Care Home: Croft Cottage

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What the care home does well The home provides a pleasant and good quality environment in a community setting for users living there. The garden in this sloping site has been designed to facilitate access by a person with a problem in mobility - including a wheelchair user - with ramps, rails and an impact absorbing surface. The needs of users were carefully assessed before transfer to the home. All seven users who moved in when it opened in 2008 were still resident at the time of this inspection. The home provides a good quality and pleasant environment for a group of seven users. Comments from both users and staff provides evidence that the users have gained benefit from the home. Users told us they were very happy living in the home, they were happy with the the support they received from staff and with the environment. Staff told us of the beneficial effect the move to the home had had on users and outlined the positive changes which had taken place since the home opened. The home`s arrangements for planning and providing support to users with complex needs are thorough. The home liaises well with a range of healthcare professionals both at the NSE and in the community. Staffing is stable. No new staff have been appointed since the home opened. This maintains continuity in support of users by staff who know them well. The organisation offers a good programme of training and development for staff. This helps to ensure that users are supported by well trained and supervised staff. What has improved since the last inspection? This was the first inspection of this new service. What the care home could do better: The registered persons must ensure that they have obtained the informed consent of users to use their photographic image in documents such as the Service Users Guide. The registered persons should develop the format of person centred plans to make them more accessible to users of the service. The registered persons should ensure that the home cease using the term `cot sides` in an adult service. `Bed rails` is an alternative. The registered persons should arrange for an audit of the homes arrangements for the control, storage and administration of medicines to be carried out.The registered persons should ensure that the home review its practice for `homely remedies` and establish a practice which conforms strictly to an approved policy governing the use of such products. The registered persons should ensure that all areas of carpeting in the home are maintained to a good standard of cleanliness. The home should establish a methodology for conducting a periodic survey of stakeholders in the service. This must include service users. The registered persons should establish a development plan for the service covering the period 2010 to 2012. Key inspection report Care homes for adults (18-65 years) Name: Address: Croft Cottage 17 Rickmansworth Lane Chalfont Common Chalfont St Peter Bucks SL9 0JY     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: Mike Murphy     Date: 0 9 0 9 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 37 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 37 Information about the care home Name of care home: Address: Croft Cottage 17 Rickmansworth Lane Chalfont Common Chalfont St Peter Bucks SL9 0JY 01494601300 01494876376 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.epilepsysociety.org.uk The National Society for Epilepsy 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 to be accommodated is 7. The registered person may provide the following categories of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical Disability (PD) Learning Disability (LD) Date of last inspection Brief description of the care home Croft Cottage is a seven (7) place care home for service users with epilepsy and learning disability. The home is a service provided by the National Society for Epilepsy (NSE) in Chalfont St Giles, Buckinghamshire. The home is a detached two storey house located in a residential area about one mile from the centre of Chalfont St Giles. It is a short distance from the main site of the NSE (also known as The Chalfont Centre) in Chalfont St Peter. Care Homes for Adults (18-65 years) Page 4 of 37 Over 65 0 0 7 7 Brief description of the care home The accommodation consists of seven bedrooms, all with en-suite facilities. The shared accommodation includes a kitchen, lounge, dining room/conservatory, and laundry. There is a medium sized garden to the rear of the home. Almost all areas are accessible to a wheelchair users - including the garden. Stairs and a passenger lift connect the ground and first floors. The home is staffed 24 hours a day. Users living in the home have access to the social and healthcare facilities on the NSE site (including specialist services for people with epilepsy) as well as those in the local area. Care Homes for Adults (18-65 years) Page 5 of 37 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: This inspection was carried out by one inspector in September 2009. This was the first inspection of this new service and involved assessment of the homes performance against all of the national minimum standards of Care Homes for Adults (18-65). The inspection process included an unannounced visit to the service on Wednesday 9 September 2009. We had previously visited the service in the autumn of 2008 a few months after it opened. The inspection included consideration of information in the annual quality assurance assessment (AQAA) submitted by the registered manager in advance of the inspection, examination of support plans and associated documentation for four users, examination of other documents such as staff training programmes, accident records, the