Care Home: Garrards Road 25

What the care home does well The registered provider is in the process of improving the written information about the home and the services it provides. This makes it more accessible to people with a learning disability. Residents are able to make decisions about their lives, with assistance as necessary. They are consulted about aspects of the running of the home, for example, menus, activities and staff recruitment. Action is taken to minimise identified risks and residents take risks as part of maintaining or developing their independence. Residents have opportunity for personal development and education and occupation and they are part of their local community. Residents have the opportunity to engage in age appropriate activities and maintain friendships and relationships. Residents are satisfied with the meals and they help to choose the menus. Residents can be assured that their complaints will be listened to and acted upon and effort is made to promote their understanding of the complaints procedures. The registered provider takes appropriate action to safeguard residents from abuse during any investigations and they take appropriate action where allegations are substantiated. The home is clean and tidy. Most of the staff have a vocational qualification and there is some progress in developing training around the specific needs of some of the residents. What has improved since the last inspection? There has been significant improvement in this service and all of the requirements made in previous inspection reports have been addressed. However, evidence suggests that some improvements and requirements were addressed only recently and with input of senior managers. There is a need for vigilance to ensure these improvements are sustained during impending management changes and when the home if fully occupied and staffed. Resettlement procedures have been revised and now provide prospective residents with a written outcome to their pre-admission assessment. The assessed and changing needs and personal goals of each resident are reflected in their improved individual care plans. Residents are consulted about these plans and have helped to write them in some cases. The home has taken steps to improve the standard of health care provided to the residents. They have done this by better planning, taking more professional advice and keeping better records. Staff are now trained to meet the specific medication needs of one of the residents and there is evidence that the provider takes the correct action when medication errors occur. The physical environment has improved since the last inspection, repairs have been completed and rooms redecorated in colours chosen by the residents themselves. There is better evidence in the home that staff are checked properly during recruitment and they are inducted properly when they start work in the home. Although home management has been inconsistent, with frequent changes, there has been good progress in addressing all of the previous requirements made in our reports and residents, staff and relatives have commented on the improvement. The quality assurance systems have improved and there are clear plans for more improvement and greater consultation with residents. What the care home could do better: There has not been a Care Quality Commission registered manager for the past 12 months. There has been a company appointed manager in post for this period however they have transferred to another service locally. This has, over the last few months, led to frequent changes in the interim management arrangements whilst recruitment to this post takes place. The company are aware of the need to appoint an experienced manager to the provide consistency and leadership. Interviews were in hand at the time of this inspection. The views of the current residents should be added to the service users guide. Prospective residents should be given a copy of the most recent Commission inspection report when they receive a copy of the service users guide. The agenda of the residents house meetings should be increased to allow for discussion about house issues and concerns and complaints. There is a need for staff to be more vigilant in administering medications and in storing and disposing of prescribed items correctly. Staff should check that there are no old prescribed items of medication, for example shampoos and creams, in bathrooms or bedrooms. The garden and kitchen are not fully accessible to those who use wheelchairs and this should be improved. The ground floor kitchen should be adapted so that residents who use wheelchairs can use kitchen equipment and the communal garden should be wheelchair accessible. A training needs analysis of the team is recommended to identify any areas of training still required.There is some concern as to whether the current staffing levels are adequate and we recommend daily review of staffing levels to ensure the health and safety of all residents at all times. The first floor lounge should have better ventilation during warm weather to keep the temperature from being uncomfortably high. Key inspection report Care homes for adults (18-65 years) Name: Address: Garrards Road 25 Garrards Road 25 Streatham London SW16 1JS     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: Sonia McKay     Date: 2 4 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © 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 37 Information about the care home Name of care home: Address: Garrards Road 25 Garrards Road 25 Streatham London SW16 1JS 02086966775 02086966773 GarradsRoad.Streatham@caretech-uk.