Care Home: Cranham Lodge

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What the care home does well There were very clear words written down about how the staff understand people, which included looking at their faces for signs of likes and dislikes. One plan told us the person liked lots to do but did not like noise. A relative told us, `the staff could not do anything better`, and felt that the staff could identify distress in her relative better than she would. The staff help people to maintain contact with their families and friends by providing transport for some family members to visit the home. The records also told us that people are helped to keep in contact with relatives by email. Some people go on holidays and short weekends away from the home. People sometimes go to the shops with the staff to help buy the food each week. People enjoy eating the fresh home cooked food and they can choose what they want. All meals are prepared daily by the staff using fresh ingredients. The staff told us the `food here is very good`. People living in the home were unable to tell us about the food, however, the sample daily record we looked at said they ate well. People are supported by others outside the home to help ensure all their food needs are well met, and the care staff are well trained to make sure people are helped to eat their food safely. The home was clean and did not have any unpleasant smells. The staff are trained and know what to do to help people with learning disabilities. Before staff start work in the home they are checked to make sure that people living in the home are safe. The staff in the home are helpful and know what to do to make sure everyone is safe. The staff know what to do if there is a fire and how to get people to safety. People are also safeguarded from financial abuse as personal monies are checked daily by two staff to ensure they are correct. What has improved since the last inspection? The home has better care plans to help make sure that what people like is taken into account. The staff are training to help make sure they can understand what people want. A new garden and shaded area outside has been started to make sure people can enjoy being outside. More staff are completing their training to help ensure they know how to look after people well. What the care home could do better: Some people need two staff to look after their needs, and at night there is only one staff member, this may not be helpful as it may mean people have to go to bed earlier than they want to. There also appears to be insufficient staff to met all needs as activities are limited. Some written work about how the home is run needs to be looked at, and the way in which people are given their tablets could be improved. The home has transport to take two people out in a wheelchair to enjoy activities in the community, and may not be able to access another vehicle easily so that more than two people can go out. The AQAA told us that the home could improve by providing more one to one activities. however, without sufficient staff available this may not always be possible. The home was fairly well maintained, however, some areas required decorating and replacement of carpets. Key inspection report Care homes for adults (18-65 years) Name: Address: Cranham Lodge Folland Avenue Hucclecote Gloucester Gloucestershire GL3 3TA     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: Kathryn Silvey     Date: 0 4 0 8 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 34 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 34 Information about the care home Name of care home: Address: Cranham Lodge Folland Avenue Hucclecote Gloucester Gloucestershire GL3 3TA 01452610644 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.brandontrust.org The Brandon Trust care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical 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: Care home only Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability (Code LD) Physical disability (Code PD) Date of last inspection Brief description of the care home Cranham Lodge is a purpose built-detached bungalow, which provides care and accommodation for seven adults with learning and physical disabilities. The home is located in the community of Hucclecote close to amenities on the outskirts of Gloucester city centre. The bedrooms and communal rooms are adapted to meet the needs of the people living in the home, this includes specialist equipment to meet their physical disabilites. The home has its own transport. There is a large garden that is laid to lawn, and a small sensory garden within a covered patio area. The home has a Care Homes for Adults (18-65 years) Page 4 of 34 Over 65 0 0 7 7 Brief description of the care home spacious lounge and dining room. The home is run by Brandon Trust and Advanced Housing manage the property. The home has a Statement of Purpose. The monthly fees are in the region of £1318.36. Care Homes for Adults (18-65 years) Page 5 of 34 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: The date of the last key inspection was 19/06/2007. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. We, The Care Quality Commission (CQC) completed this surprise key inspection during two days. We saw all the people living in the home and spoke to them with the staff so that they were aware we were looking around the home. We looked at how the care staff were talking to people. We also spoke to the senior support worker, and three of the care staff. We were also able to speak to a relative on the telephone. Care Homes for Adults (18-65 years) Page 6 of 34 A number of records were looked at including care plans, risk assessments, health and medication records. The care records of three people were looked at in detail, and we spoke to the senior staff member about the care of the other people living in the home. The home was looked at, and staff were watched helping people living in the home. The manager had completed the Commissions Annual Quality Assurance Assessment, AQAA this is information sent to CSCI each year. One staff survey was returned to us. Care Homes for Adults (18-65 years) Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: Some people need two staff to look after their needs, and at night there is only one staff member, this may not be helpful as it may mean people have to go to bed earlier than they want to. There also appears to be insufficient staff to met all needs as activities are limited. Care Homes for Adults (18-65 years) Page 8 of 34 Some written work about how the home is run needs to be looked at, and the way in which people are given their tablets could be improved. The home has transport to take two people out in a wheelchair to enjoy activities in the community, and may not be able to access another vehicle easily so that more than two people can go out. The AQAA told us that the home could improve by providing more one to one activities. however, without sufficient staff available this may not always be possible. The home was fairly well maintained, however, some areas required decorating and replacement of carpets. 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 34 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 34 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. The staff assess peoples before admission to ensure that their needs can be met, this includes obtaining information from social and healthcare professionals where appropriate. Evidence: There have been no new admissions since the last inspection. The AQAA told us that the homes admission policy required updating and the emergency admission policy had not been reviewed since 2000. We looked at the Statement of Purpose (SOP) and the Service User Guide (SUG) that provides information about the home and the staff. The guide was in an easy read picture format and included some good photographs of activities that people living in the home enjoy. The AQAA told us that there are also plans to produce the SOP in an easy read format. We discussed the possible need for producing information about the home in an audio or video format for people with sensory impairment. Care Homes for Adults (18-65 years) Page 11 of 34 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. There are detailed care plans and the staff are experienced in caring the people that live in the home. The staff are skilled in communicating with people to help ensure their needs and choices are identified and met. There may be times at night when peoples needs cannot be well met with only one member of staff on duty. Evidence: We looked at three care plans in detail, one of which had been completed by a someone that helps, outside of the home. We saw all the people living in the home and spoke to them with the staff so that they were aware we were looking around the home. The Essential Life Plan folders contained all the person centred care plans (PCP) and the new one we looked at, completed by the helper included pictorial guides of how people should be cared for and their preferences. An example of this was a picture of Care Homes for Adults (18-65 years) Page 12 of 34 Evidence: what toiletries were preferred. All the plans were detailed and had some good information to help ensure that staff knew how to meet peoples needs. The AQAA told us that people are encouraged to be involved in their choice of clothing and toiletries and that bedrooms are decorated to reflect their gender, age, likes and dislikes. We looked at peoples bedrooms and we found equipment and decorations that reflected their individuality. There was a care plan for every aspect of daily life for example communication, personal hygiene, exercise programme, mobility, pressure ulcer prevention, sleeping, medication, leisure activities and behaviour management. Each care plan was followed by a risk assessment to help ensure that risks were identified and minimised. Risk assessments were reviewed every three months. The new method for reviewing care plans every three months had no room for recording any information, and was just a signature. This is inadequate and does not summarise what has happened during the three months and whether the care plans have been updated. Reviewing whether care plans are adequate is an important task and should highlight any need for change, and include the keyworkers views, as people are not always able to communicate their needs. The information in the daily records and the other records to include, for example, weight charts and seizure charts may help to identify any changes during a three month period, which could be recorded in a review. When reviews are meaningful a continuity of care is recorded to identify any progress or deterioration which may require intervention by a healthcare professional. We looked in each bedroom and there was information on the wall about the person, which included details about how to communicate with each person. We recommended that some information about peoples medical conditions should not be on display to preserve their dignity. The information about how to communicate with people had good descriptions of what their expressions meant. The plans included what people seemed to like and dislike, for example one plan told us the person liked a varied programme of activities with limited noise. The staff spoken to were experienced and knew people well and were able to understand the way they communicate some of their choices. Care Homes for Adults (18-65 years) Page 13 of 34 Evidence: We looked at some photographs of people, in their care plans, for staff to know how to move and position them correctly. The physiotherapist