Care Home: Elizabeth Lodge

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What the care home does well Systems to manage medicines are clear and well maintained. GPs sign to authorize any change in a medicine regime or a specialised medicine administration system. People have access to a range of health care professionals in order to meet their health care needs. An open approach to complaints is in place and complaints are well managed. A robust recruitment procedure is in place which safeguards people from anyone unsuitable to work with vulnerable people. The manager readily informs us of any incident, which affects a person`s well being. There is a range of health and safety material in place, for staff reference. What has improved since the last inspection? Care plans have been totally reviewed with a new format devised. The plans are now more detailed, well written and person centred. Risk assessments have also been reviewed. A system has been developed to ensure all care plans are regularly reviewed and updated as people`s needs change. Protocols in relation to people`s health and well being have been updated and are being followed. The controlled drugs cupboard and controlled drugs book have been replaced to meet current legislation. All members of staff have received recent safeguarding training. Some staff members have been allocated to attend the local council`s training programme in adult protection. Some areas of the home such as the entrance area, lounge, computer room and sensory room have been redecorated. Equipment has been purchased, ready for the refurbishment of the sensory room. Staff were talking and interacting with people using the service rather than talking between themselves. There has been less reliance on agency staff through staff members doing additional shifts and the development of a team of bank staff. A staff training matrix has been developed which shows all training that members of staff have completed and when refresher training is required. The fire risk assessment has been reviewed. What the care home could do better: Some terms used in care planning such as `regularly` should be clarified so that staff have accurate, concise information about people`s needs. All daily records should be factual and not contain any subjective language such as `was uncooperative.` Food and fluid charts should be totalled on a daily basis and evaluated within the person`s care plan. Guidance for staff on what action to take if the person has a low food or fluid intake should be clearly stated. Further opportunities for social and leisure activities should be made available in order to enhance people`s quality of life. Potential harmful substances such as cleaning materials must be securely stored. The laundry room would benefit from redecoration and be included on updated cleaning schedules to minimize the risk of infection. Consideration should be given to how people using the service could be involved within the home`s quality assurance system. Staff should have more opportunities to be involved in fire drills so that they are competent in the home`s fire evacuation procedures. Key inspection report Care homes for adults (18-65 years) Name: Address: Elizabeth Lodge Cedar Grove Trowbridge Wiltshire BA14 0HS     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: Alison Duffy     Date: 0 1 1 2 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 32 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 32 Information about the care home Name of care home: Address: Elizabeth Lodge Cedar Grove Trowbridge Wiltshire BA14 0HS 01225761281 01225761297 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.livability.org.uk Livability care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Date of last inspection Brief description of the care home Elizabeth Lodge is a residential care home that is registered to care for eight younger adults with a learning and/or a physical disability. The service is run by Livability. The registered manager is Mr Philip Caple. Mr Caple has approximately 17 years experience of working with older people and adults with a learning disability. Mr Caple was registered with the CSCI in May 2007. People have a single bedroom on the ground floor. Two of the bedrooms have en-suite shower rooms. Some rooms have overhead hoisting equipment. There is also a separate shower room, a further bathroom and a separate toilet. There is a large lounge/dining room. People benefit from a sensory room, which is regularly decorated with a different theme. The grounds are accessible to wheelchair users. There is a sensory garden to the rear of the property and an enclosed garden to the side and front of the home. The staffing rota provides a minimum of four support workers and a senior support Care Homes for Adults (18-65 years) Page 4 of 32 Over 65 0 0 8 8 2 6 1 1 2 0 0 8 Brief description of the care home worker on duty during the waking day. There are two waking night staff and a member of staff provides sleeping in provision. There is an on call management system, twenty four hours a day. Care Homes for Adults (18-65 years) Page 5 of 32 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: Before visiting Elizabeth Lodge, we sent the home an Annual Quality Assurance Assessment (AQAA) to complete. The AQAA is the homes own assessment of how they are performing. The AQAA tells us about what has happened during the last year and about the homes plans for the future. We sent surveys, for people to complete with support if they wanted to. We also sent the home surveys to be distributed to members of staff and health/social care professionals. This enabled us to get peoples views about their experiences of the home. We received surveys from four members of staff and one health/social care professional. We looked at all