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Caretech Community Services Name of registered manager (if applicable) Type of registration: Number of places registered: care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: The maximum number of service users who can be accommodated is: 12 The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD Physical Disability - Code PD Date of last inspection Brief description of the care home Garrards Road is a residential care home registered to provide care and accommodation for twelve people with a learning disability aged between 18 and 65 years. The home is set in its own grounds facing a large park with a lido. Ramps and handrails are available at the entrance to the ground floor. It is conveniently located for public transport and for local shopping areas. The home is divided into three units. All are self-contained with separate entrances to each. The ground floor is for six Care Homes for Adults (18-65 years) Page 4 of 37 Over 65 0 0 12 12 Brief description of the care home people with physical disabilities and varying degrees of learning disability. The first floor and second floors are separate but are staffed by one team. These floors can provide care and accommodation for six people with a learning disability and behaviours that challenge. Prospective residents are given a copy of the Service Users Guide that gives information about the home and the services provided. A copy of the most recent Commission inspection report is available in the home on request. Fees currently range from GBP1125.00 to GBP1577.06 per week and depend on the individual care needs of the person using the service. Care Homes for Adults (18-65 years) Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out by one inspector over two days. The methods used to assess the quality of the service being provided were as follows. Talking with residents, staff and the home manager. Observation of interactions between staff and residents and how they were spending their time. Looking at records relating to care and staffing. Looking at the information that the provider sent to us in their annual quality assurance audit. Sending surveys to residents, staff and relatives. Completed surveys were received from eight residents, two relatives and six members of staff. Looking at the outcomes of recent safeguarding investigations and getting feedback from a social worker. A tour of the premises. Looking at ways that medicines are handled in the home. The Care Quality Commission would like to thank all those who kindly contributed their time, views and experiences to this inspection process. Care Homes for Adults (18-65 years) Page 6 of 37 Care Homes for Adults (18-65 years) Page 7 of 37 What the care home does well: What has improved since the last inspection? There has been significant improvement in this service and all of the requirements made in previous inspection reports have been addressed. However, evidence suggests that some improvements and requirements were addressed only recently and with input of senior managers. There is a need for vigilance to ensure these improvements are sustained during impending management changes and when the home if fully occupied and staffed. Resettlement procedures have been revised and now provide prospective residents with a written outcome to their pre-admission assessment. The assessed and changing needs and personal goals of each resident are reflected in their improved individual care plans. Residents are consulted about these plans and have helped to write them in some cases. The home has taken steps to improve the standard of health care provided to the Care Homes for Adults (18-65 years) Page 8 of 37 residents. They have done this by better planning, taking more professional advice and keeping better records. Staff are now trained to meet the specific medication needs of one of the residents and there is evidence that the provider takes the correct action when medication errors occur. The physical environment has improved since the last inspection, repairs have been completed and rooms redecorated in colours chosen by the residents themselves. There is better evidence in the home that staff are checked properly during recruitment and they are inducted properly when they start work in the home. Although home management has been inconsistent, with frequent changes, there has been good progress in addressing all of the previous requirements made in our reports and residents, staff and relatives have commented on the improvement. The quality assurance systems have improved and there are clear plans for more improvement and greater consultation with residents. What they could do better: There has not been a Care Quality Commission registered manager for the past 12 months. There has been a company appointed manager in post for this period however they have transferred to another service locally. This has, over the last few months, led to frequent changes in the interim management arrangements whilst recruitment to this post takes place. The company are aware of the need to appoint an experienced manager to the provide consistency and leadership. Interviews were in hand at the time of this inspection. The views of the current residents should be added to the service users guide. Prospective residents should be given a copy of the most recent Commission inspection report when they receive a copy of the service users guide. The agenda of the residents house meetings should be increased to allow for discussion about house issues and concerns and complaints. There is a need for staff to be more vigilant in administering medications and in storing and disposing of prescribed items correctly. Staff should check that there are no old prescribed items of medication, for example shampoos and creams, in bathrooms or bedrooms. The garden and kitchen are not fully accessible to those who use wheelchairs and this should be improved. The ground floor kitchen should be adapted so that residents who use wheelchairs can use kitchen equipment and the communal garden should be wheelchair accessible. A training needs analysis of the team is recommended to identify any areas of training still required. Care Homes for Adults (18-65 years) Page 9 of 37 There is some concern as to whether the current staffing levels are adequate and we recommend daily review of staffing levels to ensure the health and safety of all residents at all times. The first floor lounge should have better ventilation during warm weather to keep the temperature from being uncomfortably high. 