is offered. Any restrictions on choice are agreed with the individual and professionals and subject to review. All staff receive autism awareness training and some have completed a course in TEACCH to enable the team to support these individuals effectively. The service achieved NAS accreditation in 2008. A programme was at an early stage to empower an individual who does not have expressive language, by giving him tools to communicate with. Staff use objects of reference enabling him to make everyday decisions and to keep him informed. The support plans examined showed how the service was enabling most people to lead purposeful and fulfilling lives, encouraging development of independent living skills and informed risk taking. Observations confirmed a multi-disciplinary approach to managing the needs and behaviours of a person who refuses to leave the home, not even to enjoy the garden. Meetings between staff and people using this service ensure opportunity for people using services to have a say in how their home is run. Most have verbal means of communication and are able to inform staff of their wishes. One individual who does not use expressive language is able to make his needs and wishes known through his behaviour, supplemented by staffs knowledge and experience of him. The home also consults close relatives, advocates and relevant others as people using services may talk about their wishes with them. At a recent review meeting one person was encouraged to write a list of his likes and dislikes and an action plan agreed which is being implemented. Daily routines are flexible and the choices of people using services are respected regarding times of getting up and going to bed. Some bedrooms have been recently redecorated and refurbished and one of the senior staff who knows people using this service very well was stated to have spent a lot of time enabling them choose their new furniture.Staff encourage people using services to be involved in domestic routines. One person was observed to take his laundry from his bedroom and put it in the washing machine. Another stated they load and unload the dishwasher and lay the table for meals. During the visit individuals made their own breakfast with staff support or supervision. Changes made as a result of listening to people using services included implementation of a structured shift plan to ensure one to one time for individuals with staff is utilised effectively. We were told there are plans to implement use of pictorial menus. One individual is now supported to manage his anxiety using ipod equipment and by ensuring a low stimulus environment during his choice time. Care Homes for Adults (18-65 years) Page 14 of 31 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. People who use this service have opportunity and are supported to participate in appropriate social, educational and leisure activities and most are part of their local community. They are offered a health diet and flexible meal times and links with families and friends are promoted and facilitated. Evidence: The people who use this service have an individualised care package tailored to meet their assessed needs and preferences. These are delivered according to the funding agencys contract. Their routines are person centred, flexible and respect their diverse needs. Routines are presented in the way each person understands, for example symbols and schedules are used for one persons routines. We were informed by a person using services that he sometimes goes shopping for food with staff at a supermarket. He said he always has a choice of breakfast and sometimes of other meals. Discussions with staff confirmed their awareness of individual food preferences Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: and any dietary needs and they involve people using services in menu planning. The menu displayed was an easy read format but out of date. Staff stated they promote healthy eating options whilst respecting the food choices of individuals. Supplies of fresh vegetables, salad and fruit were available. Staff support individuals to learn and practice every day living skills, for example making a light meal, doing their laundry and taking part in domestic work. There is an equal opportunities policy promoting non-discriminatory practice and respect for the diversity of people using services. Records demonstrated the diversity needs of people had been identified and individuals encouraged and supported to express cultural and religious identities. The size and layout of the building affords opportunity for people to socialise with others or to spend time on their own. A lack of employment opportunities in the local area also the wider community and shortage of suitable college courses has limited opportunities for individuals to attend college or to secure jobs. One person attends day service operated by the National Autistic Society (NAS). He sees the NAS day services as work and this gives appropriate structure to his life. Another person attends a skills for employment course at college and another is undertaking work experience with Employability. The latter two individuals sometimes use public transport to attend college, with staff support. The home has a mini bus and a car which the designated driver and some staff use to enable people to access community resources. Individuals are involved in community activities that are not exclusively for or with other people with learning disabilities. On the day of the visit staff organised the days activities. A support worker drove one person to his day placement and another to college. Later a senior support worker went out shopping and for lunch with two people. Another person was expecting a visit from his mother in the afternoon. Staff have introduced a range of in - house activities and people using services access local leisure facilities, for example, bowling, swimming and laser quest. Two people frequently walk with staff to the shops and to the pub. Staff are flexible with their shifts to facilitate activities in the evenings, such as discos, theatre or concerts. Annual holidays are organised according to individual needs, interests and preferences for most people. One person does not go as he refuses to leave the house and another has trips out instead of a holiday away from home as he finds it difficult to cope with holiday away. His interests in art and crafts are accommodated and he has enjoyed excursions to safari parks, beaches, shows and a cricket match. Staff were organising holidays at the time of the visit. There is a set budget per person for funding holidays for people using services and staff escorts. Staff said they welcome visitors and most people using services make regular trips to visit their families. One person unable to go home has regular visits from his relative. Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: Care Homes for Adults (18-65 years) Page 17 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service are offered personal support in the way they prefer and require and their health needs are met. Whilst mostly the management of medication is satisfactory shortfalls in practice and record keeping specific to administration of controlled drugs requires attention. Evidence: The three care plans sampled evidenced that people using services receive personal and healthcare support with respect for their right to privacy, dignity, equality and autonomy. Health needs and seizures are monitored and recorded and relevant risk assessments are in place. People using services access both primary and secondary healthcare services. Individualised health action plans were stated to be reviewed annually or as needs arise. Guidelines and risk assessments were in place for the management of needs of a person who is partially sighted whose mobility is at times impaired due to limited peripheral vision. Clear protocols and guidelines were also in place for the safe management of epilepsy and related medical emergencies. Multidisciplinary agreed behavioural management plans and guidelines were followed by staff. The need to ensure service users plans are dated and signed and include review Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: dates was discussed. We were informed in the homes Annual Quality Assurance Assessment (AQAA) that developments in the last twelve months include a more robust response to changes in needs, ensuring prompt referral to specialist services. The home has previously had a good record of compliance with the receipt, administration, safekeeping and disposal of medication and has an efficient medication policy supported by procedures. A new medication cabinet has been purchased since the last inspection to increase storage.Staff receive medication training which includes an element of practice assessment, to ensure competence before being permitted to administer medication. Guidelines for administration of medication prescribed as required and for multiple seizures were clear. Medication storage was satisfactory. Some gaps in staff signatures on medication administration charts were identified. On three recent occasions staff had not recorded the administration of a controlled drug or signed and witnessed the controlled drug register. It was positive to note plans to provide annual refresher medication training for all staff. Whilst it is acknowledged that statutory inspection visits carried out by regional operations managers sometimes include a medication audits, it is recommended the homes quality monitoring system includes regular medication audits. Care Homes for Adults (18-65 years) Page 19 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected from abuse by the homes procedures. They are able to express their concerns and have access to a complaint procedure. Evidence: The home has clear, comprehensive policies and procedures for responding to concerns, complaints and allegations or suspicions of abuse. We have not received any complaints about the home since its last inspection. Each person using services has a copy of the complaint procedure on their file is an easy read format in the service users guide. We were told that the complaint procedure had been explained to each person using services and this explanation is frequently reinforced at their meetings. The home had investigated two complaints in the last twelve months and both were stated in the homes Annual Quality Assurance Assessment (AQAA) to have been resolved within twenty eight days and had not been upheld. These records were not available for inspection. The homes management encourages regular dialogue with family members and representatives of people using services through meetings, to avoid misunderstandings. Discussions in private with two people using services confirmed they were happy with the services received and had no complaints. The home has an in-house policy and procedure for the protection of vulnerable adults and a copy of Surreys safeguarding adults procedure. There is a programme of training to ensure staff receive safeguarding adults training and abuse awareness forms part of their induction. The AQAA states the home has an open culture in which Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: people using services and staff are encouraged to discuss issues freely. Unexplained injuries are recorded and investigated. Staff have received training on physical intervention to ensure this is managed safely and in accordance with procedures. The homes management is proactive in managing behavioural incidents to ensure people using services feel safe; also to ensure staff feel supported and able to discuss behaviours that challenge them. We were told in the AQAA that the personal finances of people using services are effectively managed with relevant checks and balances and guidance on expenditure. Financial records are maintained with receipts for expenditure of personal money. The Envo pack system has been introduced since the last inspection for added financial security. Two packs containing money belonging to people using services were checked and their balance verified against available records. Secure systems are in place for storage of money and shift leaders check the balance of money at hand-overs. The finance manager checks expenditure monthly and an in-house weekly audit was stated to take place. Care Homes for Adults (18-65 years) Page 21 of 31 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. The homes design and layout