Care Home: Coombe House

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What the care home does well Staff help people to spend some time in the home before they come to live there. A book that tells people about how the service works has pictures so people can see what it is like to live at Coombe House. The care plans of the people who live in the home have lots of details to help the staff to give good support. Staff have done training in the Mental Capacity Act and Deprivation of Liberty Safeguarding so that this can be put into plans so people have the right support to make decisions and be safe. Staff help people to go to see their doctor and other people if they are unwell or need a check up. Staff are good at looking after medication.They do this because people living at the home cannot do these themselves. Staff help people who live in the home to do books with pictures that tell a story about their lives, interests, family and friends. People are encouraged and supported to do things for themselves whenever it is safe for them to. Like putting clothes on and cleaning their rooms. People are supported to take part in activities that they like. The manager is always looking for new activities. The kitchen is clean with lots of choices of food. There is fresh fruit, salad and vegetables for people to have. Family and friends of people who live at the home are welcomed by staff. The home is safe and all equipment that people are helped with is checked so that it works well. There is now a sensory garden so that people can sit in and some of the plants will smell nice. Other plants will be good to touch and some will make a noise when the wind blows. There is a newsletter which tells people about the staff that supports them. It tells people what is happening in the home. All staff have got a lot of certificates thatsay they know how to support people. Staff have worked at the home for a long time. The manager is working hard to make improvements so that people living in the home have good care and the home is a nice place to live. The home has good policies and procedures. The Policies are rules that tell staff about how to do things. The Procedures tell people how to follow the rules. A survey returned wrote, `Always seems happy, clean and well fed. The house is always clean and the staff helpful`. What has improved since the last inspection? Lots of information can now be found in plans that tell staff how to keep people safe when they are supporting them so that they are not in any danger. Sometimes staff change these plans or make new plans so that they still keep people safe. Some new staff have come to work at the home so that there are enough staff to support all the people who live in the home. What the care home could do better: People should be asked if they would like staff who are female or male to help people with their care support. This should be written down in plans for staff to follow. The medicines that people take when they are required must be written within a set of rules for staff to follow to keep people safe at all times. The planning of meals should be done with people who live in the home with help from pictures of meals. Key inspection report Care homes for adults (18-65 years) Name: Address: Coombe House 54 Broomfield Road Kidderminster Worcestershire DY11 5PH The quality rating for this care home is: three star excellent 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: Sally Seel Date: 0 9 1 2 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 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. They reflect the things that people have said are important to them: 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 39 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 © (2010) 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 39 Information about the care home Name of care home: Address: Coombe House 54 Broomfield Road Kidderminster Worcestershire DY11 5PH 01562824770 01562750780 info.coombehouse@praxiscaregroup.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Praxis Care Group care home 12 Number of places (if applicable): Under 65 Over 65 12 0 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 12 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: Learning disability (LD) 12 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 39 A bit about the care home Coombe House is a nursing home that provides nursing care for 12 people with learning and physical disabilities. Care Homes for Adults (18-65 years) Page 5 of 39 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: three star excellent 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 Care Homes for Adults (18-65 years) Page 6 of 39 How we did our inspection: This is what the inspector did when they were at the care home The inspection was carried out by one inspector who visited the home without telling anyone she was coming. The deputy manager and other staff helped the inspector on the day of the visit to the home. The inspector talked to some of the staff working at the home and watched how they helped people who live at Coombe House. The inspector was shown around some of the home and said hello to some people who live there. We looked at some care support plans and plans to help make sure someone keeps healthy. We looked at the medicines and records which tell us how staff help people who live in the home with their medicines. Papers in the office were shown to the inspector to tell them how the home is run. Eight surveys were returned from people living in the home. Relatives and friends helped some people to complete their surveys. Care Homes for Adults (18-65 years) Page 7 of 39 The manager filled in a form called an Annual Quality Assurance assessment (AQAA). This shows how the needs of people who live in the home are met and what is planned for the future. The inspector would like to say thank you to people who live in the home, deputy manager and staff for helping and making the inspector feel welcome. What the care home does well Staff help people to spend some time in the home before they come to live there. A book that tells people about how the service works has pictures so people can see what it is like to live at Coombe House. The care plans of the people who live in the home have lots of details to help the staff to give good support. Staff have done training in the Mental Capacity Act and Deprivation of Liberty Safeguarding so that this can be put into plans so people have the right support to make decisions and be safe. Staff help people to go to see their doctor and other people if they are unwell or need a check up. Staff are good at looking after medication. Care Homes for Adults (18-65 years) Page 8 of 39 They do this because people living at the home cannot do these themselves. Staff help