the information that we have received about the home since the last inspection. This helped us to decide what we should focus on during an unannounced visit to the home. This visit took place on the 1st December 2009 between 10am and Care Homes for Adults (18-65 years) Page 6 of 32 6.30pm. Mr Caple was available throughout and received feedback at the end of the visit. During our visit, we toured the accommodation and met with people who use the service. Due to peoples communication needs, we were not able to gain verbal feedback about the service they received. We spoke to staff members on duty and observed how they interacted with people. We saw people having lunch. We looked at care-planning information, staff training records and recruitment documentation. We also looked at documentation in relation to health and safety and complaints. The last key inspection of this service took place on the 12th and 26th November 2008. All key standards were assessed on this inspection. Observation, discussions and viewing of documentation gave evidence, which showed whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. Care Homes for Adults (18-65 years) Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: Some terms used in care planning such as regularly should be clarified so that staff have accurate, concise information about peoples needs. All daily records should be factual and not contain any subjective language such as was uncooperative. Food and fluid charts should be totalled on a daily basis and evaluated within the Care Homes for Adults (18-65 years) Page 8 of 32 persons care plan. Guidance for staff on what action to take if the person has a low food or fluid intake should be clearly stated. Further opportunities for social and leisure activities should be made available in order to enhance peoples quality of life. Potential harmful substances such as cleaning materials must be securely stored. The laundry room would benefit from redecoration and be included on updated cleaning schedules to minimize the risk of infection. Consideration should be given to how people using the service could be involved within the homes quality assurance system. Staff should have more opportunities to be involved in fire drills so that they are competent in the homes fire evacuation procedures. 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 32 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 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures are in place to ensure that all admissions are well managed thus ensuring peoples needs would be met within the home. Evidence: At the last inspection, a large amount of information about the needs of a newly admitted person to the service was available to staff. However, there was no documented assessment in place, which showed that the persons needs could be met within the home. We made a requirement to ensure that people were fully assessed before a placement was offered. During this inspection, Mr Caple told us that a robust assessment procedure would be followed. However, there had not been any new people to the service since the last inspection. We were therefore not able to assess the admission processes in practice. The AQAA gave us detailed information about the admission process. It said we have an admissions policy which is adhered to on all admissions. We do not, as a rule, take in service users on an emergency basis due to the complexity of their needs. We go to service users present home to meet with them and other carers/support to see just Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: what they would need from us and what their expectations of the service are. We aim to be as flexible as possible so that we can meet their needs. We always offer a trial period or overnight stay to be able to meet the other service users and staff. All interested parties are invited to visit either with the service user or on their own. We always ask for an assessment from care managers and this information will formulate our own care plan. We make sure that all necessary equipment needed is in place prior to admission. The AQAA continued to say residents rooms can be personalised prior to moving in so that there are familiar objects which will help the settling in process. There is always a trial period which is agreed prior to moving in. Where ever possible the prospective service user is allocated a named keyworker during the preadmission period so that relationships can be formed and developed during this time, making admission that much less stressful. It also offers families etc a link person at a very early stage in the admission programme. Care Homes for Adults (18-65 years) Page 12 of 32 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. Due to the improvements in care planning and risk assessments, people can be assured that staff have clear information about their needs and how they should be met. Decision-making is encouraged in relation to peoples ability. Evidence: At the last inspection, care plans were in place yet they did not reflect the complexity of peoples needs and had not been regularly reviewed. We made a requirement to review all care plans to ensure they were accurate and gave staff sufficient information about the support people needed. The AQAA confirmed that all care plans had been completely restructured and families had been involved in the process. The AQAA stated the documents now provide a more rounded picture of individuals and how to support them. Risk assessments are reviewed at regular intervals. The care plans we looked at were detailed and person centred. The format of the plan was easy to follow and the information was generally well written. In one plan we saw it was written I need to have personal care regularly and at regular intervals during Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: the night. We advised that the word regularly was clarified. Another care plan stated staff need to be aware that sometimes XX can be uncooperative. A daily record was also noted as not very cooperative throughout his/her bath. We said that subjective terminology such as this should be avoided. Peoples needs were clearly identified within their care plan and step by step action points showed what was needed to support the person effectively. The plans gave indicators to help staff assess peoples non verbal communication and decision making. For example, one plan stated if I am in pain I will..., if I am thirsty I will... and if I do not want something I will... We saw that the plans had been consistently reviewed on a monthly basis. The plans showed how staff were to support people with maintaining their independence during personal care routines. Ways of promoting peoples privacy and dignity were also identified. The AQAA stated our service users are encouraged to make their own choices. Residents are recognised as individuals and staff, through regular contact with the service users are skilled in interpreting residents likes and dislikes. Staff told us about peoples needs and their particular interests. The information they gave was identified within the persons care plan. During our visit, we saw that staff interacted well with people. Staff were attentive and spoke to people about recent events and their families. Mr Caple told us that risk assessments had been reviewed and discussed with peoples care managers. We saw that a wide range of assessments were in place. These included drinking hot substances, the risk of developing a pressure sore, showering and events within the community such as horse riding. Staff told us about a situation which had an element of risk. This had been discussed with health care professionals and an action plan was in place. Some people had specific programmes in place for the support they required in daily living. We saw that one person was supported to eat their lunch as stated within their care plan. Within surveys, staff told us that good physical and emotional care and providing individuality and choice were aspects the home did well. Other comments were person centred approach, excellent care to service users (all areas of care) and staff give one hundred per cent. Concise care plans. One member of staff told us we give excellent care with each individual client in mind and we are all working very hard to make Elizabeth Lodge a home for the clients where they can relax and do what they like doing best. Care Homes for Adults (18-65 years) Page 14 of 32 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. Staff interaction with people has improved yet more opportunities for social and leisure activities would enhance peoples quality of life. Meal provision is provided in relation to individual need and preference. Evidence: Staff told us that they aim to support people within the local community as much as possible. However, they said that staffing levels often prevent the level of activity they would like to see in place. Similar views of activity provision were given in surveys. One staff member said we would all like to take the clients out on trips but extra staff are needed which is a problem. Another staff member, in relation to what the home could do better said provide more social activities - fees do not allow further staff to allow service users to go out socially in the evening as much as we would like. Fees do not cover funding for holidays. Mr Caple told us that he was aware of this and Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: acknowledged that sufficient staffing to enable spontaneous events was a challenge. The AQAA stated implementing the activities programme was something the home could do better. It confirmed the amount of time spent on activities is dependent on the needs of all the service users and this is an area where a volunteer group would be useful. Mr Caple told us that focus would be given to this area in order to improve opportunities for people. Holidays for the following year were also being investigated. Staff told us that two people attended a day service each weekday. Other people attended on a sessional basis. We saw within peoples daily diaries that opportunities for meeting their individual social needs were somewhat limited. Documentation showed that people generally went out approximately once a month. This was sometimes to the local garden centre or shopping. Staff told us that they tried to get people out for a walk as often as possible if the weather permitted. They said people were also supported to attend local theatre productions within the town. One person recently went to see a tribute band. Staff told us that they sometimes provided transport for people to go home for a weekend. They said people enjoyed close relationships with their families and visits to the home were always encouraged. Staff told us that when at home, people liked watching television and listening to music. One person liked beads and puzzles. Another person liked a foot spa. Mr Caple told us that new sensory equipment for the sensory room had been purchased. We saw that that the room had been decorated ready for the arrival of the equipment. A computer with a projector was also planned. Staff told us that the meals were based on peoples individual preferences. They said there were no special diets although most of the food was soft and therefore easy to eat. One person had their food minced due to a risk of choking. Staff told us that the menus were always being changed to accommodate personal preferences and the produce in season. The menus showed traditional meals such as roast pork, sausage and mashed potato, chicken casserole, corned beef