services statement of purpose and its service user guide (in both its original text and draft updated picture version). The inspection also included discussion with users on the day of the inspection visit, Care Homes for Adults (18-65 years) Page 6 of 37 discussion with the registered manager and staff, observation of activity, examination of the homes arrangements for the control, storage and administration of medicines, and inspection of the home environment and garden. Care Homes for Adults (18-65 years) Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: The registered persons must ensure that they have obtained the informed consent of users to use their photographic image in documents such as the Service Users Guide. The registered persons should develop the format of person centred plans to make them more accessible to users of the service. The registered persons should ensure that the home cease using the term cot sides in an adult service. Bed rails is an alternative. The registered persons should arrange for an audit of the homes arrangements for the control, storage and administration of medicines to be carried out. Care Homes for Adults (18-65 years) Page 8 of 37 The registered persons should ensure that the home review its practice for homely remedies and establish a practice which conforms strictly to an approved policy governing the use of such products. The registered persons should ensure that all areas of carpeting in the home are maintained to a good standard of cleanliness. The home should establish a methodology for conducting a periodic survey of stakeholders in the service. This must include service users. The registered persons should establish a development plan for the service covering the period 2010 to 2012. 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 37 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 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has good arrangements in place for assessing the needs of prospective users and for deciding whether it can meet those needs. However, the information it provides to prospective users, their families and referring professionals now requires updating. Evidence: The homes Statement of Purpose was reviewed in April 2008 - a few months before it opened in the summer of that year. The document outlines the organisation of services at the National Society for Epilepsy (NSE) in Chalfont St Peter. It goes on to say that Croft Cottage will be registered with the Commission for Social Care Inspection (CSCI), the former regulatory body for social care services. It describes the purpose of the home, the number of rooms, the facilities available, staffing, information on the manager, the arrangements for admission, care planning and discharge, a description of how the service seeks the views of residents, how to make a complaint, its arrangements for maintaining contact Care Homes for Adults (18-65 years) Page 11 of 37 Evidence: with relatives and friends, the arrangements for proprietors monitoring of the home, the languages and communication skills available, and the objectives for the home for ...the next twelve months (i.e. from April 2008). The document is informative and includes most, but not all, of the information required by the regulations. This inspection was carried out in September 2009 and the Statement of Purpose should now be reviewed and updated. It should reflect the service as it is now and not as it was before the move from the NSE main site. It should include the information required by the regulations and standards (in particular standard 1.1 and Schedule 1 of Regulation 4). The Service Users Guide was being updated at the time of this inspection. This was work in progress on the day of the inspection visit. The draft document was a very colourful and informative guide to the home. The registered manager told us that further work was needed and this would take account of the need to include the information required under the standards (in particular standard 1.2). The draft document includes photographs of current users and the registered persons will need to ensure that issues of consent relating to the inclusion of such images in the document have been addressed before the document progresses to completion. The NSE has well established systems in place for assessing the needs of prospective users of its service. Croft Cottage is required to conform to those processes. All the current users of this service were living together in another home before it opened. In the lead up to opening the service the needs of prospective users were carefully assessed. For those selected a series of meetings, move on meetings, were held over the course of the year preceding the move. These included the prospective user and their families as well as professionals, such as care managers, involved with them. The meetings provided an opportunity for all parties to discuss any concerns they had about the suitability of the home for each user. The process seems to have been successful. All seven users who moved into the home when it opened are still living there. More importantly, during the course of our visit, users expressed a high level of satisfaction with the home. Staff report a significant increase in independent living skills among many users. The admissions process includes consideration as to whether the home can meet a prospective users needs, provision for a visit to view facilities, and for an initial one Care Homes for Adults (18-65 years) Page 12 of 37 Evidence: month admission. At the end of the months, earlier if indicated, a review meeting with all parties is held. A permanent place is offered if all parties agree. This is a specialist service and staff qualities and skills to meet a persons needs are established