people who live in the home to do books with pictures that tell a story about their lives, interests, family and friends. People are encouraged and supported to do things for themselves whenever it is safe for them to. Like putting clothes on and cleaning their rooms. People are supported to take part in activities that they like. The manager is always looking for new activities. The kitchen is clean with lots of choices of food. There is fresh fruit, salad and vegetables for people to have. Family and friends of people who live at the home are welcomed by staff. The home is safe and all equipment that people are helped with is checked so that it works well. There is now a sensory garden so that people can sit in and some of the plants will smell nice. Other plants will be good to touch and some will make a noise when the wind blows. There is a newsletter which tells people about the staff that supports them. It tells people what is happening in the home. All staff have got a lot of certificates that Care Homes for Adults (18-65 years) Page 9 of 39 say they know how to support people. Staff have worked at the home for a long time. The manager is working hard to make improvements so that people living in the home have good care and the home is a nice place to live. The home has good policies and procedures. The Policies are rules that tell staff about how to do things. The Procedures tell people how to follow the rules. A survey returned wrote, Always seems happy, clean and well fed. The house is always clean and the staff helpful. What has got better from the last inspection Lots of information can now be found in plans that tell staff how to keep people safe when they are supporting them so that they are not in any danger. Sometimes staff change these plans or make new plans so that they still keep people safe. Some new staff have come to work at the home so that there are enough staff to support all the people who live in the home. Care Homes for Adults (18-65 years) Page 10 of 39 What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Sally Seel 77 Paradise Circus Queensway Birmingham W Midlands B1 2DT Care Homes for Adults (18-65 years) Page 11 of 39 01216005300 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 12 of 39 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 13 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a good supply of information about the home which can be made available in pictures and symbols which is meaningful to enable individuals to make an informed decision about whether they would like to live there. Pre-admission assessments are undertaken and people are encouraged to visit the home to ensure that people know their individual needs and aspirations can be met prior to coming to live at Coombe House. Evidence: A statement of purpose and service user guide is given to people who may be considering whether Coombe House meets their needs and lifestyle choices. We also saw acknowledgement that people had been given the statement of purpose and service user guide. We were told that these information guides are produced in a variety of formats, such as, pictures, symbols, audio and larger print. The service user guide that was shown to us had some photographs with large print and the information was in clear plain English. This is important as it will help people to make sense of the details provided so that they are able to decide whether the home is the right one for them. We saw that the information in the statement of purpose and service user guide hold a Care Homes for Adults (18-65 years) Page 14 of 39 Evidence: wide range of details, such as, what the home is like inside, how peoples needs could be met and what services are offered to do this, the organisation structure, management and staffing details together with the fees charged. The eight surveys we received from people who live at the home and their relatives told us that six people had received enough information about the home to help them make decisions about whether the home is the right one for them. One relative indicated they did not receive enough information with another stating, dont know. The Annual Quality Assurance Assessment (AQAA) that has been completed by the registered manager told us that improvements for the next twelve months are:- To review the Statement of Purpose and Service Users Guide by May 2010. - To pilot the Admission Assessment if the opportunity arises. - To gain feedback via our Admission to The Home Survey if a new admission occurs. This shows that the registered manager is always looking at ways to improve the information in both the statement of purpose and service user guide. This should make sure they are of value to all people regardless of their abilities which is sometimes a difficult goal to achieve. The AQAA tells us that, Perspective service users are invited to regularly visit and spend time at Coombe House, share meals and an overnight stay, comprehensive discussion and visits from friends, family and advocates are also welcomed and encouraged. This is positive as it gives individuals real opportunities of seeing what life would be like if they choose to live at the home and speak to other people who live there. This practice also gives people another way of experiencing what Coombe House has to offer, especially if reading information is particularly difficult for them. The statement of purpose, documents:The home is a nursing home that provides twelve beds for nursing care at any one time. The home is for twelve people, both male and female, with Learning and Physical Disabilities above 18 years of age. This information is also readily accessible in the home and can be seen in in the homes registration certificates which are displayed near to where people sign in and out. At the time of our visit there were twelve people living in the home, seven females and five males. There were no vacancies on the day we visited the home. The information provided tells us that all people have a full assessment of their needs before they move into the home. This makes certain that these are all able to be met by appropriate staff qualifications, experiences, skills and knowledge. There are sufficient staff on duty to meet individuals needs at all times. These details are all confirmed in the Care Homes for Adults (18-65 years) Page 15 of 39 Evidence: statement of purpose and service user guide. We saw in the care records we looked at of two people who live in the home that assessments of each persons needs were completed prior to coming to live at the home together with assessments from other professionals. Some staff told us about their training experiences and all confirmed that in the main there are sufficient staff on duty to meet individuals needs which is further reported on in the staffing section. On the day