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 10 of 37 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered provider is in the process of improving the written information about the home and the services it provides. This makes it more accessible to people with a learning disability. Resettlement procedures have been revised and now, as required, provide prospective residents with a written outcome to their pre-admission assessment. Evidence: The homes statement of purpose is informative and has been updated about recent changes in home management arrangements. The service users guide is being reviewed and improved. A copy was supplied during this inspection. It is written in plain English and has lots of symbols and pictures to make it more accessible to people who may find text only information hard to understand. The guide is designed so that photographs of key members of the staff team can be added. The views of the existing residents have also yet to be included in the guide. Care Homes for Adults (18-65 years) Page 12 of 37 Evidence: Each resident has a copy of the guide in their file. Contractual arrangements are added to the guide, for example, the cost of the placement, which may differ for each person, depending on their individually assessed needs. The cost of extras, for example, use of the house vehicle, have yet to be added.This is recommended. A copy of the most recent Commission inspection report is available in the home. Prospective residents should be given a copy of the most recent report as part of the service users guide to the home. This is recommended. The registered provider has not admitted any new residents since the last inspection and currently has a voluntary embargo in place whilst the local authority and provider monitor service improvements. At the last inspection we issued a requirement for all prospective residents to receive a letter at the end of their pre-admission assessment, confirming whether the service is able to meet their assessed needs. The annual quality assurance audit says that the new resident resettlement procedure has been revised and now includes writing to all prospective residents confirming whether the service is able to meet their assessed needs. The provider has also supplied all existing residents with a copy of this letter. The requirement is therefore met, but as there are no new residents, resettlement cannot be looked at in any depth during this inspection. Care Homes for Adults (18-65 years) Page 13 of 37 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The assessed and changing needs and personal goals of residents are reflected in their improved individual care plans. Residents are able to make decisions about their lives, with assistance as necessary. They are consulted about aspects of the running of the home, for example, menus, activities and staff recruitment. Action is taken to minimise identified risks and residents take risks as part of maintaining or developing their independence. Evidence: The registered provider has introduced a new system for planning care with each resident. Each person has a new document called a My Plan. These plans are written as if the resident has written them themselves and there are spaces for symbols and photographs to be added to make them easier to understand and more personalised. One of the ground floor residents asked me to look at her new plans with her. She has two files of written information that staff keep in the office. The resident showed me her care plan file and explained that staff had helped her to write the plans. The plans Care Homes for Adults (18-65 years) Page 14 of 37 Evidence: provide clear and concise information about her current care and support needs and also look at decision making for the future, for example, her personal goals and ambitions and also her wishes in the event of her death. The plan is an excellent example of planning with people and of active consultation. The plans includes the things that the resident herself thinks are very important and provides staff with useful information about her needs and likes and dislikes. The care and support plans also detail the risks involved with each area of care and support and how they can be reduced. I contacted the residents social worker, who had recently completed a review. He is pleased with her plans and her progress in the home and said that staff had addressed all of the action points identified in previous reviews. The resident said that she thinks that the home is very good. I looked at plans for a second resident. The plans are also clear and concise and up to date. They have been reviewed recently and contain information about risks and how they are reduced. The plans cover all required areas, including personal care, communication, cultural needs and health and mobility needs. There is information about his likes and dislikes and his personal goals. The plans have been signed by the resident himself. I looked at plans for a third resident. The resident completed the plans with his key worker in February 2010. The plans cover his behavioural support needs, communication, relationships, daily