provided some excellent exercise programmes for staff to follow, to help prevent muscle contraction. Manual handling care plans, essential for everyone, had good information and were reviewed three monthly. Some people had sleep system pictures to enable staff to place the equipment correctly to help with posture. The equipment is also used during the day as people have continence care needs at night and it requires two staff to replace them. The equipment can be used for a maximum of eight hours in twentyfour so this is divided between day and night. Two staff are not available during the night. We are concerned about only one staff being available during the night as most people require changing at least twice and the use of slides sheets for some staff may cause people discomfort, which they may be unable to communicate and staff may be at risk from injury. Four people have epilepsy and working alone at night without backup from other staff may be inappropriate for people that have more than one disability. A notification we recently received from the home stated that one person had a prolonged multiple seizure at 3:20 am and had been given the maximum dose of intervention medication to help control it, however an ambulance was called. Care Homes for Adults (18-65 years) Page 14 of 34 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 are supported to have contact with their family and friends, and to use community facilities whenever possible. There are not enough staff to support people outside the home and not enough transport so that peoples needs for activities are not being met. Menus are planned to provide a variety of food and the staff prepare fresh nutritious food daily. People are supported by healthcare professionals to help ensure all their nutritional needs are well met, and the care staff are well trained to ensure that they receive the correct diet safely. Evidence: We looked at the activity board in the dining room that identified the activities for the week. The AQAA listed all the activities that people currently take part in outside the home, which includes; hydrotherapy, horse riding, St Vincents Centre, Luncheon club Care Homes for Adults (18-65 years) Page 15 of 34 Evidence: and the Worcester snoozlum. Everyone including the staff dressed up like Michael Jackson to go to a Michael Jackson tribute event at the monthly Luncheon club when we visited the home. Four people went to Worcester snoozlum during the inspection. People also use local community facilities such as the library, shops, hairdressers, the bank and a chemist. The AQAA told us that social activities are investigated that are relevant to an individuals age, gender, likes and dislikes and that people are supported to attend religious festivals. The manager attended Equality and Diversity training in July 2009 and will be able to tell the staff about identifying and managing these important issues. People also engage in house activities, these include aromatherapy massage, Indian head massage, reflexology and music groups. The staff help people to maintain contact with their families and friends by providing transport for some family members to visit the home. The AQAA also told us that people are supported to keep in contact with relatives by email. We looked at four weekly staff rotas and there were only four days that four staff were on duty during the morning and most afternoons only three staff until 21:15. Two care plans we looked at in detail identified that the two people went out only four times in the previous month. Without sufficient staff available people can not go out accompanied, and leave two people at the home available to look after highly dependent people that may have a seizure, and need constant supervision. The daily records were well written and recorded what people were doing in the morning and the afternoons, for example; listening to radio, sensory lights on, relaxing on the bed, sat in the garden, watching television, visitors, dancing, and watching a DVD. The AQAA told us that the home could improve by providing more one to one activities. However, without sufficient staff available this may not always be possible. The staff told us there are not enough staff to take people out as often as they would like. We saw one person playing with books on the hall floor and staff engaging with people singing, and talking to them. There were no signs of distress heard or seen and the experienced staff knew how to respond to people to reassure them. One carer told us that one person goes to a disco twice a month, however, all three staff interviewed Care Homes for Adults (18-65 years) Page 16 of 34 Evidence: were concerned that they were permanently losing one of the homes vehicles the following day, which would further limit the trips out that people really enjoy. We looked at the four week menu, which provided a good variety of food, and we discussed with the staff food preparation. All meals are prepared daily by the staff using fresh ingredients. The staff told us the food here is very good. People living in the home were unable to tell us about the food, however, the sample daily record we looked at said they ate well. We observed one person eating well. The main meals on both days looked nutritious, with plenty of fresh vegetables included. There is a folder in the dining room with specific risk assessments and instructions regarding peoples eating plan as some people are at risk from choking. The staff we spoke to were well aware of the risks and what to do. We looked at the record of peoples monthly weights, which help to monitor anyone at risk. No one was currently identified as at risk. Soft diets and pureed food were provided. the Speech And Language Therapist (SALT) review their eating and drinking needs and alter the Percutaneous Endoscopic Gastrostomy (PEG) feed regimes as required. The AQAA told us that the staff are trained to use the PEG feeds and staff told us that each person with a PEG feeding system has their equipment and food stored separately. The AQAA told us that fifteen staff had attended Eating and Drinking workshops The timing of meals is flexible to fit in with peoples daily routines, for example people can have a brunch if they sleep longer in the morning and people have lunch as a main meal if they have been out to Worcester and return late, to avoid meals being close together. Lunch is usually light and the main meal is at approximately 17:00 hrs. One persons plan identified that an early main meal would encourage appetite, so this person was always supported first. People are weighed regularly and the Speech And Language Therapist (SALT) review their eating and drinking needs and alter the Percutaneous Endoscopic Gastrostomy (PEG) feed regimes as required. The AQAA told us that the staff are trained to use the PEG feeds and staff told us that each person with a PEG feeding system has their equipment and food stored separately. The AQAA told us that fifteen staff had attended Eating and Drinking workshops Care Homes for Adults (18-65 years) Page 17 of 34 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. The staff provide personal care with regard to peoples privacy and dignity. There was a shortfall in social care assessment of needs, and providing essential equipment, however, this has been rectified since the completion of this inspection. Healthcare professionals support people with medical conditions when required. Medication administration could be improved to ensure safe handling and administration of medicines at all times Evidence: Personal support is well recorded in the daily records and person centred care plans. Every persons plan is individual and their preferences are recorded. Best practice for completing the care is detailed to promote health and wellbeing. We saw some good examples and generally the right equipment was used to support people with the exception of four very old profiling beds, which were unreliable and sometimes did not function. This problem has been ongoing for several months and staff were having difficulty accessing new beds from either the District Nursing services or the Community Learning Disability Team (CLDT). The problem was reported in the last Care Homes for Adults (18-65 years) Page 18 of 34 Evidence: regulation 26 visit recorded by Brandon Trust on 1st July 2009. Several people were at risk as they required the beds to tilt when having PEG feeds and for other health issues. During the inspection the senior carer in charge was proactive in contacting the district nursing services directly and obtaining an assurance that occupational therapy assessments would be arranged within a few days to assess the type of new bed each of the four people would require. This was a positive response and we expect to be notified as soon as the new beds arrive, as this is a health and safety issue that must be addressed quickly. Brandon Trust should have addressed this important safety issue when it was identified and supported the manager to find a resolution several months ago. Since we have completed the fieldwork for the inspection we have been informed that the new beds and mattresses have been provided. It was noted during the inspection that all the people living in the home had not had an annual review from the Community Adult Care Directorate (CACD) previously known as Social Services, for several years. Whilst this is a CACD oversight the managers of the home should have contacted CACD to invite them to annual reviews in the previous seventeen years. A full review assessment for each person living in the home has been completed recently, which staff in the home helped with. We looked at a sample of the reviews. The new health facilitator plan we looked at was excellent and addressed all the health issues to include dates for the last health checks completed. The checks included were optical, dental and hearing. There were good medical histories and medication reviews had been completed. Continence health reviews were completed by the continence adviser and any other health problems were well recorded. A good example recorded was of a well mens check that included a testicular examination. There were clear records of when the doctor visited and the outcomes of any blood test were recorded. We were told that no one had a pressure ulcer or required visits from the district nurse. It was evident that people were supported by healthcare professionals from the CLDT. One person with Parkinsons disease was supported by the consultant neurologist. The four people with epilepsy were either supported by their GP or a specialist nurse from the CLDT. We recommend that people with epilepsy should be able to have support from a consultant neurologist when required. We looked at the detailed as required Care Homes for Adults (18-65 years) Page 19 of 34 Evidence: protocols completed by the CLDT for the administration of medication should people have a seizure that requires intervention. The specialist nurse from the CDLT provides an annual training session for all staff to ensure they know what to do when someone has a seizure and how to administer medication. We looked at the medication administration records and storage in the home. The homes medication procedure was last reviewed in 2000 and there was no policy for homely remedies included in it. However, the staff told us that the Care Quality Commissions guidance and the Royal Pharmaceutical Society Guidance for Care Homes were available from the homes computer. We recommend that these guidance are printed and kept for ease of reference, and that the homes medication procedure is reviewed and updated. There was