we visited we spoke to a mixture of staff who provide care and assistance to people at Coombe House. We spoke to the, deputy manager, nurses, a cook, a person who helps to keep the home clean and tidy, staff who support people with their daily tasks and interests together with a staff member that drives the homes vehicle as well as other daily tasks with people. Full discussions with people living at the home were not appropriate. Therefore our observations and discussions with staff together with the surveys we received will be referred to throughout this report. Responses from relatives who completed surveys told us:I consider it was an excellent choice and that my son is fortunate to be at Coombe House. We feel so lucky that X (persons name) is living at Coombe. Staff told us:Very happy home, lovely people and staff. Really good training to meet needs. Standard of care is very good to meet each individuals needs. Care Homes for Adults (18-65 years) Page 16 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are detailed with the participation of each person, their relatives and or representatives to make sure that peoples needs are met and risks are fully assessed. This will help to ensure that people get the care they need in ways that suit them best, and be supported to stay safe from harm. Evidence: The care and support provided to two people who live in the home was focused upon to ensure that individuals are supported and encouraged with meeting their individual goals in relation to their specific needs. Each individual had their own care plan. These plans were clear and held sufficient information to enable staff to meet peoples needs. Areas included, routines, personal care, communication, family contact, making choices, meals, behaviour, health, activities and cultural needs. We saw that each persons plan shows clearly how goals are to be achieved together with what staff actions are required in order to assist the person in their daily lives. We also saw communication plans have been developed with the help of appropriate external professionals, such as, speech and language therapists This means that any care planning processes use each persons appropriate communication methods and or aids. We saw care plans are regularly Care Homes for Adults (18-65 years) Page 17 of 39 Evidence: reviewed and up dated as required to make sure that peoples needs are effectively met at all times. Staff that we spoke to had good knowledge of peoples specific needs and how these are met. Survey responses that we received told us that the home always or usually gives the support and care to their relative that is expected and agreed. At the last inspection it was reported that care plans were being developed within a person centred approach. We could see that this is being achieved by various methods, such as, named nurses and key workers who are building close relationships with individuals. They are gaining knowledge of peoples preferences and dislikes so that consistency of care is maintained. Also people are able to share any issues and or concerns they may have in the presence of a staff member they feel comfortable with. Named nurses and key workers help individuals to arrange annual meetings where people are supported to influence their own care planning. This ensures the focus of care is driven by each person who lives in the home, rather than the needs of the service and the limits to what it can provide. Importantly we were told and it is also stated in the AQAA that peoples, representatives, family, friends and advocates, statutory and non statutory team members are invited and encouraged to attend. One area that could be further developed whilst considering a person centred approach to care planning is to highlight gender specific care. This means establishing whether people who live in the home prefer a female or male to assist them with their personal care tasks. The registered manager has also acknowledged this within the AQAA as an area to be developed in the next twelve months so that people feel comfortable with staff that are completing their personal care tasks. In the AQAA it informs us that, The taking of reasonable risks and the achievement of new experiences are supported. Risks are comprehensively assessed and measures are put into place to minimise potential risk and to maintain a service users safety and independence without being restrictive. We certainly found that this is the case from looking at how risks are documented and managed with appropriate staff guidance in place within the care records we saw. This is one area that has improved since we last inspected the home. We were told that staff have also received training in risk and support planning to help inform their practices so that people in the home are protected from harm but unnecessary restrictions are not forced upon individuals. Peoples ability to exercise choice and to make informed decisions is variable, according to their individual needs. Care files sampled showed that individuals are supported to make decisions. Where practicable and safe peoples wishes are acted upon and followed through. Care records looked at, discussions with staff and observations of practices, indicates that choice is offered. This is continually reviewed to make certain that preferences in relation to activities, meals, times of going to bed and getting up are altered where needed in individuals care plans. On the day we visited we certainly saw the people were well dressed in clothing that reflected each persons personality and choices. We also saw that people travelled around the home as they chose and came into the dining room to sit at the tables even when meals were not being served. This Care Homes for Adults (18-65 years) Page 18 of 39 Evidence: demonstrates that choices are not dictated by institutional methods of onlu using the tables at set times. The AQAA informs us that, All service users now have a Deprivation of Liberty Safeguards Support Plan which details what may be potential deprivations of liberty and what is currently in situ to support and protect service users to ensure there is no deprivation of liberty. We saw in care records where decision making was highlighted where peoples independence was also considered in relation to individuals access to visitors. Also locked front door, freedom to move around house, wheelchair safety belts, contributing to the running of the home, right to privacy, control of care package, opportunity to access community and maintain friendships. For some more complex decision making and where individuals do not have the capacity to make decisions we saw that meetings were held with all professionals that needed to be involved. This demonstrates a proactive approach is taken when making decisions about the way people experience their