Care Home: Douglas Jackman House

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What the care home does well People have person centred care plans that they have been involved in.People who live at the home are given support to enjoy their leisure time and do things in the community.Managers and staff are caring and like to work with people who live at the home. They want to improve things at the home. What has improved since the last inspection? At the end of the key inspection in 2007 there was nothing that the home needed to do. What the care home could do better: It is important that information about the home is right so they know if it is the right place for them.People can only come to live at the house if the staff know how to care for and support them and they can safely live with other people at the home. If things change staff need to reassess their needs. Care plans must include all the information about people, be kept up to date so that staff know what care and support people need.Risks need to be assessed and managed so staff know what to do so they can keep people safe.Information about people must be kept private so that other people cannot see it.People must see health workers when they need to, to make sure that they stay well.Staff need to make sure that medication is given safely.People who use the service must be protected from, abuse, neglect and harm.The two people who share a room must be given the choice to have their own bedroom.There need to be more staff on duty at night to meet people`s needs.Staff need to be trained in how to care for and support all of the people who live at the home.The management of Douglas Jackman House needs to improve to make sure that people are safe and live and benefit from a well run home. Key inspection report Care homes for adults (18-65 years) Name: Address: Douglas Jackman House 1 Weymouth Avenue Dorchester Dorset DT1 1QR The quality rating for this care home is: zero star poor 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: Jo Johnson Date: 1 4 0 4 2 0 1 0 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Care Homes for Adults (18-65 years) Page 2 of 44 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 44 Information about the care home Name of care home: Address: Douglas Jackman House 1 Weymouth Avenue Dorchester Dorset DT1 1QR 01305251598 01305268972 g.joslin@dorset-cc.gov.uk www.dorsetforyou.com Dorset County Council Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Gillian Caroline Joslin Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 14 0 care home 14 learning disability Additional conditions: Staffing levels must be those determined in accordance with guidance recommended by the Department of Health. Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 44 A bit about the care home Douglas Jackman House is is a large house in Dorchester. Up to 12 people can live at the home. It is a three-storey house, with one shared ground floor bedroom and the others on the first and second floors. There is a car and a bus service. It is close to the shops. Care Homes for Adults (18-65 years) Page 5 of 44 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: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 44 How we did our inspection: This is what the inspector did when they were at the care home Two inspectors visited the home. We decided to inspect because we had concerns that people in the home may not be safe. We looked at information we received about the home. We looked at records about how the home is run, as well as health and safety records, staff training, recruitment, care plans and activities. Care Homes for Adults (18-65 years) Page 7 of 44 We spoke to people who use the service, we observed life in the home, and we spoke to staff and the manager. What the care home does well People have person centred care plans that they have been involved in. People who live at the home are given support to enjoy their leisure time and do things in the community. Care Homes for Adults (18-65 years) Page 8 of 44 Managers and staff are caring and like to work with people who live at the home. They want to improve things at the home. What has got better from the last inspection What the care home could do better It is important that information about the home is right so they know if it is the right place for them. Care Homes for Adults (18-65 years) Page 9 of 44 People can only come to live at the house if the staff know how to care for and support them and they can safely live with other people at the home. If things change staff need to reassess their needs. Care plans must include all the information about people, be kept up to date so that staff know what care and support people need. Risks need to be assessed and managed so staff know what to do so they can keep people safe. Information about people must be kept private so that other people cannot see it. Care Homes for Adults (18-65 years) Page 10 of 44 People must see health workers when they need to, to make sure that they stay well. Staff need to make sure that medication is given safely. People who use the service must be protected from, abuse, neglect and harm. The two people who share a room must be given the choice to have their own bedroom. Care Homes for Adults (18-65 years) Page 11 of 44 There need to be more staff on duty at night to meet peoples needs. Staff need to be trained in how to care for and support all of the people who live at the home. The management of Douglas Jackman House needs to improve to make sure that people are safe and live and benefit from a well run home. Care Homes for Adults (18-65 years) Page 12 of 44 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Jo Johnson Colston 33 33 Colston Avenue Bristol Avon BS1 4UA 01179307110 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Care Homes for Adults (18-65 years) Page 13 of 44 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 14 of 44 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. At present people do not have access to information about the service in a format they can understand. Information about the service does not give an accurate picture of the provision. Peoples needs are assessed but they cannot be sure that the home can meet their complex needs whilst maintaining the safety and well being of others. Evidence: The statement of purpose is not clear on the range of needs