some excellent information about the medication for each person, to include the use and side effects. However, the administration folder was so bulky with information it was not easy to access the Medication Administration Record (MAR) sheets when administering. The protocols for epilepsy should remain with the administration records, all other information could be in a separate folder for reference when required, which may make administration records more easily accessible. The homely remedies agreed by the two GPs had been listed and signed by them. However, there was no indication of how many doses should be administered before contacting the doctor. There was a audit of the homely remedies every time they were administered, which is good practice and a clear record of who had been given the remedy. We recommend any medication given is recorded on the back of the MAR to enable the amount administered to be reviewed. Two homely remedies had been administered that were not on the doctors list, which the senior carer agreed to rectify with the doctor immediately. We were informed this had been completed the day after the inspection. The home uses a monitored dosage system to administer medication. We looked at the controlled drugs record and observed staff checking the records, a monthly audit is completed for this medication. The controlled drug storage should be updated to provide a rag and rawl bolt fixing to the wall to comply with the latest regulations for Safe Custody. We completed two spot checks of medication not on the monitored dosage system and both were incorrect, which was probably due to staff not recording at the beginning of each month how many tablets were in stock. We recommend that all tablets not on the system are dated when the container is opened and a total carried forward to the Care Homes for Adults (18-65 years) Page 20 of 34 Evidence: new MAR sheet. A monthly audit should be completed for all medication. We were told that staff who order medication see the original prescription before ordering from the local chemist. We looked at the medication records which were generally well completed. An error was noted for one medication that should have been stopped for one day and had been signed as given. When Warfarin is stopped for one day all strengths should have a zero mark to indicate to staff not to give it to avoid mistakes. After discussion with the senior carer it was apparent that the Warfarin had been signed by mistake but not given, as advised by the hospital. We looked at the system for recording changes in Warfarin doses, this was correct. We advised the staff that some foods should be avoided by people taking Warfarin as the individual guidance indicated. The senior carer copied this information for staff preparing food to be aware of. All staff that administer medication have completed an accredited medication course or a National Vocational Qualification (NVQ) 3 in medication and they update their knowledge annually with an e-leaning course on the computer. Staff are observed six times to help ensure they are competent before they administer medication independently. A British National Formulary medicating reference book was available and the home is signed up to the website to access the latest information about medication. Care Homes for Adults (18-65 years) Page 21 of 34 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. The home has a complaints procedure, however, staff rely on visual communication to help ensure that people are satisfied. Relatives and friends are included in reviews and where possible are consulted about any changes in the care plan. People are safeguarded from abuse as staff have suitable training and there are procedures to follow. Evidence: There had been no complaints recorded in the last twelve months and the staff told us that any concerns from families or friends are usually dealt with on a daily basis. The staff told us they have a good relationship with relatives and friends and regularly provide transport to enable them to visit the home. We spoke to one relative on the telephone and she told us the staff could not do anything better, she also said that the home provides transport to enable her to visit. The relative told us she would speak to the person in charge if she had any concerns, and felt that the staff could identify distress in her relative better than she would. The home plans to complete individual complaint formats to suit peoples communication needs. Care Homes for Adults (18-65 years) Page 22 of 34 Evidence: The AQAA told us that externally facilitated Person Centred Plans are being achieved, which gives people and their family the opportunity to share their views. Staff members have been identified to be part of a Total Communication Group that share ideas and experiences about communication methods. Information gained will be incorporated into the support given to encourage people to share their views. Quality assurance questionnaires are available for friends, family and other health care professionals to provide the manager with additional information to help improve the service. Staff have Protection Of Vulnerable Adults (POVA) training as part of their induction training. We looked at staff training records and most staff had completed specific POVA training in 2006. We recommend that staff update the POVA training. People are safeguarded from financial abuse as personal monies are checked daily by two staff to ensure they are correct. Care Homes for Adults (18-65 years) Page 23 of 34 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 home was clean and fairly well maintained, however some areas required decorating and replacement of carpets. Evidence: We looked around the home which is spacious and allows easy access for wheelchairs. Bedrooms are personalised and