daily lives within the home. This gives confidence to all people that all restrictions to individuals lives are made in their best interests using formal processes which were positively seen documented in care records that we looked at. This shows that people living in this home are encouraged and supported as their abilities allow so that their independence is promoted and valued. The management team and staff should be commended for their hard work in relation to the current practices which reflect the legislation that supports and protects people in all areas of their lives, such as, the Deprivation of Liberty Safeguards Support Plans. Care Homes for Adults (18-65 years) Page 19 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at this home are assisted to participate in a range of leisure and social activities, which are supportive in helping them, lead stimulating and meaningful lives. Staff fully support people to keep links with their families and friends thereby ensuring important relationships are maintained. Generally daily routines are operated on the principles of choice and respect. Food is wholesome and varied with healthy eating promoted. Evidence: Positively, we saw that peoples life stories are documented with words and photographs used for illustration purposes to bring events and peoples relationships alive. These are important to people as they create talking points, help to celebrate the diversity of individuals and are able to be used to make certain individuals interests are followed to bring meaning to their lives. We saw a range of activities documented in peoples care records to show the lifestyles people are leading. All activities and social stimulation is then reviewed as individuals minds change and or if people become anxious about activities as we saw from looking at a persons care records. Care Homes for Adults (18-65 years) Page 20 of 39 Evidence: We acknowledge that there is some difficulty in planning some activities for everyone as we were told some people do not like a lot of noise and sometimes individuals may be too poorly to participate in any activities. However, we spoke to some support staff that work with people on a part time basis and are known as enablers. These members of staff have worked with individuals for some years so they have become quite knowledgeable in relation to supporting and encouraging people to follow their chosen activities. Also people who live in the home have the facility of their own home transport to enable them to access activities and follow their interests in the community. On the day we visited we saw that people were being supported to go out into the community and we were told that activities can range from, bell ringing, going for a coffee, visiting garden centres, carol concerts, going to the cinema and shopping. The AQAA confirms a range of activities, eating out, Severn Valley Railway trips, visits to the theatre and pantomimes, churches, local farms, the library. This reflects what is documented in the statement of purpose and service user guide so people are able to see if their lifestyle choices will be met if they choose to live in the home. Also people who are living in the home and or their relatives or representatives are able to look at the service user guide to ensure that individuals activities are being followed in line with what the service user guide tells people will be planned. Individuals are also encouraged and supported to participate in a range of activities in the home and these were noted in the care records we looked at so that it could be seen whether they reflected a personalised approach. Activities documented were, listening to music, reflexology, watching sport channel, aromatherapy and household chores. People responded to the question, Does the home arrange activities that you can take part in if you want, five stated usually and the other three people said always. One person said, I would like to do more activities during the day when I am in the home with staff. The registered manager has stated in the AQAA that they continually sourcing new opportunities and activities for service users. We are confident that the registered manager has shown that they will continue to source activity opportunities both in the home and community. For example, an area of the garden has been designed into a sensory area since we last inspected the home for people to enjoy. This will be further discussed in the Environment standard of this report. We will focus upon activities and social stimulation that people receive when we next inspect the home to ascertain if any new opportunities and activities have been found to meet individuals needs. Daily records and care files sampled showed that contact with family and friends is supported. Relatives are invited to review meetings where appropriate and we saw care records where minutes confirmed this practice. There are parent and carer liaison meetings that take place every six months, a monthly newsletter, annual quality surveys, gatherings for special events where relatives and friends are invited. There are no restrictive visiting policies apart from bearing in mind late nights and very early mornings. We were told that the registered manager does have an open door policy where family members can call in and or contact by telephone if they wish. This practice Care Homes for Adults (18-65 years) Page 21 of 39 Evidence: ensures good communication links are maintained with relatives and friends. In each care file we found a daily record of individuals meals which includes documentation for people who may require additional food supplements. Food charts are maintained in the kitchen for staff referencing purposes. We spoke with one of the staff members who undertakes the cooking of meals in the home and has worked at the home for many years. They told us that meals provided are healthy and menus were devised by the manager. The cook has some good knowledge of peoples likes and dislikes together with medical conditions that mean individuals require a certain diet. The cook told us that they are able to tell if a person does not like their meal and or they will not eat it. It is a credit to the members of staff who undertake cooking in the home as we saw homemade bread and meals to meet individuals cultural needs. Also the Christmas and New Year menu was made to look special with dishes that reflected the festivities for people to choose. The main meal is served in the evening and we looked at the menus for four weeks which showed that a variety of meals are offered, such as, Lamb and mint casserole or Quorn lasagne, creamed potatoes, mixed vegetables and cheese sauce, Chicken sweet and sour with rice or creamed potatoes, fresh salmon, parsley sauce with cauliflower, peas and courgettes. It was positive to