of people that the home can support or the age range. The service user guide and statement of purpose are not in an accessible format, the manager told us they are in the process of being updated. There is a service user guide that has been produced using widget (pictures above words). Staff told us that there is only one person who can read so this means that the guide is not accessible to a majority of the people living at the home. The last person to move into the home is now moving on to another placement as the Care Homes for Adults (18-65 years) Page 15 of 44 Evidence: home is not able to meet their complex needs. There are two other people who following the recent safeguarding investigations that have also been identified as inappropriately placed and the home is not able to meet their needs along side the other people who live at the home. From discussion with the manager, staff and from a survey from a health and social care professionals, the most recent admissions into the home have had a negative impact on the safety and welfare of other people living at the home. There is no evidence to support how the people who live at the home are consulted or considered when new people are admitted. There were not any records of any planned visits ( where it was appropriate) and or how other people were asked or their reactions recorded when people visited. We acknowledge that some people with complex needs and behaviours were admitted as emergencies. However, when it was apparent that their behaviours were severely impacting on other people living at the home no action was taken to identify that the home was not able to meet their and other peoples needs. Following the safeguarding investigations, the manager told us that they are now clear that they need to consider the needs of everyone that lives at the home when new people move in. They told us that they will also need to consider the range of needs that the staff have the skills and knowledge to be able to safely support and care for. One person is an older person and they share a bedroom with another younger person. The older persons needs and behaviours are changing as they grow older and are now having a significant impact on the other individual. There has not been any reassessment of this individuals needs regarding the appropriateness of them continuing to share a room with another person. The surveys from health and social care professionals told us that the care services assessment arrangements always (4) or usually(1) ensure that accurate information is gathered and the right service is planned for people. We looked at several contracts and found they are not accessible for people. We could not find any evidence of how they have been supported to understand their contract and their rights. Care Homes for Adults (18-65 years) Page 16 of 44 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and risk assessments are not always detailed enough or completed for all areas identified in assessments to ensure that peoples specific needs are identified and met. Evidence: We looked at the care records for four people. Each person has a minimum of four separate folders kept about them. In addition to this there are activities folders, food facts files and some people also have communication passports. Overall all of the records are complex and include assessments and some irrelevant information that is out of date. There are also organisational care plans, health and social care professional assessments and many different risk assessments. The organisational formats for assessments care plans and risk assessments are in small print and have blocks of print under the headings. It is not easy to access or follow all of the relevant information that staff would need to be able to support an individual. The care plans and risk assessments for two people do not describe how staff are to Care Homes for Adults (18-65 years) Page 17 of 44 Evidence: support individuals when they self injure. There were no risk assessments in relation to one person that bites other people. There has been no acknowledgment of the risks to other people of blood borne infections. The manager agreed to contact the individuals GP to follow this up and identify who has been bitten by the individual. One person who has complex needs that presents challenges to staff and others, has many different documents for staff to follow. However there is information that is mentioned in some documents such as risk assessments or care needs assessments that are the not clearly planned for. For example there have been incidents where staff have been injured by the individual in a public place when the individual was unsettled by a dog. The assessment information and care plan and risk assessments refers to them being unsettled and unsure around children and dogs. However, it does not describe how the individual lets this be known and what and how staff are to support them at these times. This individual is being supported on a one to one staffing basis and this is again included in a separate risk assessment. However, the risk assessment does not describe how staff are to support the individual so that they protect others, keep themselves safe and allow the individual privacy when they need it. One persons needs are changing as the get older. There is some information within the care records that this individual now refuses personal care on a regular basis, has some urinary incontinence, lays in bed for long periods of time during the day and is wakeful at night purposefully waking the other person who shares their room. There were not any pressure area risk assessments in place for this person or plans that detailed how they monitor their individuals refusal to accept personal care, their urinary incontinence and refusal to have creams applied. As previously identified this individual shares a room with another person and their changing needs will be having an impact of the other persons privacy, dignity,well being and being able to access their bedroom during the day. Each person has a Person Centred Plan but these are kept in the office and are not in an accessible format for each individual. There have been goals and aims set when the plans were produced and at review. It was not clear how these goals or aims are reviewed or evaluated on an ongoing basis. Care plans and risk assessments are reviewed