living skills, social and leisure, motivation and initiation of activities, finances and healthy eating. Risk assessments are in place and have been reviewed recently also. These have been signed by the resident also. At the last key inspection we made requirements about care plans and risk assessments. Evidence seen during this inspection indicates that both of these requirements are met. Examination of these plans shows that residents have been consulted about their care and support arrangements. Each resident also has regular opportunities to discuss issues with their key worker. There are records of these discussions on file. There are regular house meetings where residents from each floor meet as a group to discuss activities and plan weekly menus. These are fixed agenda items. The scope of these group meetings could be increased to include discussion about house issues as well. This is recommended. Residents are also consulted during staff recruitment procedures. They are given an Care Homes for Adults (18-65 years) Page 15 of 37 Evidence: opportunity to meet applicants and give their opinions about their suitability. There are also plans to survey residents about their views of the home and the services it provides. Care Homes for Adults (18-65 years) Page 16 of 37 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunity for personal development and education and occupation and they are part of their local community. Residents have the opportunity to engage in age appropriate activities and maintain friendships and relationships. Residents are satisfied with the meals and they help to choose the menus. Evidence: Each resident requires staff support to go out in the community. Some residents have additional one to one hours each week for specific support needs or activities. The resident group, staff group and local community are culturally diverse. There is a house vehicle and designated driver. Some residents with mobility needs also access taxis. The home is close to high street shopping and public transport links and there is off road parking available. Care Homes for Adults (18-65 years) Page 17 of 37 Evidence: The annual quality assurance audit provides the Commission with information about how residents are supported to maintain the lifestyles of their choosing. It says that visitors are welcomed and residents are supported to maintain links with their family and Friends by visits, weekends away, telephone calls and letters. All residents are registered to vote and are supported to do so if they wish. Some residents regularly attend a variety of community based activities, including day centres, clubs and discos and there are outings to cinemas and sports centres. At the last inspection we recommended that staff review the need for residents to have access to information and advice about sex and relationships if they wish. During this inspection I note that one of the residents had attended a womens group where these issues had been discussed. One resident has completed a college course, has been helped to complete a CV and has undertaken voluntary work in the local area. She has also recently attended courses in Information Technology, Administration, Health and Safety, and Food Hygiene. I observed that the resident is also planning a themed fancy dress birthday party and staff have assisted by helping her to make an invitation on the computer. Personal goals and aspirations have been included in the care planning process. The plans seen during this inspection included plans for residents to engage in a number of activities, such as, going to an arena to watch a wrestling match, going to a concert and planning holidays. The resident discussed the activities she enjoys and the things that she plans to do. She is happy that she has already purchased tickets to a wrestling match, has been to see a show and thought it was fantastic. She said that the home is getting better, that they are going out more often and she can go to anywhere she wants. She said that she had been on holiday with her key worker and that it had been fun. She said that the food is OK and she enjoys making cakes. Preferences for daily routines are also recorded and I observed that for one resident his recorded preference is to sometimes get up late and have a late breakfast, whilst others may be preparing for or having lunch. He also enjoys an apple with his meals. I observed these preferred routines to be being observed by staff during this inspection. And there were good supplies of apples available. One of his recorded interests is making models from kits and he showed me models he had made that are displayed in a glass cabinet in the lounge. A member of staff was observed to be helping him to make another model in the lounge later that Care Homes for Adults (18-65 years) Page 18 of 37 Evidence: afternoon. The resident said that he likes carpentry and other activities involving making things. Another resident says she enjoys watching television and playing board games with staff. She was observed to enjoy a game with a member of staff during this inspection. Another resident was preparing for a weekend visit to relatives and spoke to me about the things he enjoys doing. He likes sports and swimming. A member of staff explained that he was not attending college at the moment and that they are looking at alternative day time activities. The resident said that the food is nice and he enjoys playing pool with his Friends. Residents were observed to spend time with staff and time alone, either in their bedrooms or in the communal areas. Some residents have a fuller week than others, and staff on duty said that work is underway to develop more structured weekly plans for those with less to do. A relative completed a survey and