individual sensory equipment is included in some bedrooms. The home was clean and fairly well maintained, however, we identified that four bedrooms, a bathroom, a shower room, a toilet and the dining room required decorating. Three bedroom carpets and one bedroom chair, identified, need replacing. In the last twelve months the following improvements have been made; the hallway has been rearranged to provide another seating area, redevelopment of the garden has started to include a sheltered area and sensory garden, the lounge has a new large screen television, lamps and curtains, and the kitchen has a new cooker, microwave and dishwasher. The bathrooms have appropriate equipment to meet peoples needs. Four people required new beds, and this has been addressed since the inspection to include new Care Homes for Adults (18-65 years) Page 24 of 34 Evidence: pressure relieving equipment. Special adaptations for hoisting people and managing their pressure relief were being used. We have some concerns that there is only one carer on duty during the night to help ensure that people are moved and cared for safely and in comfort. As people may not be able to communicate their distress at all times and some staff may be compromised. We recommend that all manual handling procedures are reviewed to ensure that staff of every stature can maneuver people safely. The latest Environmental Health Officer report has been complied with and new fly screens have been fitted. The AQAA told us that a housekeeper has been recruited and has some responsibility to ensure that the home remains clean, safe and comfortable. The housekeeper is also responsible for ensuring all infection control equipment is ordered and stored appropriately. There is a separate laundry area and we recommend that infection control information for the handling of laundry is available there for staff to follow. The AQAA informed us that twelve staff had completed an accredited infection control course in 2008. Care Homes for Adults (18-65 years) Page 25 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has experienced and well trained care staff that are supervised regularly and any training needs are met. There appears to be insufficient staff to met all the needs of the people as activities are limited, and lone night staff may be putting people at risk. Recruitment methods are good and people are safeguarded. Evidence: The AQAA told us that seven care staff had achieved either an NVQ level 2 or 3 in health and social care, and that three staff were working towards an NVQ level 3. The home has two qualified NVQ assessors and one trainee assessor. One team member is a registered nurse and the homes registered manager is involved in a PMLD special interest group. The group is currently looking at the inclusion of people with mutilple disabilities in the recruitment process. A team member has been identified to attend a Total Communication Group where they are able to share and gain ideas from other staff members from other Brandon trust homes. We interviewed three care staff and all were knowledgeable about the people they were the keyworker for and about all the other people in the home. Two of the staff Care Homes for Adults (18-65 years) Page 26 of 34 Evidence: had worked at the home for many years and one had recently transferred from another home. The staff told us that regular formal supervision with the manager helps to identify their training needs and that the manager is approachable and accessible should they have any concerns. We looked at the training matrix and most staff had completed mandatory training which included first aid, manaula handling, fire safety, food hygiene and health and safety. Additional training had been completed by some staff to include many subjects, for example; continence care, achieving equlity and diversity, health issues,Percutaneous Endoscopic Gastrostomy (PEG) feeding and palliative care. We looked at the staff rotas covering a four week period and there were only four morning shifts when four staff were on duty. This means that with three staff on duty people cannot go out as oftenas they should or would like to. Risk assessments indicate that one staff member goes out with one person living in the home. However, the policy used to be two staff to accompany in case emergency seizure control medication did not work. There should always be two staff available in the home. At the weekends there are only three staff on duty and we were told this is insufficient to facilitate care and complete activities for the seven people accommodated who have multiple and complex needs. A recent staffing levels audit was completed for Community Adult Care Directorate (CACD) the staff as part of their annual review. The results indicate that additional staff may be required to meet peoples needs A relative and some of the staff was concerned that there is only one person on night duty, particularly as people need to be changed regularly at night. Also because two staff are required for the hoist most people have to be in bed by 9:15. Should there be an emergency and someone has a seizure or there is a fire there may be a need to have another staff member on the premises at least. We looked at an example of the homes recruitment records for a new member of staff. The records were complete, including interview notes. The Brandon Trust only allow new staff to begin work when a full Criminal Records bureau check has been completed. We also looked at the induction record for the new staff member, which may need updating to ensure all the areas identified from the Skills for Care induction are included. We were told that all staff have a training folder and we looked at an example. Care Homes for Adults (18-65 years) Page 27 of 34 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. The home has a