in writing on a monthly basis by staff. There is very little personal life history information in peoples plans. Life story works have photographs and items in them that show what the person has been doing in their lives. Staff should develop life story books/works where appropriate and in formats that suit each individual with the people living at the home, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. This means that people can be actively Care Homes for Adults (18-65 years) Page 18 of 44 Evidence: involved in the monthly reviews of their plans and goals. Life history works should be developed where appropriate that include details and photographs of their history such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. There are new staff working at the home so it is important that this information is available to assist staff in getting know the people who live at the home. There are daily records that are kept and personal care checklists, the personal care checklists are inconsistently completed. These records do not reflect how the person has spent their time, how they have been and detail the personal care and support they have received. There not any means for people to be involved or included in the records kept about them. There needs to be further consideration about the language that some staff record in care plans and care records. For example records seen included the statements; when Im told that I cant do something I get grumpy and lash out at people, I throw myself on to the floor xxx was well behaved. There is a communal diary in use that includes personal information about people. All information and recordings about individuals should be in their personal records. Care Homes for Adults (18-65 years) Page 19 of 44 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Further work is needed to ensure that people are supported to participate in activities, attain personal goals and develop their life skills. Evidence: The manager told us in the AQAA that they do the following well:Support service users to maintain good family relationships and contact. Support service users to access a variety of activities, in the home and in the wider community to meet their individual needs. Help people to communicate their daily choices using an increasing range of tools. Encourage and support people to be as independent as possible :- supported self catering and house keeping skills. Assist residents in monitoring their finances and support them to budget. Consult residents about their healthy eating needs and plan menus to suit. Encourage residents to make their own decisions and recognise their rights and choices. We looked at how people are supported to have and achieve goals. These have been identified in Person Centred Plans but it was not clear if these were meaningful for the individuals. For some people the goals had not been reviewed or include details how they Care Homes for Adults (18-65 years) Page 20 of 44 Evidence: are to be achieved. During the visit a majority of the people were participating in community activities at least for part of a day. There is an activities co-ordinator at the home and they are starting work on developing person centred activities planners for people at the home. As identified in the individual need section there is not always the detail in the daily recording of how people have spent their time either in the house or in the community. Surveys from health and social care professionals, parents and advocates commented positively on the community opportunities that have been developed for people. Three of the four staff surveys commented that further work needs to be completed on meaningful activities for people who communicate differently or are not able to make their needs and wishes known. The surveys from people told us that they can always (4) or usually (2) make decisions about what they can do each day. The manager told us in the AQAA that the following improvements have been made in the last 12 months: Person centred portfolios now include all relevant documentation that has been developed for each resident. Family members have worked alongside key staff members to contribute to the development of person centred plans for 2 residents. Residents have enjoyed a greater range of experiences and activities due to the development of community based opportunities during the week. Partnership work with local churches has led to inclusive short services on weekdays being developed to meet the needs of local community, including our residents. One resident is receiving support to take a food hygiene qualification to enable them to work in a charity cafe in the local community in the future. People participate in some of the daily routines at the home. They are supported to do their own laundry, unload the dishwasher and one person assists with vegetable preparation. The limitations of the central kitchen mean that people do not have the same opportunities in developing daily living skills as people who live in smaller houses and with a smaller number of people. We observed lunch, people are supported to go to the kitchen to choose their meals from two plated options. As there are twelve people who live at the home this can take some time and as each table at a time goes to choose this can means that some people become very animated whilst waiting for their food. This can then be difficult for some people who like it to be quiet at meal times. There has been some positive work completed about how best to support individuals at mealtimes. Consideration is being given to one person eating with staff in the upstairs kitchenette. The manager and staff should continue to explore the most person centred ways of supporting such a large group of people with very differing needs in having a relaxed mealtime. Care Homes for Adults (18-65 years) Page 21 of 44 Evidence: People are not involved in the planning or choosing of menus or involved in the shopping for groceries. This should be reviewed and ways of people being involved developed. The kitchen was clean, the fridges and freezers were well stocked there was evidence of fresh fruit and vegetables being used. We observed that some people had tabards on rather using napkins or serviettes. Plastic glasses given to every person regardless of whether there were not any risks of them breaking glass or crockery. These