thinks that the service could improve by encouraging greater participation in physical and social activities and by providing more structured activities. Residents are supported to attend Church if they wish and staff have access to information about faith observations and cultural needs. Staff prepare the main meals. There are three kitchens, one on each floor of the home. The residents on the ground floor have a kitchen with a wheelchair accessible worktop so that they can take part in some elements of meal preparation. Residents on the first and second floor eat together in the first floor lounge. Food supplies were observed to be adequate and to contain fresh fruit and vegetables. Individual preferences are recorded and residents help to plan the menus. Staff assist residents to maintain healthy eating plans, with advice from dietitians as necessary. Records of what meals are served are kept and staff support residents to weigh themselves and keep records of their weight. Care Homes for Adults (18-65 years) Page 19 of 37 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has taken steps to improve the standard of health care provided to the residents. They have done this by better planning, taking more professional advice and keeping better records. Staff are now trained to meet the specific medication needs of one of the residents and there is evidence that the provider takes the correct action when medication errors occur. There is a need for staff to be more vigilant in administering medications and in storing and disposing of prescribed items correctly. Evidence: Residents need varying levels of support to maintain there personal care and appearances. Some need full support with transfers and bathing and equipment is available to help with this. Others need advice and supervision. The nature of the support required is detailed in personal care plans. Personal care is provided in the privacy of bedrooms and bathrooms, some of which are adapted to meet the needs of those with a physical disability. There are both men and women within the staff team and same sex personal care support is provided. At the last inspection we made requirements about improving health care planning and maintaining records of the outcome of health care appointments. Evidence seen Care Homes for Adults (18-65 years) Page 20 of 37 Evidence: during this inspection indicates that both requirements are met. The homes annual quality assurance audit says that new documents called My Keeping Healthy Plans have been introduced along with the new care planning system. These plans are being developed with each resident at this time. The audit says that all residents are registered with a local GP and dentist and that the staff are working with input from occupational therapists, physiotherapists and psychiatrists to promote good health and support practises. The audit says that all residents have regular reviews of their medication. The audit, completed by an interim home manager, identifies that the service could get better at adding to planning documents as changes arise. There are also plans to encourage residents to becoming involved in maintaining a record of the outcome of their health care appointments themselves. The manager said that new daily record booklets are also being introduced for staff to record daily events, activities and observations of each residents health and wellbeing. These types of records are kept, but in other formats, at the time of this inspection. Health plans and records of appointments for three people were looked at during this inspection. One resident looked at her Keeping Healthy Plan with me. This demonstrated her ownership of the plan. The plan contains pictures and symbols to make it more accessible. The resident sees a range of health care professionals in addition to the GP, Dentist and Podiatrist. The plan is sufficiently detailed and up to date. There are records of recent appointments. The resident is prescribed oxygen at night and attends a hospital clinic for checks about this health issue. The home has also referred for advice about a new bed and speech and language therapy. The resident demonstrated a facial exercise advised by a speech and language therapist. I looked at health plans for a second resident living on the ground floor of the home. The resident has a mobility need and is unsteady on his feet. He is advised to wear a protective helmet, but a member of staff said that he refuses to. Staff were observed to have some difficulty helping him to transfer from his walking frame to a lounge chair, but his key worker said that a turning circle was being provided to help with this sort of transfer. There are plans for the resident to attend physiotherapy sessions at a day centre to help him improve his mobility. The resident has epilepsy and there is a monitor in place to alert staff if he has a seizure whilst in bed. A speech and language therapy referral was made recently and occupational therapy are being asked about the Care Homes for Adults (18-65 years) Page 21 of 37 Evidence: suitability of a new bed. There is a record of the health care appointments attended and of the advice given at these appointments. Staff said that follow up appointments are all put in the house diary so that staff are aware of the appointments when planning the staff duty roster and shift. A relative who completed a survey thinks that the service could improve by being more proactive about health care to minimise the onset of chronic conditions, such as immobility. The relative said that they had raised health care issues, that in their opinion had serious implications for their relative. They consider these issues were not being addressed until recent changes in home management took place and the relative is concerned