hash and chicken pie. Staff told us that the meals were generally cooked from scratch with fresh ingredients. We saw a range of vegetables being prepared for the evenings casserole. Staff told us that some people liked finger foods which they could manage independently. We saw one person being supported with their meal. This was undertaken in a sensitive, quiet manner with the person given time to eat properly without being hurried. People were offered fresh fruit. One person was offered their favourite snack in order to encourage them to eat. We saw within care plans that the foods people liked to eat were identified. Within one plan, it was recorded that the person often asked for cornflakes yet they may not want to eat them. The information showed that the person might want another form of food. Care Homes for Adults (18-65 years) Page 16 of 32 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. Protocols are now in place to meet peoples health care needs. People have good access to health care provision. The systems for managing medicines are clear and minimize the risk of error. Evidence: Within staff surveys, good contact with relatives, doctors and other professionals was mentioned as something the home did well. Another staff member told us in their survey we always make sure Drs appointments are kept and we are in touch with other professionals. A health care professional told us in their survey, provision of equipment recommended by health staff appears to be very difficult. There often appears to be reluctance to do so and it takes time. They also said implementing changes to individuals daily routine can be difficult when different to other service users. Staff told us that peoples daily routines were individual and determined according to how people felt and their commitments of the day. They said that going to day services for example, meant that people needed to get up earlier than if they were staying at home. The support people required to maintain their personal care routines was now stated within care plans. The information was clear and well written. Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: We saw within the plans that people were supported to have regular intervention from health care professionals in order to meet their health care needs. There were referrals to an occupational therapist for a new shower chair due to one persons changing needs. There was also a referral to a physiotherapist in relation to posture and manual handling advice. A GP had authorized a new bowel management protocol for one person. The Community Team for People with Learning Disabilities had also given advice about gentle exercise and stretching techniques for one person. Mr Caple told us that epilepsy management plans had been reviewed although some were waiting to be signed off by the relevant health care professionals. In the event of a person not being able to make an informed decision about medical treatments such as vaccinations, staff had consulted family members. At the last inspection, one person appeared agitated when going out. We advised that the persons agitation be investigated and measures be put in place to aid relaxation. Staff told us that a behavioural therapist had been consulted and guidance agreed. This was documented within the persons care plan. At the last inspection, we saw that some health care protocols were not being consistently followed. During this inspection, we saw that suppositories were being given at the required times, as identified within bowel management protocols. Fluid charts were in place for some people yet these were not consistently being completed and totaled at the end of each day. Staff told us that if a person had not been drinking well, they would pass this information on to the next shift during handover. We advised greater use and evaluation of food and fluid charts. Staff told us that they would also encourage people to have food items such as jelly, custard, ice cream and yoghurt if their fluid intake was low. Within their survey, a GP told us follow protocols in seeking medical advice was something the home did well. We saw that a record of peoples weight was regularly maintained. We saw that staff were observant and noted any marks or bruising noted on people. Some staff gave clarity to the entries they made on peoples care records. Other entries were more vague and included information such as large red mark. Mr Caple told us he would discuss good principles of clear recording with the staff team. There was a list of peoples prescribed medicines within their care plan. The information also detailed the reason for the medicines. Some people had their medicines covertly in food or drink. The persons GP had authorized this practice in writing. We saw that the GP also documented any change in the persons medicine in the care records. At the last inspection, we made a requirement to ensure that the controlled drugs book and cupboard complied with legislation. Staff told us that the cupboard had been replaced and the controlled drugs book was now bound and Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: contained numbered pages. There were clear records of medicines received into the home, those administered and those returned to the pharmacy. However, we saw that staff had not consistently signed to show that they had applied one persons night time eye cream. There was guidance within care plans in relation to medicines which were prescribed to be taken as required. Staff told us that they had received epilepsy awareness training. This included the administration of emergency rescue medicines. There were a number of certificates showing the epilepsy training staff had received. We advised that a list of staff, competent in the procedure of the administration of emergency medicines