note that fruit and vegetables are offered to ensure that people receive the recommended five a day to promote healthy and nutritious diets. Also puddings were varied, such as, bread and butter pudding with custard or instant whip, Blancmange or rice pudding and strawberries in jelly. The AQAA informs us that nutritional care training will be provided to all staff in the next twelve months which will further enhance peoples dietary requirements and maintain their health. We were told by some staff that we spoke with that meals are excellent. There is one area that could further enhance peoples choices and independence. This is for menus to be devised into pictorial formats so that people could participate in menu planning, an aid to choices and also this would be a good reminder if displayed. We were told by staff that at least four people who live in the home would be able to understand pictorial menus. The registered manager in the AQAA has also recognised this as an area for improvement in the next twelve months and it will be an area we will look at when we next complete an inspection at the home. Staff that we spoke to were able to inform us how some people who live in the home are assisted to eat their meals and this reflected some good practices that refelcted respect and dignity whilst assistance is being given. The environmental health officer visited the home recently and awarded five stars which is the highest grade given to reflect the high standard of kitchen and food hygeine practices within the home. Care Homes for Adults (18-65 years) Page 22 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to health care within the home and the local community ensuring individuals health needs are monitored and met effectively so that people stay healthy and well. The management of medication is good which ensures people get the right medication at the right time. Developments in as required medications have bee acknowledged to further protect people. Evidence: Observations and examination of records confirm that peoples privacy and dignity is respected. For example staff were seen escorting individuals to their bedrooms and bathrooms in order that personal care could be given in order not to compromise their dignity. Assessments and care plans contain comprehensive guidelines for staff regarding individuals personal preferences about how they are guided, supported, moved and transferred. We were told that the home have a Dignity Charter in place and staff practices that we observed mirrored the principles of this. As stated previously in this report this could be further enhanced to reflect individuals choices in relation to gender specific care. Survey responses told us:The home looks after my everyday needs. Care Homes for Adults (18-65 years) Page 23 of 39 Evidence: It looks after me in the best way possible. He receives excellent attention at all times. In the AQAA the registered manager confirms, Coombe House works very closely with other professionals to effectively meet service users personal and healthcare needs; G.Ps, Physiotherapists, Occupational Therapists, Consultants in a variety of specialisms, Speech and Language Therapists, District Nurses, Community Learning Disabilities Team, McMillan Team and Primary Care Teams. We found this to be the case as care records provided information about individuals past and present medical conditions so that people living in this home can be confident that their medical health and physical, emotional and mental health needs are being consistently met reviewed and promoted. On the day we visited some people who live in the home were going to their GPs surgery for their swine flu injection. Weight records showed that staff are regularly checking peoples weight to ensure they are not losing or gaining a significant amount of weight that could be an indicator of an underlying health need. This is particularly essential for people who have limited communication, understanding and or may not be able to consistently express if they are unwell. The management team and staff should be commended on the intervention plans we saw in relation to managing individuals thyroid difficulties, constipation and continence management and other medical needs that individuals may have at any given time. These plans contained diagnosis of the particular conditions, strategies for staff to follow which were extensive in their details. Such as, thorough washing and drying of certain parts of a persons body, medications, the changing of continence pads to ensure comfort and minimise any irritations, and dietary requirements. Reasons for all interventions were documented to protect people from unnecessary practices and preserve good practices to ensure healing is aided so that people stay healthy and well. We reviewed the administration and storing of medications with the deputy manager. Medication is stored in an appropriate locked cabinet. The medication is supplied by the pharmacist. Medication Administration Records (MARS) had been signed appropriately and these cross-referenced with the amounts of medications left to take indicating that medication had been given as prescribed. We were told that people have their medication reviewed regularly to ensure that this is still of benefit to them and is effective in meeting their health needs. We discussed with the deputy manager medications that are prescribed to people on an as required (PRN) basis and whether there were any protocols for staff to follow. The deputy manager confirmed that there were none. Although we do acknowledge that there is a stable core staff team at this time but nonetheless individual protocols must be in place for all individuals who are administered PRN medications. The registered manager has confirmed in the AQAA, To develop individual care plans for the administration of as required medication for all service users. We have made this a requirement and will check any individual protocols that are Care Homes for Adults (18-65 years) Page 24 of 39 Evidence: in place for PRN medications when we next undertake an inspection of the home to make certain people are protected by robust medication procedures and practices. All medication is administered by staff qualified to complete these tasks and we saw that policies and procedures are in place so that people living in the home are protected by these. As was reported at the last inspection information is available regarding peoples and their relatives wishes in relation to death and dying which include preferred funeral arrangements. The registered manager has shown that palliative care for individuals who may have a terminal illness is provided in ensuring that empathy and sensitivity is highlighted through all end of life care delivery. The registered manager has also completed a Diploma in