through the organisations arrangements for recruitment, induction, training, development and supervision. These are supplemented by the skills of the health and social care professionals who are based on the main NSE site. The contract relating to an individual user of the service is agreed between the NSE and the funding authority. Care Homes for Adults (18-65 years) Page 13 of 37 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. Care plans are comprehensive and detailed and support the organisation and provision of care appropropriate to each users needs. Evidence: A support plan is in place for each user of the service. Support plans are comprehensive but the present format is not person centred in terms of accessibility to users. While the overall standard of support planning is good - very good in places the format is unlikely to engage service users in the process. There were signs that the home was beginning to address this. The draft Service Users Guide using scanned in images (although the important issue of user permission will need consideration by the organisation), a large print easy read section in support plans, and, in the case of one user, entries by a user in their daily diary may be evidence of this. These intiatives should be developed further over the coming year. Care records for users at present comprise four documents: (1) support plans, (2) medical records, (3) daily folders, and, (4) medicines administration records. Care Homes for Adults (18-65 years) Page 14 of 37 Evidence: The present suport plans include personal information on the user, a pen picture, photograph, their likes and dislikes, risk assessments, support requirements and a night care plan. One section entitled Clinical Management Plan is focused on the users epilepsy. Another section Care Plan is in large print and easy read format covers (among other items), diet, eating and drinking, exercise, bathing, communication, dressing, sleeping and waking, medication, home chores and engagement in society. Daily notes are recorded three times a day in a diary for each user. The quality of these records was generally very good - in some cases excellent. In one record it was noted that the service user had made entries on some days. This is a good practice and is a useful addition to the staff entry for that period. Evidence of annual reviews was noted. The care of six of seven users living in the home had been reviewed with the funding local authority since it opened, only one ws awaiting such a review. However, some of the care plans examined included documents which did not appear to have been reviewed for some time. One example was a self-medication assessment which in the case of two users did not appear to have been reviewed since 2006. In another plan the section on goals and action plan wasnt dated so it was difficult to say whether it had been reviewed. Some risk assessments in one file appeared to relate to the former home, Victoria House. One care plan stated that the user could have contact with an advocate but the manager told us that the home did not currently have contact with an advocacy organisation. The relationship between users and staff appeared good. Users seemed at ease with staff. Users and staff hold house meetings together. Users are involved in discussions on activities, trips out, shopping and menus. Users are invited to contribute to reviews of their care plans. The home had a comfortable ambience which encourages communication. Risk assessments cover a wide range of activities. In the care plans examined risk assessments covered (among others), accessing the community, using a wheelchair, using the shower, risks associated with mealtimes, swimming, the use of cot sides (a term which should now read bed rails),use of electrical equipment, using a vehicle, working in the kitchen, self-medication, cycling and use of an adventure playground. However, while risk assessment were considered to be thorough and comprehensive there did appear to be weaknesses in the homes systems for reviewing them. In one case some of the risk assessments still referred to the previous home, and in some Care Homes for Adults (18-65 years) Page 15 of 37 Evidence: cases, those relating to self administration of medicines did not appear to have been reviewed since 2006. Those risk assessments may still be valid. They should however, have been reviewed on the move to Croft Cottage and at least once since then. Arrangements for dealing with confidential information are satisfactory. Care Homes for Adults (18-65 years) Page 16 of 37 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. Users are supported in experiencing a range of activities both within the home and the wider community and in developing practical skills. Evidence: Service users plans are recorded in the weekly diary section of their support plan. Support plans include details of each persons likes and dislikes. Within the home users have a range of opportunities to develop practical skills such as cooking, doing laundry and household chores. the home had a pleasant atmosphere throughout our visit and users were noted to mix well together and with staff. The home provides for individual interests such as reading, watching television or just taking it easy. It also offers opportunities to participate in activities with others. Users attend activities run on the NSE site which is about a five to ten minute walk Care Homes for Adults (18-65 years) Page 17 of 37 Evidence: away. These may include sports such as tennis, cycling or squash as well as events such as bingo, discussions, performing arts or discusions. Some users go to college in Amersham and Uxbridge. No user was in employment at the time of this inspection although a number have had jobs in the past. Staff