that these recent improvements in health care arrangements be sustained. I looked at health care plans and records for one of the residents living on the second floor of the home. The resident showed me the plans himself. The resident has support to manage his behaviour and epilepsy. Contact details for the health professionals involved are available and the records show that he has seen a range of health professionals on a regular basis. Staff undertake training in the safe administration of medications before they are allowed to administer, and they repeat the training every two years. Policy and procedures are in place and staff are required to confirm they have read them with their signature. Their competence is tested every six months. The new acting manager has identified that some competency assessments are overdue and she has arranged reassessments. None of the residents administer their own medications at this time. There have been two medication errors recently, both where staff had failed to administer a dose. These omissions are being investigated, and staff are removed from medication duty until investigations are complete and their competence with medicines has been retested. One of the residents is prescribed a medication for epileptic seizures that requires specialist administration. At the last inspection an insufficient number of staff had been trained to administer this medication so we issued a requirement. At this inspection, some more staff had been trained and the remaining staff were booked onto the training. The requirement is therefore met. At the last inspection we recommended that the home obtain a controlled drugs register in case any controlled drugs were prescribed. This has been done and there is Care Homes for Adults (18-65 years) Page 22 of 37 Evidence: also suitable controlled drugs storage available. Residents each have their own lockable medication cabinet in their bedrooms and most medication is supplied in measured dose blister packs by a local pharmacy. Medication administration records are kept with the supplies. I looked at supplies and records for two residents. The manager has printed information about the prescribed medications so that residents and staff are aware of any side effects to look out for. There were no gaps in the administration recordings and the stock available tallied with the records. Doctors agreement has been obtained for circumstances when as required medications are to be administered and there is a list of home remedies that residents are safe to take. The home manager checks the handling of medicines each week and staff record the temperatures that medications are stored at. I observed that one resident had a prescribed shampoo available on a shelf in her en suite bathroom. This prescribed item was not on her chart. The medication was dispensed in June 2008. When I queried its use, a manager said that the resident did not use it anymore and removed the item for safe disposal. The manager explained that she had recently introduced a new stock audit record for medicines not supplied in blister packs. Care Homes for Adults (18-65 years) Page 23 of 37 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that their complaints will be listened to and acted upon and effort is made to promote their understanding of the complaints procedures. The registered provider takes appropriate action to safeguard residents from abuse during any investigations and they take appropriate action where allegations are substantiated. Evidence: The complaints procedure document has been revised to make it more accessible to residents with a learning disability. Each resident has a copy in their file. Each resident is offered a weekly one to one session with a member of staff to discuss any concerns they may have. The manager keeps a records of complaints in the office. There is one recorded complaint since the last inspection. I looked at records of how the complaint was handled. A resident had complained about a member of staff. The records show that the complaint was addressed promptly and that the resident was satisfied with the outcome of the complaint. A relative expressed concern that the service has not always responded appropriately when they have raised concerns about health care issues but also notes recent improvement and hopes this is sustained. Care Homes for Adults (18-65 years) Page 24 of 37 Evidence: The annual quality assurance audit says that the provider has improved the service by appointed a safeguarding lead to provide advice and assist home managers with safeguarding issues. Since the last inspection the provider has been working with the local authority safeguarding team during four safeguarding investigations. The majority of staff have now attended training about safeguarding and further training is planned for March 2010. Evidence suggests that managers recognise safeguarding issues and raise alerts themselves if needs be. Four safeguarding investigations have been completed and the outcomes are that one allegation against a member of staff was substantiated, two allegations were partly substantiated, one in regards to staffing levels and another in regards to staff conduct and one investigation into inadequate staffing levels was inconclusive. Two further investigations are ongoing at this time, one in regards to staffing levels and another about missed doses of medication. The outcomes of these investigations provide evidence that the provider takes appropriate action to safeguard residents during investigations and where safeguarding concerns are substantiated. The provider has also voluntarily decided not to admit residents to the first and second floors of the home until they are satisfied that the service is sufficiently improved. The provider has