Professional in Palliative Care which further shows their commitment to this important time in peoples lives. Staff told us:Personal care is good and retains independence for all people as much as possible. Peoples dignity is upheld by staff and people are encouraged to live as independently as possible. Care Homes for Adults (18-65 years) Page 25 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure is comprehensive and is available to people should they need to make a complaint but ways are being sought to continually improve procedures. There are systems in place to ensure people are safeguarded and protected from harm. Evidence: We were told that there have been no complaints made in the last twelve months and this is also confirmed in the AQAA together with the complaints log we saw which is kept in the home. The registered manager is going to develop a pictorial complaints procedure making it more accessible. We saw that the complaints procedure has the relevant and required information so it was clear how people could make a complaint if they are unhappy with the service provided at the home. The levels of learning disability of most of the people living in this home indicate that they would require a great deal of support or advocacy to ensure their rights are protected. Therefore the one to one time that people have with their keyworkers is important as individuals are able to have the opportunity of comfortably raising any concerns and or complaints knowing these will be listened to and action is taken appropriately. Completed surveys from eight people gave us the following information, five people said the staff always listen to them and act on what they say with two stating, usually and one stating, sometimes. Also in response to, Is there someone you can speak to if you are unhappy, all eight said yes. In answer to, Do you know how to make a formal complaint; five people stated yes, one person left their answer blank whilst two people indicated that they did not know how to make a formal complaint. Care Homes for Adults (18-65 years) Page 26 of 39 Evidence: As reported previously within this report, we were told that there are parent and carer liaison meetings, annual quality surveys and staff meetings where individuals are able to share any complaints and or concerns they may have. We were also shown the new comments cards that are displayed near to the front door of the home. These are available for visitors to state what the home does well and or what they have not done so well. It is suggested that these cards could be used where appropriate with people who live in the home as they are so easy to use. Also the registered manager has stated that they are seeking ways of attracting more people to attend the parent and carer liaison meetings. This shows that the management team and staff are continually seeking ways to gain peoples views where improvements could be made and or what is actually working well for the benefit of people who live at Coombe House. In the AQAA it is confirmed that there have been no incidents of alleged or actual abuse reported. The staff training matrix informed us that all staff working at the home have received adult abuse training. This should ensure staff able to describe and recognise the actions that they would take if they witnessed any form of abuse. We sampled two staff records and found that appropriate recruitment and selection checks have been followed. This means that the systems in place for the recruitment of staff are satisfactory which is discussed further in the staffing standards of this report. Care Homes for Adults (18-65 years) Page 27 of 39 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 who live in this home are provided with a homely, clean and comfortable environment. A proactive approach is taken to ensuring equipment is in place to meet individuals needs and areas within the home and garden promote peoples independence, dignity, safety and sensory needs. Evidence: Coombe House is a large Victorian house where management and staff have strived to ensure that it meets individuals needs as well as keeping it homely. Homely touches were seen throughout the home, such as, clocks, pictures, and other items relevant to people who live in the home. There are seating areas in the large hallway for people to choose to sit, the flooring by the front door has the old Victorian tiling which adds to the character of the home and further compliments the sense of homely touches. The deputy manager told us that they have recognised features like these. The management team and staff have worked hard to ensure these can be maintained and are risk assessed where necessary so that they remain in the home for people to enjoy. Also we found the atmosphere within the home to be calm and relaxed with people moving around as they choose some with help from staff. The home was decorated to reflect the Christmas festivities. We saw various types of equipment to meet individuals needs, such as, overhead ceiling tracking, profiling beds, mobile hoists, wheelchairs and specialist baths. Some improvements have been made through various purchases which are noted in the AQAA as, A new specialist arjo shower trolley and wispa mobile hoist. A new nurse Care Homes for Adults (18-65 years) Page 28 of 39 Evidence: call system has been fitted throughout the building. Therefore physical abilities and independence can be promoted giving individuals more freedom in their home. This shows that although nursing care is offered to people living at Coombe House efforts have been made to retain the homely feel within the home. Therefore ensuring the environment is able to meet individuals health and physical needs in practical terms which is sometimes to difficult to achieve within a nursing home environment. We were shown some of the bedrooms and found these to be nicely decorated to reflect individuals chosen colour preferences together with their own personal tastes. It was positive to see that some thought has been given to peoples bedrooms and how they meet individuals needs both in the practical terms and their interests. For example, we were told that one persons bedroom is prominently placed to watch the wildlife as they like birds and we observed this to be the case. Another persons bedroom window looks out on to a wooded area. Each person has purchased their own furniture which looked well made and sturdy. We were told that if a person is unable to do this then there is some furniture that has been donated to the home which can be used so people are not disadvantaged. There are two lounges and a dining room for people to choose to sit in. In the larger lounge we saw a television and easy chairs, some to meet peoples individual needs. The smaller lounge has a television and is the quieter of the two so that