told us that they would support any user who wished to pursue employment in future. Users appear to maintain good links with the community. Although the homes main food shopping is delivered, staff and users frequently shop at local convenience stores. Occasional visits are made to cinemas in Uxbridge and Gerrards Cross. Users also go shopping in Uxbridge or Chalfont St Peter. Some users and staff attend social events run by a local Catholic church. The manager said that staff are always present at all times on such occasions. Staff report a significant improvement in users since transferring from the NSE site to the home. One person who was reported to have been quite withdrawn in the previous home was now active and downstairs mixing with users and staff for most of the day. A reduction in the frequency of seizures was observed in another. Another user who was also reported to have been withdrawn, inactive and have poor appetite in the previous home was now reported to be chatty, eating well and mixing with others. The users we met during the inspection were all very positive in their views of the home. Users and staff have had breaks in Bognor Regis and Blackpool so far this year. The NSE makes a contribution toward the cost of a holiday. Most users are in contact with their families and some have gone on holiday with them. The manager told us that the home was looking towards more short breaks later in the year. Meals are planned and cooked by staff with some assistance from users in the home. The manager said that the menus is based on a four week rotating menu. There is an alternatives list for users to select an alternative to the planned menu item on any given day. Breakfast is served between 7:00 and 9:30 am and consists of cereal, fruit, toast or crumpets and hot drinks. Lunch is served around noon and is a light meal such as Cornish Pasty and Salad, Mushroom Croquettes or Cheese with bread or biscuits and grapes. Dinner at around 6:00 pm is the main meal of the day and consists of a main course with vegetables followed by dessert. The alternatives list consists of 18 or so items and includes such dishes as Quiche, Vegetable Burgers, Gammon Steak and Tomato soup. Meals are served in the dining room. The manager told us that a dietician would have advised on the nutritional content of the menu when it was being drawn up. More recently the advice of a dietician had Care Homes for Adults (18-65 years) Page 18 of 37 Evidence: been sought in relation to three users. A speech and language therapist had advised on swallowing problems experienced by another user. Users are weighed monthly or more often if required. Care Homes for Adults (18-65 years) Page 19 of 37 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 health and personal care needs of users of the service are well met and promote health and well-being. The homes arrangements for the storage and administration of medicines are generally satisfactory but some aspects of practice should be reviewed with a pharmacist to ensure that users receive medication in a safe and consistent manner. Evidence: Staff have good knowledge of service users needs and preferences having moved to the home with them in 2008. Details of users likes and dislikes are recorded in their care plans. The home offers a good level of flexibility which accommodates the varying needs of individuals. At the same time the staff and users have established a routine together which addresses individual and group needs. The home has a number of technical aids to assist users. These include a staff call system, ceiling mounted tracking hoists (in one users room and in a bathroom), support rails around WCs, wheelchairs, an assisted bath, a wheelchair ramp from the street and in the garden, handrails and an impact absorbing surface is a number of Care Homes for Adults (18-65 years) Page 20 of 37 Evidence: areas in the garden, and a passenger lift which can also accommodate a wheelchair. Service user healthcare needs are recorded in their support plans. The quality of such entries was generally good, particularly those that apply to epilepsy. All users are registered with a local GP group practice and with a neurologist. Most healthcare services are provided through the main NSE site. The manager told us that as a result of discussion between the service and the GP users were now being seen more often in the GP surgery. It is said that this begins to reflect a shift away from the established practice of users being seen in the GP surgery on the main NSE site which normally takes place on Tuesday mornings. This is a positive development. Users have access to a wide range of medical services through the NSE. These include neurology, psychiatry, specialist epilepsy nurses, psychologists, occupational therapists. First Line nurses (general nurses). Evidence was also noted in support plans of the involvement of a dietician and speech and language therapist. In its AQAA (Annual Quality Assurance Assessment) the home states that it is ...planning to use community healthcare services more. Providing users arent disadvantaged then this would be a move in the right direction for a service which is now based in the community. The service should look to that community to provide the services required by users. Staff practice with regard to the administration of medicines is governed by NSE policy (last reviewed in March 2005) and practice. Medicines are prescribed by the users GP, neurologist or specialist epilepsy nurse. Medicines are dispensed by the pharmacy on the main NSE site. Systems are in place for recording medicines received in the home and those returned to pharmacy. Systems are also in place for recording and reporting errors in administration. The NSE carries out periodic audits of