be maintained. Care Homes for Adults (18-65 years) Page 19 of 32 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. An open approach to complaints is maintained and clear systems are in place. People are further protected from abuse due to the recent staff training in safeguarding vulnerable people. Evidence: The AQAA stated dealing with complaints is outlined in our Policies and Procedures. How to complain to Livability or CQC is fully explained in our service users guide. Mr Caple told us that people generally continued to rely on others to raise any concern on their behalf. He said an open approach to complaints was adopted and any issue was addressed to improve the quality of service people received. Within the AQAA, it was stated we have good relationships with service users families and most concerns will be dealt with before they become more serious complaints. We do have a complains log and every complaint received whether this is in writing or word of mouth is written in the log and dealt with in the appropriate manner. We looked at the complaint log and saw that concerns had been investigated appropriately. As general practice, Mr Caple told us that either he or a senior member of the organistaion would meet with the person concerned. The issue would then be openly discussed and resolved as quickly as possible. Staff told us that they had regular contact with peoples families. Due to this, they felt that relatives generally felt comfortable expressing their views. Staff told us that they would immediately deal with the concern if they could. They would then inform Mr Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: Caple or a senior manager. Staff told us that if the matter was of a serious nature, they would immediately inform a member of senior management. They said it would then be the responsibilty of the senior staff to respond as per procedures. At the last inspection, we made a requirement that all staff must have up to date safeguarding training. In response to this, Mr Caple told us that in house safeguarding training sessions had been organised. In addition, staff had been put forward to attend the local councils training courses on adult protection. We saw that staff records demonstrated the training staff had undertaken. Mr Caple told us that all staff had received a copy of the Wiltshire and Swindon safeguarding protocols, No Secrets. However, this had been a while ago so Mr Caple told us that he would revisit this and re-issue the documentation. Within one persons care records, we saw that a staff member had left an instruction for the night staff to remove a persons facial hair. We discussed this with Mr Caple as the intended procedure was inappropriate. We said clear guidance for staff was required in this area to ensure consistency of care and to minimise potential distress. Due to complex health conditions, people required full assistance to manage their financial affairs. Mr Caple told us that work had recently been undertaken to ensure that the organisation no longer had any responsibilities for the management of peoples finances. Mr Caple told us that either family members now undertook the responsibility or people were subject to court of protection. A number of people continued to have some personal monies held safely in the home. We saw that the process for managing this was organised and showed a clear audit trail of transactions. Care Homes for Adults (18-65 years) Page 21 of 32 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. People benefit from an environment which has been improved through the redecoration of certain areas. Secure storage for cleaning substances is needed to safeguard people from harm. Evidence: People had a single room on the ground floor. Two of the rooms had an en-suite facility. We saw that all rooms were personalised to varying degrees and reflected peoples preferences and interests. There was a large lounge with a dining area and a smaller room where the computer was located. There was a sensory room which was in the process of being refurbished. At the last inspection, we noted that the environment looked tired and uninviting. We recommended that attention be given to refurbishing certain areas. Following this, the communal areas and the entrance hall were redecorated. New curtains and shelving was installed in the lounge and a fish tank was purchased. Consideration was being given to replacing the carpet in the lounge and entrance area with laminate flooring. Mr Caple told us that the bathroom was also due to be refurbished. We saw that the laundry room would benefit from redecoration. Due to the layout of the room, it was not easy to ensure that the areas between and around the machines were kept clean. Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: There were cleaning substances in the room which were not securely stored. Staff told us that they had access to disposable protective clothing as required. There was an enclosed sensory garden to the rear of the property and a newly developed garden to the front. The area to the front had planted containers and was to be further developed in the spring. Within surveys, staff mentioned the environment as an area of ongoing development. Specific comments were some updating and refurbishing of the premises is being done and will improve the environment when completed and Elizabeth Lodge has been given a face lift with the lounge, hallways being painted. In relation to what the home does well, one staff member said clean, tidy environment - individually decorated to individual tastes. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from greater consistency with their support due to less reliance on agency staff. Staff engagement with people has been improved upon. People are safeguarded through robust recruitment procedures. Staff training has been developed which enables the team to be better equipped to meet peoples needs. Evidence: Members of staff told us that when each person using the service was at home during the day, there were generally five staff on duty. They said that staffing levels fluctuated in relation to the number of people in the home at any one time. One person received twenty four hour one-to-one staff support. These hours were lost if the person was at their parental home, for example. Staff told us that at night there were two waking night staff and another staff member completed sleeping in provision. There was an on call management system in place. Staff told us that they continued to be responsible for all housekeeping tasks in addition to supporting people with their daily routines. This included cooking, cleaning and the laundry. Staff told us that they believed staffing levels were adequate to meet peoples individual physical needs. They said people were well looked after. However, staff told us that doing extras such as going out in the community and supporting people with new opportunities was a challenge, due to the staffing levels in place. Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: Within surveys, staff told us we would like to take the clients out on trips but extra staff are needed, which is a problem and it is a shame we dont have enough staff to do extras like Gateways club, holidays, only the basics. One staff member said higher staff levels at some times was what the home could do better. As stated earlier in this report, Mr Caple agreed that maintaining staffing levels which promoted a high level of external activity was a challenge. He said yes, I would love to be able to have more staff yet with the current climate the cost of additional staff could not be met. We are looking at how best to manage the situation we have. At the last inspection, we saw that a high level of agency staff was being used. This impacted upon the quality of service provision. The engagement with people was limited and members of staff spoke between themselves rather than with people using the service. Mr Caple told us that less agency staff were now being used. During our visit, we saw that staff were much more attentive and communicated well with people. We saw staff talking to people about specific tasks being undertaken. This included supporting a person to their room and supporting a person with their meal. Mr Caple told us that work had been undertaken in relation to teamwork and staff responsibilities. This was confirmed within the AQAA which stated the frequency of supervision has been increased by delegating the task to members of the senior team. It also stated team building is also on the agenda so that we can improve our overall performance and provide a better service for our residents. Acting on information received through supervision was something the AQAA stated the home could do better. Within surveys, a health care professional told us support staff are very caring. They are always enthusiastic to implement changes recommended by myself and will communicate with myself whenever any changes occur. A member of staff told us staff go over and above what a lot of homes do. We do make sure birthdays of families are done and Christmas presents. Another staff member said staff give one hundred per cent and well trained staff were things the home did well. We looked at the recruitment documentation of the most recently employed staff member. The file generally contained the required information to demonstrate a robust recruitment procedure. There was an application form and two written references. The staff member had been checked against the Protection of Vulnerable Adults register before commencing employment. They had a Criminal Record Bureau (CRB) certificate in place. Both checks ensured the staff member was suitable to work with vulnerable people. Mr Caple told us that the staff members declaration of fitness Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: was held at the organisations main office. We advised that this information be documented on the staff members file as part of the recruitment process. The AQAA confirmed the recruitment process by stating staff are employed only after all pre employment checks are made. This includes checking if a person has the right to work in the UK. CRB checks are made and re-checked every three years. The AQAA stated staff receive induction training and start work on a six month probation and progress is monitored during this time. Also during this time the employee will complete the LDQ (Learning Disability Qualification.) We will not continue the employment of someone who has not demonstrated that they are suited to the work. If specialist training is identified as a need then this will be provided. Staff told us that a high level of training was organised. One member of staff told us that they had completed training in death and dying at a local hospice. They had also completed training in infection control and health and safety. The staff member said their training needs were identified through formal supervision sessions with their supervisor. They said that if they felt they needed specialised training in relation to peoples health or personal care needs, they just needed to ask. Another staff member told us that they had recently completed training in infection control, health and safety, first aid, food hygiene and epilepsy awareness. They had also done an intensive interaction course and were now doing safeguarding training. Mr Caple told us that staff were generally up to date with their mandatory training. He said they had also completed training on teamwork. Mr Caple told us that moving and handling training, which would address peoples complex needs, had