people are given a preference. The hall had some leather sofas for people to choose to sit and we were told people do use these. The dining room is spacious and there are sufficient seats for people to be able to choose to join others for their meals. We saw a bathroom which is equipped for people with physical difficulties. There are assisted baths and showers for choice. These looked clean and had appropriate hand wash facilities such as liquid soap and paper towels so that staff could follow good infection control methods. In the AQAA it tells us, Privacy is at all times maintained and respected, bathrooms and toilets are fitted with appropriate and safe locking devices, service users bedrooms are also fitted with appropriate safe locking devices. We saw that this was the case. This shows that peoples safety is made paramount without detracting from their rights for privacy and respect. There is a snoozelan which is a room dedicated to hold equipment and aids to enhance individuals relaxation and stimulate their senses. On the day we visited we saw this being used and staff said that some people were very fond of sitting in the snoozelan. There is a ramp that leads onto the garden area for people to access this easier and a path winds around the new sensory garden that has been designed for people to sit and enjoy as they choose. This has been achieved through fund raising efforts which reflect the dedication of the staffing team to make sure the garden holds peoples attention and meets their needs on a higher sensory level. We were told that more plants will be p;urchased to meet peoples different senses, such as, smell, touch, sight and hearing. Care Homes for Adults (18-65 years) Page 29 of 39 Evidence: We also saw a raised bed that is used for vegetables and a greenhouse which some people enjoy growing plants in. We saw people being assisted by staff in their wheelchairs around the garden on the day we visited. We were told that the homes environment will continue to improve and change where necessary so that people living there will be reassured that their home can meet their individual needs to include their physical and emotional wellbeing. The AQAA tells us that the registered manager will continue, To liaise with Nexus Housing with regard to effective energy preservation within the building of Coombe House IE: replacement windows and fulfilment of roof repairs. The AQAA also highlights that all staff have received training in infection control as discussed further in the staffing standard. On the day we visited we found the home to be clean, hygienic and tidy to provide a homely and welcoming environment to live in and the comments we received in the surveys confirmed that the home was always fresh and clean. Care Homes for Adults (18-65 years) Page 30 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made to ensure a stable, well trained and diverse staffing team are in place to meet individuals needs competently. Robust recruitment practices provide the homes commitment to keeping people safe and protected from harm. Evidence: On the day we visited we observed staff helping people where necessary in a respectful manner. We were shown the staffing rotas and told by staff that individuals needs are met appropriately by the numbers of staff on duty at any given time. We were told that there is one staffing vacancy and interviews are scheduled for early January. The rotas do not show any staffing levels falling below what the home confirmed with us. We observed staff interacting with individuals in an unhurried manner. Any tasks were completed which further confirms that staffing levels seem to be appropriate for the twelve people living in the home at this time. There seems to be a stable staffing group and recruitment has improved since we last inspected the home. This means that people who live in this home have consistency in the support they receive due to building familiar relationships with staff, some of whom have worked at the home for many years. The registered manager has demonstrated that they are open and transparent in relation to staffing levels in the home. For example, they have acknowledged in the AQAA that there has been some staff sickness which has required managing but they have said, Absences have been covered with a consistent core of agency staff or by regular staff Care Homes for Adults (18-65 years) Page 31 of 39 Evidence: fulfilling extra hours to promote consistency of care. Two staff records were sampled and we found appropriate recruitment documentation, such as, Criminal Record Bureau (CRB) checks, and completed application forms. Records included two written references for each person and a copy of an application form. This demonstrates that the home has carried out appropriate checks to make sure staff employed by them are suitable to work with vulnerable adults. As at the last inspection all new staff complete an induction course for one week in Belfast and we spoke to staff who were able to confirm that this was particularly useful. We were also told by staff that they are supported by the management team to familiarise themselves with the home, people who live there together with health and safety matters, such as, fire drills and escape exits. The (AQAA) shows that 12 staff are trained to NVQ level 2 or above, and that training provided meets national standards and statutory guidelines. We saw the matrix which has been developed to show training that staff have completed and highlights when refreshers are due. We can see from the matrix that staff have been maintaining their mandatory training in health and safety, moving and handling, food hygiene, safe handling of medications, first aid, protection of vulnerable adults and fire training. It was positive to find that staff have received specialist training in order to meet individuals needs, such as, Mental Capacity Act, Deprivation of Liberty, equality and diversity and epilepsy are just a few examples. This ensures that people living at Coombe House can feel confident that the care and support they receive is provided by a skilled and knowledgeable staff group. All staff spoken with told us that they valued their supervision sessions as an opportunity to gain feedback in relation to their care practices and to check out how they could improve their practices. This is a positive reflection that people living in this home are supported by staff that are fully supervised and recognise their duties and responsibilities within their caring roles. Care Homes for Adults (18-65 years) Page 32 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements ensure that the home is run in a open and transparent way that benefits the people living there and promotes their best interests. Staff have good direction and appropriate supervision, which means they meet