medicaation errors across its services. Staff are trained by attending an in-house course on Medication Management run by the NSE. Update training is provided every two years for those staff who have already done the basic course. Competence is assessed in the home by the manager or deputy manager. Training in the emergency use of rectal diazepam or buccal midazolam is provided by the specialist epilepsy nurse. The arrangements for the storage of medicines are generally satisfactory. There is a lockable medicines cabinet in each users room - a good practice and more comprehensive storage facilities in the staff office. We were told that medicines requiring cool storage would be kept in a lockable container in one of the refrigerators. Care Homes for Adults (18-65 years) Page 21 of 37 Evidence: Examination of the homes practice gave a mixed picture. Medicine records included a photograph of the service user. In general the home appeared to be conforming to NSE policy and practice. Medicines were correctly prescribed and medicine administration records (MAR charts) were generally completed appropriately. It was noted on one chart that an item which had been prescribed had not been recorded as administered for some period of time. The staff on duty at the time were unable to account for this. It was also noted that a medicine cupboard included a stock of Vick Vaporub and Lemsip. The home also had a stock of Paracetamol. Lemsip is an over the counter medicine which includes paracetamol and other substances. Lemsip may interact with other medicines and may be contra-indicated in some circumstances. The home should have a very clear policy on the use of homely remedies. This should conform to current good practice such as that outlined on minor ailments in the current guidance on medicines in social care published by the Royal Pharmaceutical Society of Great Britain. The registered manager contacted us the day after our visit and informed us that the item which had not been recorded on the MAR sheet was a pressure bandage which the GP had prescribed on a repeat basis.This raises the question of staff knowledge of medicines prescribed for users. The registered manager undertook to request an audit by a pharmacist of the homes arrangements for the control, storage and administration of the homes practice. This action is supported in this report. A record of the outcome of the audit should be retained for future inspection. The issue of ageing and death is a sensitive one in a service which supports younger adults. At the same time the registered manager and staff acknowledge it is a subject which needs to be considered by the service. The home is part of a larger organisation with experience of this subject and which ought to be able to inform its approach. In the context of a home which has been in operation for just over a year it is accepted that it should keep this matter under review with senior managers. Care Homes for Adults (18-65 years) Page 22 of 37 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 good arrangements in place to ensure that complaints and protection are effectively managed to protect the interests and well-being of users. Evidence: The home is required to conform to the NSE policy and practice on handling complaints. There is a reference to complaints on pages 8 and 9 of the service users guide. This however, simply states that the complaints procedure is on display in Croft Cottage and that further information ....is included in NSEs policy manual. This falls short of the expectation that the service users guide should include a copy of the complaints procedure (Standard 1.2.ix). Summary and pictorial versions of the complaints procedure was on display on a notice board. The home has a procedure for recording complaints. The manager said that no complaints had been recorded since the home opened. According to information provided by the manager the NSE complaints procedure was reviewed in May 2005. We have not received any complaints about this home since it opened in the summer of 2008. The manager reports that the NSE has a policy on safeguarding adults and the prevention of abuse. This was last reviewed in April 2005. The home had a copy of the current version of Buckinghamshire joint agency guidelines on safeguarding vulnerable Care Homes for Adults (18-65 years) Page 23 of 37 Evidence: adults - although this was not readily accessible at the time. It was located after a 20 minute or so search. The manager said that some filing was being reorganised around the time of our visit. The subject of safeguarding is included in the staff training programme. Staff seen during the course of our visit to the home had knowledge of the subject and expressed confidence in managers to investigate any concerns. Any user requiring the services of an independent advocate would be informed of contact details for Peoples Voices, a local advocacy organisation. There is no ongoing contact with the organisation however. Most of the users in this home are in contact with their families. Parents maintain a strong interest in the welfare of the users. While on the one hand this is a strength of the service, it is also important that users have access to independent support. The staff training programme includes training on responding to challenging behaviour. Staff have had experience of such behaviour on occasions. The homes arrangements for dealing with users money were in the process of change at the time of this inspection. These were formerly managed through the finance department on the NSE site. At the time of this inspection the manager informed us that at the end of August 2009 an account had being opened for six of seven users at a branch of either the HSBC or Natwest bank in Chalfont St Peter. Many families