practices should be reviewed. Care Homes for Adults (18-65 years) Page 22 of 44 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people in this home receive is not always based on their individual needs. Evidence: There were positive relationships and interactions observed between staff and the people who live at the home. Staff present as caring and told us that they want to support people in the best possible way they can. The six surveys from people told us that staff always treat them well. We looked at peoples help lists which detail how they prefer to be supported and their preferred routines depending on the time of day. Peoples preference of gender of staff is not actively sought or recorded in peoples assessments or plans. The home uses a key and link worker system to give people continuity in their care and support. We spoke to two of the key workers for people we were case tracking, they were knowledgeable and enthusiastic about the people they support. They were keen to improve they ways in which they support people to make sure the individuals are able to Care Homes for Adults (18-65 years) Page 23 of 44 Evidence: develop their life skills. People receive additional specialist support and advice as needed. One person has recently been referred and assessed by the intensive support team from the Dorset Healthcare Foundation Trust. Surveys from health and social care professionals told us that peoples social and health care needs are always (4) or usually (1) properly monitored, reviewed and met by the care service. We found records for a number of people where there had been inappropriate intimate contact with other people at the home. There is not clear guidance in plans on how staff should support people or how information is given to individuals in ways they can understand on personal and intimate relationships. Staff have not been provided with training on how to safely support and guide people with personal and intimate relationships and expressing their sexuality. People living at the home do not yet have accessible health action plans. Some elements of peoples health records and care plans showed that their right to goodquality health care is being promoted. However, we found examples of where it is not clear whether peoples health issues had been followed up as there are a number of different records and files kept about people. One person had a sore sacrum and groins identified in their care records in January 2010. However there was no body map completed for this and there was no evidence in the medical records that the individual was seen by a General Practitioner or nurse. We found that there was a permanent opt out form from cervical screening for one person with a mark that was accepted as the individuals signature. Staff told us that this person would not be able to understand this form or what they were being asked to sign. This person has also not attended breast screening and there is reference in their care plan that staff must visually check the individuals breasts. It does not specify how often, who should do this and there was not any obvious record that this has been completed. The opt out of screening and care plan must be reviewed. Different ways of explaining to people must be explored so that they are able to make informed decisions about their healthcare where appropriate. We looked at the medication systems and records at the home. The medication policy is dated 2006 and needs reviewing in line with the National Pharmaceutical Society guidelines. There is not any auditing or monitoring system in place to ensure that people are receiving their medication as prescribed. Hand written entries had not been double signed on the medication administration Care Homes for Adults (18-65 years) Page 24 of 44 Evidence: records. Checking and signing hand transcribed directions by two staff is good practice and minimises the risk of errors. There was not any patient information about the medications in use at the home. A number of people have as required medication prescribed. There was not any PRN plans in place for the use of paracetamol. There must be PRN (as needed) medication plans in place. These plans need to include under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. These should be agreed with the prescribing practitioners or learning disability health practitioners where possible. It is recommended that these plans be kept with the administration records so that staff can easily refer to them. The training matrix tells us that only nine of the 41 staff at the home have been trained in the administration of medication. From the information provided by the home only a further three staff have been identified to complete medication training. Care Homes for Adults (18-65 years) Page 25 of 44 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The serious shortfalls in the managers and staffs knowledge and understanding of adult protection means that allegations were not all reported to the relevant authorities and or investigated and people were and continue to be at risk of harm or abuse. Evidence: There have been no complaints made to the Commission about the home since the last inspection. There is a written complaints procedure that is available to people and their families or representatives. This is not accessible to the people who live at the home. The six surveys from people told us that they know who they can speak to if they are unhappy. The surveys from health and social care professionals and relatives , carers and advocates told us that they know how to complain and raise concerns. As some of the people who live at the home communicate in complex ways, written and or pictorial information is not necessarily accessible to all of them. There are some descriptions in peoples plans as to how they let people know when they are unhappy and unsettled. These should be developed further. Further consideration should be given to developing ways of each individual having accessible information about how they can complain or let staff know they are unhappy. Care Homes for Adults (18-65 years) Page 26 of 44 Evidence: Dorset County Council commissioned a safeguarding audit of the home and found many issues of assault between people which had not been properly reported under safeguarding protocols and not reported to the commission. Safeguarding investigations were undertaken