well qualified manager and experienced senior support staff and care staff. When the manager is full time at the home this will help ensure that there is always sufficient staff available. Quality assurance methods are used to improve the outcomes for people and there are plans to include people to help ensure they have more control over their lives. The home has comprehensive health and safety policies and procedures, however, additional staff at night may be required for fire safety. Evidence: The AQAA told us that the new manager has completed NVQ level 2, 3 and 4 in health and social care, and the NVQ level 4 Registered Managers Award. She also has an A1 City and Guilds NVQ Assessor qualification and ten years experience of working within the learning disabilities sector. There are two senior support workers at the home and both have a lot of experience Care Homes for Adults (18-65 years) Page 28 of 34 Evidence: supporting people with a learning disability. A senior support worker was most helpful during the inspection as the manager was unavailable. One senior staff member is a Registered Nurse Learning Disability (RNLD) and one has an NVQ level 3 qualification. The new manager started in December 2008 and we agreed with Brandon Trust that the manager is overseeing the management of two homes in the Trust until March 2010, and divides the time by working three days at Cranham Lodge and two days at Fairhaven, a short distance away. We were also informed that the manager will apply to The Care Quality Commission to become the registered manager for Cranham Lodge. In view of the multiple needs of the people living at Cranham Lodge a full-time manager will be required as soon as possible, and the Trust must ensure that the managers registration is completed before March 2010. The home uses minimal external bank staff or agency staff as they would not be able to meet the multiple needs of the people living in the home as well as the permanent staff. The manager has completed a quality assurance plan, and an action plan. We looked at the action plan for the home, which is used to improve the outcomes for people. The plan included developing the person centred care plans for the people in the home to ensure they have more control over their lives. Much of this work will be fully implemented by March 2010. The AQAA told us that equipment has been serviced or tested as recommended by the manufacturer. It also told us that many of the important policies and procedures relating to health and safety in the home had been reviewed within the last two years. However, we were informed that Brandon Trust are currently reviewing all the policies and procedures in their home. The fire safety policy and procedure was last reviewed in October 2007 and may require updating with the most recent guidelines. Care Homes for Adults (18-65 years) Page 29 of 34 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 30 of 34 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 6 12 The registered person shall 14/10/2009 ensure that proper provision for the care, and where appropriate, treatment, education and supervision of service users. The care plans and risk assessmnets must ensure that the provision of care, in relation to manual handling procedures, can be achieved safely with the current level of staff during the night. 2 12 16 The registered person shall make arrangements to enable people to engage in local and community activities. There should be adequate provision for people to go out more often with regard to transport and staffing levels. 31/10/2009 3 20 13 The registered person shall make arrangements for 31/10/2009 Care Homes for Adults (18-65 years) Page 31 of 34 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 recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The original container and MAR sheet must be with the staff when they administer medication. The homes medication policy must be reviewed and updated. Homely remedy protocols must be complete. Medication not on the monitored dosage system must be dated when opened to ensure that a regular accurate audit can be completed. The controlled drug storage cabinet fixings must comply with the latest regulations as specified in this report. 4 33 18 The registered person shall 31/10/2009 ensure that at all time suitable qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Care Homes for Adults (18-65 years) Page 32 of 34 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 The registered manager must ensure that peoples needs can be met at all times and that there are sufficient staff at night to safeguard people. 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 1 We recommend that alternative formats for providing information about the home are explored for people with a sensory impairment. We recommend that peoples medical conditions are not displayed in their bedrooms to protect confidentiality and uphold dignity. We recommend that people with epilepsy should be able to have support from a consultant neurologist when required. We recommend that any external medication guidance used should be printed for ease of reference. We recommend that there is at least a monthly audit of all medication to help ensure that any errors in administration are rectified. We recommend that staff update their POVA training completed in 2006. We recommend that four bedrooms, a bathroom, a shower room, a toilet and the dining room be decorated, and three bedroom carpets and one bedroom chair, identified, are replaced. We recommend that infection control information, for the handling of laundry is available in the laundry for staff to follow. 2 10 3 4 5 19 20 20 6 7 23 24 8 30 Care Homes for Adults (18-65 years) Page 33 of 34 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). 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