play a role in supporting users in managing their money by acting as appointees. It was planned that the bank accounts would be joint accounts in the names of both the appointee and service user. The home has a safe for storing money and valuables where required. There is also a lockable cupboard in each room for storing items of value. Records are maintained of all transactions and receipts are maintained. The manager told us that, at a minimum, balances are checked and reconciled weekly with additional checks on a random basis. On the day of our visit to the home its arrangements were being checked by an internal auditor. Care Homes for Adults (18-65 years) Page 24 of 37 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 provides a very good standard of accommodation for users of the service. It is well located for the amenities of the local area. Evidence: The home is a detached two storey house located in a residential area about one mile or so from the centre of Chalfont St Peter. There is limited car parking to the side of the house and in nearby streets. The nearest rail stations are Gerrards Cross, Amersham or Little Chalfont - all some distance from the home. We are informed that there are buses to Chalfont St Peter, Uxbridge and Slough at approximately 40 minute intervals during the day. The home has its own small vehicle for local travel and has access to larger vehicles via the NSE site. There is a ramp for disabled access from the footpath to the front door. Practically all areas of the home are accessible to a wheelchair user. The ground floor accommodation comprises entrance hall, lounge, conservatory with dining room, kitchen, ancillary room, laundry, offices, staff sleep-in room, WC, bathroom with assisted bath, ceiling hoist and wc, and four bedrooms. A ceiling hoist has been fitted in one bedroom to meet the needs of the current user. Care Homes for Adults (18-65 years) Page 25 of 37 Evidence: Stairs and a passenger lift lead to the upstairs accommodation which comprises three further bedrooms and store areas. All bedrooms have en-suite facilities (shower, wc and handbasin). The home has a pleasant and good sized garden to the rear with access from the car park and dining room. Ramps have been installed in the garden to facilitate wheelchair access on a sloping site. Some areas of the garden have a non-slip impact absorbing safety surface. The garden is reasonably secluded through wooden fencing, shrubs and trees on the boundary. The garden has two areas for seating - a patio area by the house and another area towards the centre of the garden. There is a lawn, flower beds, shed, and greenhouse. Tomatoes were being grown in one area of the garden. Entry to the home is overseen by staff. On the day of our visit we were let in by a service user living in the home who immediately referred us to the manager. The overall standard of accommodation is good and the home seems to fully meet the needs of current users. All bedrooms have en-suite facilities. This is an older style building and bedrooms vary in size and layout. Those seen during the course of our inspection visit were bright and pleasantly decorated and personalised by the occupant. All bedrooms have two lockable cabinets - one for medicines and one for storing valuables. Furniture included a bed, bed side cabinet, armchair and wardrobe. Users have TVs, music centres, games, in one case a phone, notice boards, photographs and pictures according to their individual interests. All rooms have a staff call system with staff carrying pagers to respond if needed. Residents expressed a high level of satisfaction with the home. The main areas of activity during the day are the lounge and dining rooms. These are separated by a folding door which can be closed to form two separate rooms (useful for meetings or separate activities) or opened to form a single room. The lounge area is a pleasant room with sofas, large screen TV, stereo, books etc. The dining room is in the conservatory and is a pleasant and bright area. The kitchen is reasonably spacious and suitably equipped for current use. It was clean and well organised on the day of this inspection. The refrigerators and freezers are in small room adjacent to the kitchen. This room, which may once have been a store room, is at a slightly higher level than the kitchen. Care Homes for Adults (18-65 years) Page 26 of 37 Evidence: The laundry is sufficiently equipped with new equipment for current use. It too was well organised, tidy and clean on the day of inspection. In addition to the en-suite facilities there are two WCs (one of which has some adaptations for a disabled person) and an assisted bath which also has a jacuzzi function. There is a ceiling track mounted hoist for use if required. A mobile hoist is also available. There is some pressure on storage space and this will needs to be carefully monitored by managers. Standards of housekeeping are good. However, while most areas of the home were clean and tidy, the stair carpet, which is a light colour, would benefit from cleaning. Care Homes for Adults (18-65 years) Page 27 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is supported by the NSE Human Resources department in maintaining good standards in staff recruitment, training and development. This ensure that users are supported by staff with appropriate qualities and skills. Evidence: Staff are appointed in line with the policies and procedures of the NSE. All staff have a job description provided as part of the application pack by the human resources (HR) department. Copies of the GSCC codes of conduct are issued to staff as part of their induction programme. The qualities and qualifications of prospective staff are assessed during the course of the appointment, induction and