taken disciplinary action against some staff and is working with the local authority in regards to ongoing investigations and improvements. Procedures are in place that allow staff to be suspended without prejudice whilst investigations are underway. This safeguards vulnerable adults. The provider conducts enhanced criminal records checks and checks against the list of people who should not work with vulnerable adults during recruitment. Residents need to support to manage their financial affairs and to look after their money and valuables. Each has a financial support plan in place which describes the type of support that they need. Cash and valuables are held in safekeeping and are regularly checked. Expenditures are validated by receipt and staff and resident signature where possible. A spot check of cash held for one resident tallied with the associated record and the resident had signed out for cash himself. Care Homes for Adults (18-65 years) Page 25 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical environment has improved since the last inspection, repairs have been completed and rooms redecorated in colours chosen by the residents themselves. The garden and kitchen are not fully accessible to those who use wheelchairs and this should be improved. The home is clean and tidy. Evidence: The home is situated in a residential area close to open space, shops, leisure facilities and public transport links. The home is divided into three units, one unit on each floor. There is ramped access to the front door as the ground floor is designated for people with a physical disability, some of whom use wheelchairs and need adapted bathing facilities. At the last inspection we noted that a water leak was causing a slip hazard on the ramp and we made a requirement for this to be repaired. A maintenance manager attended the home during this inspection and explained the work underway to address the problem. A temporary fix is in place to reduce the leak whilst work on a listed drainpipe is completed. The requirement is therefore met. Feedback from staff and managers about repairs and maintenance response times, Care Homes for Adults (18-65 years) Page 26 of 37 Evidence: which had been an issue of concern to them at the last inspection, is also more positive and staff reported that maintenance issues are addressed more promptly now. There is a large front garden but access is limited for people who have a physical disability as there are no suitable paths for people who use wheelchairs to use. The dining room on this floor has tables at an appropriate height for people using wheelchairs and a worktop where they can prepare some snacks and meals. The kitchen facilities are not adapted and the home would not be suitable for people with physical disabilities who wish to cook their own meals. Residents on the first and second floor have their own communal lounges and small kitchenettes. Staff prepare the meals on the ground floor and first floor. Residents from the second floor eat with the resident on the first floor in the first floor lounge. The first floor kitchenette has been refurbished. Smoke damage to the third floor kitchenette has also been redecorated. Each resident has their own bedroom and access to en suite facilities and there is an adapted bathroom with a Parker bath on the ground floor. At the last inspection we noted that there as a drainage problem in a en suite bathroom on the first floor. This has been repaired during a bathroom refurbishment and the requirement is therefore met. Refurbishment of a second floor bathroom is planned for this year. The central heating broke down during the winter and alternative heating was provided. This is a recurrent problem and feedback in surveys indicates that residents and relatives are dissatisfied with this. The first floor has poor ventilation in the communal lounge, this is a problem for residents and staff in warm weather, when room temperatures are too high. We recommend that this is addressed. At the last inspection we noted that some of the fire doors were inadequate or damaged. These doors have been replaced and visual checks of the fire doors are part of the monthly health and safety monitoring of the environment. The requirement we issued about this is therefore met. During a tour of the premises a resident showed me his newly decorated bedroom and bathroom and another resident showed me his bedroom and said he is happy with it. Some of the bedrooms seen had been personalised and a resident said she had extra bedspreads at night if she wished. A new television was being installed in a protective Care Homes for Adults (18-65 years) Page 27 of 37 Evidence: case on the second floor during this inspection and the residents who use this lounge were pleased with it. Residents can lock their bedroom doors if they wish and staff have emergency access in an emergency. The home was noted to clean and tidy and there were no unpleasant odours within the building. There is still a bad smell at the main entrance because of a drainage problem, and this is being looked into at this time. Care Homes for Adults (18-65 years) Page 28 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most of the staff have a vocational qualification and there is progress in developing training around the specific needs of some of the residents. A training needs analysis of the team is recommended to identify any areas of training still required. Staff are checked properly during recruitment and they are inducted properly when they start work in the home. There is some concern as to whether the current staffing levels are adequate and we recommend daily review of staffing levels to ensure the health and safety of all residents at all times. Evidence: Staff are divided into two team each with