enables people using this service to live in a safe, wellmaintained and comfortable environment which promotes independence. Evidence: The home is in a quiet private road with easy access to local shops and other community amenities. It is fit for purpose, domestic in character, comfortable and furnished to a high standard. The accommodation is spacious with a large fitted kitchen, dining room, lounge, sun lounge and office on the ground floor and toilet and bathing facilities.All bedrooms are for single occupancy and have either shower or bath en-suite facilities. There are two ground floor bedrooms and five on the first floor, accessible by stairs only. There is also an assisted bathroom on the first floor. The two bedrooms sampled were nicely personalised and furnished, reflecting the choices and preferences of the people occupying these rooms. One of these rooms has a large balcony which overlooks the front garden. Since ACH took over the home in September 2008 most areas have been redecorated including five bedrooms. New floor covering has been fitted in the office and laundry room and bedroom furniture replaced. Future plans were stated to include a new dining suite and possibly replacing the parquet flooring in the lounge with carpet. The sun-lounge overlooking the enclosed rear garden was stated to be used by visitors. Discussions with a staff member confirmed the glazed roof can at times cause extremes of temperature in this Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: area and recommendation made for blinds to be fitted for the comfort of people using services and visitors. The home was clean throughout all areas viewed and staff encourage and support people using services to be involved in the homes domestic routines. The laundry room was clean and hygienic and good standard hand washing facilities provided throughout. There is an infection control policy and effective arrangements described for the safe handling and disposal infected linen and management of incontinence. The senior support worker confirmed advice had been sought from an incontinence adviser regarding management of an individuals incontinence. The company employs a maintenance manager who ensures repairs are carried out systematically. A staff member who drives the homes vehicles undertakes minor maintenance work as well as maintaining the grounds. The gardens were well maintained and tidy on the day of the visit. Care Homes for Adults (18-65 years) Page 23 of 31 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 good 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 are supported by competent staff who are trained, skilled and in sufficient numbers. Recruitment practices are safe. Evidence: Staff were professional in their conduct and had a good understanding of the needs of the people they support. Two senior support workers and a support worker was on duty at the time of the visit. One of the senior support workers was the designated shift leader for Beech Trees, the organisations other care home in Woking. She was working at Combe House covering an absent support worker who did not report for duty or make contact with the home. This had left Beech Trees without a senior support worker and one short of their usual staffing levels. The senior support worker had been unable to redeploy a support worker from Beech Trees for various reasons. She was observed in regular phone contact with Beech Trees throughout the visit, directing and supporting the staff and coordinating transport arrangements. Since the last inspection changes in staffing and management responsibilities have had an impact at Combe House, for a time affecting continuous improvement and staff performance. Following an internal review of staffing in March this year it was decided to merge the staff teams from Combe House and Beech Trees into one, now called the Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: Woking Team. The rationale being to increase the pool of experienced staff available to work in both homes. An impact assessment was carried out and the decision taken for staff to receive an induction before being deployed in homes that are not their work base. This new staffing arrangement was implemented on 1st April and the induction process is ongoing. Discussions with staff confirmed that whilst these arrangements can have benefits, they can also be anxiety provoking for some individuals who use this service. Staff from both homes are still learning about each other and getting to know people using services and their support needs.Though staff were very positive about the new company and stated they were gradually getting used to new ways of working, the transfer from a small provider to a corporate organisation had inevitably involved major changes which they had not always found easy to adjust to. They emphasised however they were getting there. There has been a 50 turnover in the direct support workforce in the past 12 months. Four support workers had been recently recruited and on the day of the visit the home manager was in London carrying out staff interviews. Staff on duty did not have access to personnel files it was therefore not possible to sample these to evidence staff vetting procedures and practice. We were informed by the homes Annual Quality Assurance Assessment (AQAA) that the staff team is diverse and reflects the local population. Recruitment practice is underpinned by an equal opportunities policy. Developments include a diversity and equality monitoring system. Recruitment practice was stated to be robust to ensure the protection of people using services. At least two written references are obtained and health questionnaire completed and an enhanced CRB disclosure obtained. The home manager is supported by a human resources department. The inspection process included an interview in private with a support worker who is relatively new in post. Her feedback indicated statutory requirements are met by the homes recruitment practice. All new staff go through a process of in-house induction which has been developed and improved in the last twelve months. This incorporates getting to know people using services, the service philosophy and the organisations policies and procedures. The support