probation period. The home employs 17 staff. This number provides for four staff in the morning, four staff in the afternoon and evening, and one waking (8:00 pm to 7:00 am) and one sleep-in staff at night. The staff structure is comprised of the manager, deputy manager, team leaders, shift leaders, and support workers. The home has not been required to use agency staff since it opened. Staff and users of this service transferred from another home, Victoria House, which was located on the main NSE site. No new staff were appointed in connection with the move and no new staff have been appointed since the home opened in the summer of Care Homes for Adults (18-65 years) Page 28 of 37 Evidence: 2008. The home is supported in the recruitment of staff by the organisations Human Resources department. Staff records are held at the offices of the department and good standards of practice have been noted on previous inspections of this organisation. Because no new staff had been appointed staff records were not examined on this inspection. It is the responsibility of the registered manager to maintain a checklist of key information held on individual members of staff by the HR department. Staff have access to a comprehensive programme of training run by the NSE. This includes mandatory training such as Basic Life Support, Emergency Aid, Challenging Behaviour, Epilepsy Awareness, Fire Safety, Food Hygiene, Immediate Life Support, Infection Control, Medication Management, Moving and Handling, and Safeguarding Adults. The training programme for the final quarter of the calendar year to December 2009 also included training in management (disciplinary and capability procedures, and, Vetting and Barring), Shift Leader training, NVQ, and COSHH. Training workshops for service managers during the final quarter of 2009 and for 2010 include Service User Empowerment, Quality Assurance, Care Plans, and Audit of supervision, seizures, and medication. The manager told us that staff also have access to training events run by Buckinghamshire County Council. Subjects have included Learning Disability, Bereavement, Leadership, Inspection, Grievance and Harrassment, and Diversity. Two staff had acquired NVQ at level 3 and five, NVQ at level 2. Two staff were pursuing NVQ at level 3 and five staff at level two. It was expected that staff would complete their NVQ training by the end of 2009. Personal staff supervision is established in the home. Supervision sessions are planned in advance. Notes are taken using a Support and Supervision proforma. They include action notes and are signed both by the supervisior and the supervisee. Staff seemed very satisfied with the move to Croft Cottage. They told us that the introduction of rotation (where staff work day and night shifts and there is not a separate night team) had improved communication and ensured greater consistency in working with users. Staff reported having more time to spend with users and also noted an improvement in team working. Care Homes for Adults (18-65 years) Page 29 of 37 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 management and administration of the home generally promotes a good standard of service to users. This could be enhanced by the formulation of a development plan which builds on the strengths identified over the last 18 months. Evidence: The registered manager is a registered nurse in the field of learning disability. The manager has a Diploma in Management and is experienced in NHS services in learning disability and autism. The manager has worked at the NSE for around three and a half years and has managed this particular service since it opened 14 months or so ago. The manager is also responsible for the management of a 17 place home on the NSE site. That home is scheduled for closure in 2011. Management time is currently apportioned as three days a week for Croft Cottage and two days for the other service. The manager maintains his knowledge and skills by attending training events run by the NSE. There is also a deputy manager in post. Care Homes for Adults (18-65 years) Page 30 of 37 Evidence: Certificates were displayed as required by Regulations. With regard to the ethos of the home the registered manager said that it aims for the following: to feel like a normal home, to empower the users living there, to make use of community facilities, to give users choice, to give users freedom, and to Look at positives. From the feedback we received from users and staff, comments in reports of proprietors visits (Reg 26 visits), and reported feedback from families the home has made good progress in establishing itself as a distinct from the former service based on the NSE site. We have referred elsewhere in this report to the positive changes observed in some users since the home opened in summer 2008. The home seems to have made a good start and it now needs to build on this. It did not have a development plan at the time of this inspection. The manager said that this work was scheduled for the coming winter. It was expected that a clearer sense of future direction would be in place by the first quarter of 2010. This may include indicators of progress and attainment. There was no question that the users we spoke to were enthusiastic about living in the home. Staff were enthusiastic too and noted positive changes in most users - some changes quite significant in contrast to behaviour noted in the former home. We were also told that users were making greater use of local community services. Increasing community involvement was in part a consequence of moving to a new setting, in part a consequence of changes at the NSE, a reflection perhaps of a slightly higher staff ratio for users, and in part driven by external factors (such as the requirement to open service