for ten people who live at the home as a direct result of the audit undertaken. They were all substantiated for physical and institutional abuse. The management and staff team at the home have been working co-operatively with safeguarding team and us to improve the safety of people at the home. The staff spoken with were keen to acknowledge that there had been serious shortfalls in safeguarding people at the home and wanted to improve the safety and well being of all of the people living at the home. We found that people are still potentially at risk and they are not being supported to live safely in their own home. We found ongoing evidence in the incidents being recorded of individuals targeting and bullying other more vulnerable people in the home repeatedly and no clear immediate plan on how to reduce the incidents of this happening. For example; one person continues to assault both other people and staff even though they are supported on a one to one basis. One person intimidates other people in the use of a downstairs toilet, this person also purposefully wakes the other individual they share a room with. Safeguarding information should be made available to the people who live at the home in a format that is accessible to each individual. This is so that they know who they can communicate with if they dont feel safe or they are worried about abuse. Following the recent safeguarding investigations it is strongly recommended that all staff have a refresher training session in adult protection. The manager is booked on a managers safeguarding training course in June 2010. The whistle blowing policy did not have information on public concern at work and did not have the commissions contact details. People are supported to manage some aspects of their finances. Most people choose to go to the bank to collect their money. We looked at the financial records for the people we case tracked. The monies and records balanced. However, one person had monies in the safe in excess of the amount specified in the policy. The recording system for the finances refers to one staff and service user signature. This is only appropriate where the individual is able to understand their finances and or read the amounts withdrawn. Where the individual is not able to sign all entries should be signed by two staff. The registered provider has since informed us that all transactions are signed by two staff. Page 27 of 44 Care Homes for Adults (18-65 years) Evidence: The manager and staff have made Deprivation of Liberty Safeguard applications as and when necessary. Care Homes for Adults (18-65 years) Page 28 of 44 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home does not enable people who use the service to live in a safe home which promotes independence. Evidence: The house was originally two houses that have been joined together. The living accommodation is set over three floors. Due to the number of people who live at the home with very different and complex needs this means that it is difficult to staff and safely support all of the people who live at the home. This was also identified in a health and social care professional survey. There is a large communal living room, dining room, conservatory and smaller lounge on the ground floor. There is a small kitchenette with a washing machine and tumble dryer on the first floor. However, the cooker is not operational so people are not able to cook there. Three people showed us around the house and their bedrooms. The bedrooms were personalised and reflected the personalities of the individuals. The home was clean and free from any offensive odours. A few people are involved in the daily chores of looking after the house. Care Homes for Adults (18-65 years) Page 29 of 44 Evidence: As identified throughout the report there is a shared bedroom on the ground floor. From discussion with staff and the manager there has not been any meaningful consultation with the individuals about sharing a room. There has not been any acknowledgment by the home or the placing authority that this is not acceptable. Particularly as the behaviours and changing personal and physical care needs of one of the individuals has an impact of the other person. There are established policies and procedures in place for the control of the risk of infection in the home and staff practices during the visit were seen to be safe. Care Homes for Adults (18-65 years) Page 30 of 44 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always sufficient staff on duty to meet peoples needs safely. Peoples needs are not consistently met and they are supported because staff do not get the right training, supervision and support they need from their managers and organisation. Evidence: We looked at the staff rotas for one month. The staffing has been increased since the safeguarding investigations so that one person has one to one staffing during the waking day. However, the staffing levels at night have not been increased. There is only one waking night staff on duty. The manager has undertaken an analysis of the changing needs of one person and determined that the staffing did not need to increase. However, we are concerned that there is one person who targets and injures staff and no consideration has been given to what would happen if the staff member was injured during the night. In addition to this we have also identified that one person is purposefully waking another person during the night and at least one other person has recently been wakeful at night. As identified in the environment section of the report the building is over three floors with two separate staircases to bedrooms. The staff surveys told us that there is only usually (2) or sometimes (2) enough staff to meet the individual needs of all the people who live at the home. We looked at the recruitment files for three staff, we found application forms, health Care Homes for Adults (18-65 years) Page 31 of 44 Evidence: declaration, references, proof of identity letters offering job and CRB and PoVA 1st disclosures for two of the staff. The manager told us that the information for the most recent member of staff was at County Hall. All information relating to staff should be on the premises. As already identified some people living at the home have very complex needs and different ways of communicating. Staff present as caring and want to be able to support