the needs of the people. There have been sustained better outcomes for the people who live at Coombe House due to the skilled leadership of the home. Evidence: As at the previous inspection Mrs Emma White is the registered manager of Coombe House. The registered manager has been in post since 2004 and is a registered first level nurse in learning disabilities who has completed the Registers Managers Award NVQ Level 4 and a Diploma in Professional in Palliative Care course. Mrs White is supported in her management role by a deputy manager, Ruth Egginton who is also a registered first level nurse in learning disabilities and provided assistance to us during the inspection of the home as the registered manager was on leave at the time. Staff spoke to seemed happy with the registered manager and the way the home was run. We observed people who live in the home and staff conversing with the deputy Care Homes for Adults (18-65 years) Page 33 of 39 Evidence: manager in a relaxed and comfortable style. It was clear from speaking with the deputy manager that they have knowledge of the people who are living in this home. This demonstrates that the management team enjoys a hands on approach within their management style of the home. Also a proactive approach is taken to make certain that people who live in this home have new opportunities to increase their independence and ensure improvements are continually sourced. Some of these opportunities and improvements have been reflected throughout this report, such as, risk assessments, building of a sensory garden, staff recruitment, environment improvements and purchased specialised equipment and so forth. There are many varied ways in which the measurement of the quality of services for people who live at Commbe House are completed. This should make certain individuals are able to have their views listened to so that practices and services are influenced to provide good outcomes for all people. For example, we saw records of the monthly visits that are undertaken by the assistant director for Praxis Care. These informed us that people who live in the home are enabled to share their views together with staff, the homes environment is inspected together with care records, medication and financial management, various policies and procedures, complaints and compliments. We were told that parent and carer liaison meetings happen regularly every six months together with distriubution of annual surveys to relatives, representatives and so forth. Some of the responses we saw from the annual surveys were:The food at Coombe always looks and smells delicious has a special dietary needs and staff are always aware of this but manage it without making life a misery. Has got a lot less mobile of late and now needs a hoist. I think she found this difficult but the staff have helped her adjust. My family are pleased they can visit any time of day. My sister who lives there seems perfectly happy. Coombe is now beautifully decorated and furnished and feels very homely always a pleasure to visit. We feel lucky to have living in such as lovely home and it really is home to her where she is happy and secure. We are confident that the management team are actively listening to peoples views. For example in the November newsletter we saw that there is a clear description of how the home is staffed together with their qualifications. The registered managers role is going to be described in the forthcoming December newsletter but their qualifications, home life and interests are noted for peoples interest which is a nice touch. The newsletter is being used effectively to ensure events; improvements to the home and so on are shared with Care Homes for Adults (18-65 years) Page 34 of 39 Evidence: people and includes people in any changes or news that is meaningful to their lives at Coombe House. The AQAA was as previously confirmed completed by the registered manager and returned to us. It was very detailed and provided us with some excellent insights into practices in the home. The registered manager should be commended for the insight and recognition that they showed in relation to what they need to do to improve the service provided together with how they planned to achieve this. This shows that the management team have the best interests of the people who live at Coombe House at the very heart of all that is achieved to shape service delivery in an open and transparent way. We found that health and safety checks were completed. For example, water temperatures and staff know what the required temperatures should be to ensure they are not too hot or cold. This ensures temperatures stay within the recommended safe limits so that people were not at risk of being scalded. The water had been tested for Legionnella. Suitably qualified engineers complete the test of the gas equipment and electrician completed the test of the electrical wiring and stated that it was in a satisfactory condition. The fire risk assessment detailed what action, if any, needs to be taken to ensure that the risks of there being a fire are minimised as much as possible. Regular fire drills are held so that staff and the people living there know what to do if there is a fire. These records show that people are protected from any risks to their health or care needs within peoples living environment. Care Homes for Adults (18-65 years) Page 35 of 39 Are there any outstanding requirements from the last inspection? Yes  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 Care Homes for Adults (18-65 years) Page 36 of 39 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 Description 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 Description Timescale for action 1 20 13 Appropriate information 22/01/2010 relating to when required medication must be kept, for example, individual protocols to ensure that staff know how to use and monitor all medication including when required, as directed medications. This will make certain that all medication is administered safely, correctly, consistently and as intended by the prescriber to meet individual health needs. 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 17 It is recommended that pictorial menus are developed to aid individuals choices of meals, participation in menu Page 37 of 39 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations planning and displayed as a reminder to the choice of meals on any given day. 2 18 It is recommended that gender specific care is offered to all people who live in the home and this is reflected in documentation so that they have a choice of females or males in relation to assiting them with their personal care tasks. Care Homes for Adults (18-65 years) Page 38 of 39 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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