worker interviewed confirmed she worked supernumerary to staffing levels when she first took up post for a set period. During this time she shadowed staff, observing practice. Her induction covered fire safety and safeguarding procedures. This worker had prior relevant experience and training.Though in receipt of an induction workbook this had not been completed. The need to do so was discussed and to be signed off by the manager, noting she works unsupervised when escorting people to and from their day services and colleges. It was positive to note feedback from this worker that she is very happy working at Combe House and her experience of receiving good support from her manager and colleagues. It was evident from available information the organisation is committed to training and developing its Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: staff. This starts with induction, mandatory training, service specific courses, National Vocational Qualifications in Care or Health and Social Care (NVQ) and staffs continuous professional development. The AQAA states that 50 of the staff team have at least NVQ Level 2 and 20 are working towards this qualification. To ensure delivery of high quality services training opportunities for the team are tailored to the needs of people using services. The training records on the staff training portfolio sampled were noted to need updating. It was good to note future training includes the Mental Capacity Act and equality and diversity for the team. Care Homes for Adults (18-65 years) Page 26 of 31 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 good 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 benefit from a well run home. Their health, safety and welfare is promoted and their views are sought and underpin self monitoring systems. Evidence: The homes management structure comprises of a manager, deputy manager and senior support workers. Combe House and Beech Trees were taken over by the company in September 2008 which has other registered care homes for people with learning disabilities outside of Surrey. The decision for one manager to be responsible for the day to day management of both homes in Surrey which is a major change since the last inspection, was made by the previous providers and unchanged. The registered manager at the time of the last inspection is no longer in post, having left in March 2009. Prior to this she had been on special leave of which we do not have a record of having been notified. Other shortfalls in notifications of incidents were also identified during this inspection. A new manager has recently taken up post and stated to be preparing to apply for registration. There has also been a change of deputy manager since the last inspection. Discussions with staff confirmed they find the new manager knowledgeable, supportive and approachable and they feel they are listened Care Homes for Adults (18-65 years) Page 27 of 31 Evidence: to. As previously stated in this report the home manager was not present at the time of the inspection visit. The deputy manager was also not on duty. The senior support workers competently facilitated the inspection process as far as they were able, as they did not have access to some information and records. By coincidence an unannounced statutory visit took place the same day by the regional operations manager on behalf of the responsible individual. This was helpful, providing access to regulation 26 reports held electronically not accessible to staff. The homes Annual Quality Assurance Assessment (AQAA) contained clear, relevant information supported by a wide range of evidence. Records were overall of a good standard and the organisations policies and procedures were being implemented. Discussion took place with the regional operations manager for review of confidentiality of information held about people using services in respect of the practice of storing care records on open shelves in the office. The service has a clear health and safety policy and staff are aware of the same and trained to put theory into practice. Regular random checks take place to ensure they are working to it. Hot water temperatures to baths and washbasins are controlled by safety valves and temperatures regularly monitored. Excessively high water temperatures to two baths had been identified in an audit, though the record incomplete and not signed and dated, and reported to the maintenance department, though not yet received attention Though formal risk assessments had not been carried to ensure the safety of people using services in respect of this hazard, staff were adamant this posed no risk to the people they support. It was suggested that formal risk assessments be carried out to evidence this information, however. The home has a consistent record of meeting relevant health and safety requirements and legislation and of effective service and maintenance arrangements. A number of maintenance and service records were sampled. The fire risk assessment was dated 2007 however staff said there was a more current one that could not be found. Comprehensive risk assessments are carried out for the environment, people using services and staff. Risk assessments are also in place for two staff with specific health needs. The requirement at the time of the last inspection had been met and risk assessments carried specific to potential hazard posed by the step leading from the patio to the lawn and unguarded radiators. Care Homes for Adults (18-65 years) Page 28 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 31 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 20 13 For review and improvement 13/07/2009 to recording and administration of controlled medication. To ensure compliance with regulations and the safety of people using services. 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 20 24 For the homes internal management systems to include regular audit of controlled medication. For blinds to be fitted to the glazed roof of the sun-lounge. Care Homes for Adults (18-65 years) Page 30 of 31 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. Care Homes for Adults (18-65 years) Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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