people well. However, the staff have not been provided with training to be able to meet the very complex needs of the people at the home. We were sent the staff training matrix following the inspection. Where training has been identified as mandatory not all staff have completed it or has it been updated. There were staff who have not completed the following training: Challenging behaviour ( breakaway training), medication and adult protection. It is not clear from the matrix whether all staff have received any specialist training such as; total communication, Makaton, autism, care of older people, nutritional care, mental capacity training and deprivation of liberty safeguards. We have been sent the training needs that have been identified with individual staff during their annual personal development reviews. The organisation should ensure that staff are trained in the areas identified in their individual reviews and this report. The staff do not all receive regular supervision from their line manager. Staff support people with complex needs and therefore need regular support and supervisions to ensure that they are able to safely meet their needs. Care Homes for Adults (18-65 years) Page 32 of 44 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home do not benefit from or live in a home that is consistently well managed or that has effective monitoring systems. Evidence: There were clear lines of accountability in the home, the management team comprises the manager, and senior care community services officers. During the visit staff appeared confident in their roles, the home was relaxed and people appeared at ease and comfortable. The monitoring and quality assurance systems of the management team and organisation have not identified the shortfalls we have reported and these systems must be improved. The manager told us that they acknowledge the serious shortfalls and that they are keen to improve the quality of the service and safety and well being of the people who live at the home. There are a number of serious shortfalls in the assessment of risks for people, care plans, Care Homes for Adults (18-65 years) Page 33 of 44 Evidence: access to health care, the recognition and reporting allegations of abuse, staff training and the reporting to the commission. There have also been failures in reporting incidents that effect the well being of people to us. We were concerned that monthly regulation 26 visits were not picking up issues in the home. There are house meetings that people can contribute to if they communicate verbally. It is not clear how people who communicate differently contribute or are consulted about their views of the home. The home has recently sent pictorial surveys to people who live at the home. Many of the homes policies and procedures have not been updated for several years ( in some cases 2004). This means that they do not reflect current good practice advice and guidance may not provide the right information to staff. There is no evidence that staff and people who use the service are involved in the development of policies and procedures. Policies are not reviewed and amended. Individual records are not in good order and are maintained in a way which is not always in accordance with the Data Protection Act 1998. Information sent to us in the AQAA (Annual Quality Assurance Assessment) in October 2009 tells us that equipment is serviced or tested as recommended by the manufacturer or other regulatory body. The homes training programme includes mandatory training; fire safety, first aid, food hygiene and moving and handling. However, the training matrix supplied by the home showed that staff are now booked on to mandatory training over the next six months. We are concerned that until recently there has not been any monitoring of whether staff have completed mandatory training. Care Homes for Adults (18-65 years) Page 34 of 44 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 35 of 44 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 2 14 People must only be 01/07/2010 admitted to the home following an accurate full assessment that demonstrates that staff have the skills and knowledge to meet their needs. Peoples needs must be reassessed as their needs change. This is to make sure that people are placed at the right home, and that their needs can be met. 2 6 13 Any areas of risk identified for an individual must be assessed and these assessments must include individual behaviours, self harm or harm to other people, nutrition and pressure area care. They must include descriptions of how staff are to support them. 01/07/2010 Care Homes for Adults (18-65 years) Page 36 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action This is so that any risks are minimised and staff know what action to take to keep people safe. 3 6 15 Peoples care plans must be 02/08/2010 reviewed, kept up to date, and include all the individuals needs identified in their assessments and their wishes and aspirations. This is so staff know what care and support people require to make sure that all their needs are met and they are well cared for 4 19 13 People must have their rights 02/08/2010 to access to healthcare upheld and they are given accessible information about their health so they can be supported to make informed decisions. Current practices may be considered to be institutionalised and may mean that people are at risk by not receiving necessary health checks or having accessible information so they can make these choices themselves about their Care Homes for Adults (18-65 years) Page 37 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action health and lifestyles. 5 19 13 People must have access to health professionals as and when required. 01/07/2010 This is to make sure that peoples health needs are met. 6 20 13 The medication practices at 01/09/2010 the home must be safe. There must be PRN as need plans, handwritten entries must be double signed and staff must be trained in the administration of medication. This is to make sure that people received their medication as prescribed, accurate records are kept and staff are trained. 7 23 13 Action must be taken by the registered persons to safeguard all of the people who live at the home. 01/06/2010 This is to ensure that people are kept safe from institutional, emotional, physical, financial and sexual abuse. 