been organized for the following week. Since the last inspection, a training matrix had been developed. This identified each staff member and the training they had completed. Dates when refresher training was required were stated. Care Homes for Adults (18-65 years) Page 26 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from an improved service due to the developments to systems such as care planning, risk assessment and staff interaction. Systems to manage peoples health and safety are in place. Evidence: Mr Caple was registered with us in May 2007. He came to the home originally, to cover the post, on an agency basis. Mr Caple has worked in various care settings, for approximately 17 years. He has the Registered Managers Award (RMA) and the City and Guilds Advanced Management for Care qualification. Mr Caple told us that he recently did all the mandatory training with the staff team. As stated earlier in this report, Mr Caple has been involved in teamwork sessions and looking at staff roles and responsibilities. This was confirmed within the AQAA as it stated senior staff have received training to develop their role and take more responsibility. As a means to further improve the service, the AQAA stated to continue with the training programme for seniors and deputies to produce a more integrated team with more clarity of responsibilities. Care Homes for Adults (18-65 years) Page 27 of 32 Evidence: Mr Caple told us that he recently completed some shifts as part of the working roster to minimize the use of agency staff. We saw that records showing the monthly visits undertaken as part of regulation 26 were being maintained. At the last inspection, we saw that a quality assurance system was in place yet action plans were not clear. There were also limited systems in place for gaining the views of people using the service. Mr Caple told us that the organistaion was currently in the process of developing this area. The organisations quality and policy manager had undertaken a recent audit of the service. Areas earlier identified in this report such as social activity provision were identified as an area which could be developed. Mr Caple and staff told us that everyone had worked hard in the last year to develop the service. This was noted as requirements we previously set had been met. Significant improvements had been made in relation to systems such as care planning. Within a survey however, one health care professional told us provision of equipment recommended by health staff appears to be very difficult. There often appears to be a reluctance to do so and it takes time. Although the support staff are willing to implement changes the difficulties appear to be more of a managerial level. There is often dispute about funding. We saw that a range of health and safety policies were in place. Risk assessments had been reviewed and updated. At the last inspection, we made a requirement that the fire risk assessment was updated. This had been addressed. We looked at the fire log book and saw that there was information which could be archived. The log book showed that the fire alarm systems were tested as required yet there were some weeks in October 2009 when the emergency lighting had not been tested. We advised that the fire precaution officer section of the log be updated. We also advised that more fire drills be arranged so that all staff were regularly involved and clear about their responsibilities. Staff told us that they maintained records in relation to the temperatures of the refrigerator, freezer, hot water and all cooked food when served. Care Homes for Adults (18-65 years) Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 32 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 23 13 Written guidance must be available to staff in relation to a persons resistance to personal care intervention. So that people receive the appropriate support and their well being is maintained. 30/03/2010 2 30 13 All substances such as cleaning materials which could be harmful to a persons health must be securely stored. To ensure people are protected from harm. 28/02/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 6 12 Staff should ensure that all written entries in care plans and daily records are clear, concise and factual. Greater opportunities should be made available to people Page 30 of 32 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 so that they can be more involved in both social and leisure activities. 3 19 Any care charts such as food and fluid intake should be totaled and evaluated at the end of each day. The information should be cross referenced to the care plan and give guidance to staff about what to do in the event of poor intake. Staff should record clear, factual information to describe any mark or bruising. This should include the size, colour and exact location of the area in order for healing to be monitored. Staff should consistently evidence whether the identified persons eye cream was applied. If the person refused the application, this should be clearly stated on the medicine record. The laundry would benefit from redecoration and should be included on updated cleaning schedules to minimise the risk of infection. The medical fitness of a prospective member of staff should be held on their personal file as evidence that they are fit to do the job. Consideration should be given as to how people using the service could be more involved in the quality assurance system of the home. Information within the fire log book should be reviewed and archived if out of date. Staff should be involved in regular fire drills so that they are competent in the homes fire evacuation procedures. 4 19 5 20 6 30 7 34 8 39 9 10 42 42 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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