user accounts with a High Street bank). Whatever the reasons, we did not speak to anyone who thought that users had not gained from the establishment of the home. There did however, appear to be a concern that the potential for further development may not be realised. A development plan covering the next two years or so, drawing on the views of a range of stakeholders,including service users, would address these concerns and guide the future development of the service. The home has not carried out a survey of stakeholders since it opened. The manager believes that now, around 15 to 18 months after opening, might be a good time to conduct such an exercise. Proprietors visits (Reg 26 visits) are carried out monthly by trustees of the Care Homes for Adults (18-65 years) Page 31 of 37 Evidence: organisation. Reports are filed after each visit and copies of recent reports were seen during our inspection visit. The home is involved in the audit of medication errors and untoward incidents which are coordinated by the NSE. The manager told us that feedback from relatives and professionals on the home had been positive. We received positive feedback from users and staff. Although the home has details of a local independent advocacy organisation it is not in regular contact with it. The manager told us that the parents of service users form a strong body which acts in the interest of users. We have no doubt that this is the case. There are however, occasions when service users benefit from an independent voice. The home is required to conform to the policies and procedures of the NSE. These are formulated and reviewed by senior managers of the organisation. There is an extensive policy manual governing a wide range of activities. To a large extent record keeping in the home is governed by NSE policy. While most records were maintained in good order it was noted that accident and incident records were loose filed and included records from 2007 - before the home opened. It was also noted that the Buckinghamshire joint agency policy on Safeguarding Vulnerable Adults was not readily accessible at the time of inspection. This was attributed to administrative changes which were under way in the home at the time of our visit. This is a new service in a former nursing home which has been completely refurbished and adapted for current use. The quality of the environment is good. All the equipment such as baths, tracking hoists, emergency call system, lift, kitchen and laundry equipment is new. A relatively minor modification to the interior has been made since opening. This has not affected service user accommodation. While no one can be complacent about health and safety matters our inspection has not raised any matters of serious concern. The home was advised that the homes water supply had tested positive for Legionella bacteria in August 2009. An independent consultant had advised on control measures and treatment and at the time of this inspection in September 2009 the manager told us that measures were in place to minimise the risk of infection. The home is subject to the Health and Safety policies and procedures of the NSE. The NSE provides regular training to staff in health and safety matters. These include moving and handling, infection control, first aid, food hygiene, and fire safety. This is provided at basic and update level. Care Homes for Adults (18-65 years) Page 32 of 37 Evidence: Standards of housekeeping were good. The garden was tidy and did not present any obvious hazards to users. the kitchen was clean and tidy. Foods in the fridge which had been opened were labelled appropriately. The temperature of food served is recorded on the menu for that day. Systems are in place for recording accidents and incidents. Forms are completed and copies forwarded to a health and safet adviser based at the NSE. 11 forms were examined. As noted earlier these are loose filed. The majority of forms related to falls experienced by users. The service appears to have good arrangements in place for conducting risk assessments and numerous assessments were noted while examining user support plans. However, as noted earlier, a small number did not appear to have been reviewed during the previous 12 months. The overall management of the home is the responsibility of the NSE. The home is supported by the organisations management and administrative processes. Lines of accountability both within the home and to the larger organisation are clear. Care Homes for Adults (18-65 years) Page 33 of 37 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 34 of 37 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 1 5 The registered persons should ensure that a service users guide, in a form that is accessible to users and which includes the information outlined in standard 1.2, is made available to each user of the service. So that users of the service have a straightforward guide to what the service offers. 30/11/2009 2 1 4 The registered persons must 30/11/2009 ensure that the statement of purpose is up to date and that it includes the information required under Schedule 1 So that all stakeholders have up to date information on the service. 3 20 13 The registered persons must 30/11/2009 ensure that the homes arrangements for the control and administration of Page 35 of 37 Care Homes for Adults (18-65 years) Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action medicines protect the interests of users of the service. To ensure that the homes arrangements for control and administration protect users from errors in administration. 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 Care Homes for Adults (18-65 years) Page 36 of 37 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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