8 24 12 The use of the shared bedroom must be reviewed and reassessed on the basis that the needs of one of the 01/10/2010 Care Homes for Adults (18-65 years) Page 38 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action people has changed. This is to make sure that each individuals rights to privacy, dignity and space is respected. 9 33 18 The manager must reassess whether the current staffing arrangements at night and staffing must be increased. This is to make sure that there is enough staff to meet all of the needs of the people at the home without placing restrictions on any individuals and protecting other peoples right to privacy, safety and undisturbed sleep. 10 35 18 All staff must be trained in all 01/11/2010 of the mandatory areas and specialist training such as: medication, breakaway training, total communication, Makaton, autism, care of older people, nutritional care, mental capacity training and deprivation of liberty safeguards, adult protection and assessing and understanding risks. 01/07/2010 Care Homes for Adults (18-65 years) Page 39 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action This is to make sure that staff have the skills and knowledge to be able to meet peoples needs. 11 39 24 The overall management of 01/11/2010 the home must improve, and develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. 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 The statement of purpose should be updated. The service user guide should be supported by photographs of the home and of key people, such as the staff. This is so that people have accurate, up to date and accessible information about the home. Assessments should include and explore peoples cultural and faith, preference of gender of staff, sexuality and important personal relationships, their finances and their communication needs. This is to make sure that that the Page 40 of 44 2 2 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations home can meet all of peoples needs. 3 4 5 4 5 6 People who are already living at the home should be consulted about any new people who may wish to move in. The contract should be in a format that is accessible to people who live at the home. Individual ways of including people in their reviews and their care plans should be developed. This should include investigating different recording mediums such as photographs, communication in print, DVDs, audio and the computer. This is so people are involved with the records kept about them and have this information in a format or medium that is accessible to them. Care plans ( known as help lists) should be available in language and format the individual can understand. Their plans should be held by them unless clear reasons not to are recorded. Care plans should establish individualised procedures for people likely to be aggressive or cause harm, focusing on positive behaviour, ability and willingness. It is recommended that the monthly reviews collate all of the information recorded about individuals. This is so there is a clear monthly summary that gives a picture of how people have been and how they have spent their time. Life history works should also be developed that include details and photographs of their history such as family, friends, where they have lived, pets, work etc where appropriate. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. All information handled about people who use the service should be in accordance with the homes written policies and procedures and the Data Protection Act 1998. There needs to be a more proactive and positive risk taking approach to more people being involved in the day to day living at the home. These are important life skills that people should be encouraged to develop. Page 41 of 44 6 6 7 6 8 6 9 6 10 10 11 11 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 12 17 Current good practice recommends that serviettes or napkins be used to protect peoples clothes rather than tabards which can appear institutional. People should be provided with ordinary crockery, unless their individual risk assessment restricts this for safety reasons. People should be involved in the menu planning at the home. A collection of photographs of food should be developed so that the people who communicate differently can participate in the menu planning. Staff should be provided with training on how to safely support and guide people with personal and intimate relationships and expressing their sexuality. Peoples preference of gender of staff should be actively sought and recorded in peoples assessments or plans. There should be information available about medication for staff and there should be regular medication audits completed. Individuals should be facilitated to have health action plans. There should be a separate easy read complaints procedure for people. For those people who this information is not accessible there should be descriptions in peoples plans as to how they let people know when they are unhappy and unsettled. It is strongly recommended that all staff have a refresher training session in adult protection. Peoples finances should be kept in line with the organisations polices. Where an individual is not able to understand or sign all entries should be signed by two staff. Safeguarding information should be made available to the people who live at the home in a format that is accessible to each individual. This is so that they know who they can communicate with if they dont feel safe or they are worried about abuse. 13 17 14 17 15 18 16 17 18 19 18 19 19 22 20 21 23 23 22 23 Care Homes for Adults (18-65 years) Page 42 of 44 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 23 24 24 24 The kitchenette should be equipped with working appliances such as a cooker. The organisation should consider and make plans for how the home can be managed so that people live in smaller living groups. Staff recruitment files should be transferred to the home before staff start work at the home. Staff should receive regular supervision. The registered person should ensure that policies and procedures are regularly reviewed and updated to make sure they reflect current good practice advice and legislation. 25 26 27 34 36 40 Care Homes for Adults (18-65 years) Page 43 of 44 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 44 of 44 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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