a deputy manager. One team staff the ground floor and the other team staff the first and second floors. There is one overall manager but this post is vacant at this time and interim management arrangements are in place. The manager who facilitated this inspection had taken over in interim management of the home in recent months and is being supported by another home manager for three days each week. There has been frequent changes in home management in recent years and a relative is concerned that recent improvements in management responsiveness be sustained. Care Homes for Adults (18-65 years) Page 29 of 37 Evidence: There are male and female staff on the team and low turnover. Recruitment records are stored at head office and have been deemed satisfactory during Commission inspection. As required at the last inspection, a record of documents obtained during recruitment is maintained on file in the home. Records for two new members of staff were examined and were all in order. As required at the last inspection, there is also a record of their home induction and mandatory induction training. Each member of staff has a file containing their supervision and induction records and a supervision matrix is in place. There are regular team meetings and records are kept of the discussions. A resident commented that her key worker was the best she had ever had and that she made her laugh and they had fun together. Another resident commented that staff are very friendly, supportive and caring. A third resident commented that the home should provide more staff. A member of staff completed a survey and also thought that the home should employ more staff. Another relative who visits is concerned that staffing levels are too low, especially when staff are cooking or in a meeting. There are less staff on duty because the home is under occupied at this time. The stated staffing ratio is one member of staff to two residents and this indicates that residents will not receive one to one attention from staff at all times unless additional one to one hours are purchased by the placing authority for specific care and support needs. Some residents have these additional hours and these additional hours of support are recorded and accounted for. This staffing ratio, along with additional one to one hours, was in place at the tome of this inspection. When a member of staff is out with a resident there are fewer staff about in the home, and as the home is large this gives an impression of low staffing. Residents were observed to spend periods of time alone in their bedrooms or in the lounge. The interim manager said she was trying to combat this by putting herself on shift when staff go out and by asking staff to complete tasks and paperwork in the communal lounge so that they are more accessible and available to interact with the residents. There has been an instance when staff left the home at the end of the shift and left only one member of staff on duty. This was partly substantiated during a safeguarding investigation and the provider, who raised the alert themselves, took appropriate action to prevent this happening again. Care Homes for Adults (18-65 years) Page 30 of 37 Evidence: There is also concern that a resident on the third floor is left alone at times while staff work with residents on the middle floor. This is being looked at under safeguarding to assess if there are any risks. The Care Quality Commission received an anonymous call saying that there were too few staff on duty. This issue was referred to the local safeguarding team and the outcome of their investigation was inconclusive. We recommend whilst that whilst the home is under occupied and there are fewer staff on duty that staffing levels be kept under daily review to ensure that there are sufficient staff on duty at all times. Most staff have attained a vocational qualification in care and others are working toward an award. The registered provider has a training department and training is run on a regular basis. The home manager showed me training plans for the next few months. These plans are based on a matrix that identifies what training staff have already attended and when refreshers are due. The annual quality assurance audit identifies that the service could improve by recruiting staff who are more experienced in supporting people with learning and physical disabilities. And there are plans to improve staffing by recruiting a full team and offering specific training that better meets the needs of the current residents. A team training needs assessment is recommended. Care Homes for Adults (18-65 years) Page 31 of 37 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although home management has been inconsistent, with frequent changes, there has been good progress in addressing all of the previous requirements made in our reports and residents, staff and relatives have commented on the improvement. The quality assurance systems have improved and there are clear plans for more improvement and greater consultation with residents. Evidence: The previous home manager was moved to a smaller service and interim management arrangements have been put in place. These arrangements were changed again recently and at the time of this inspection a new manager who is registered to another home is providing management support with input from a second registered manager. Both managers work for the registered provider in other homes. The registered provider is in the process of recruiting a new home manager at the time of this inspection. The managers who facilitated this inspection are experienced and qualified and they facilitated the inspection process well. The manager said that residents would be able to give feedback about the current home manager candidate after she visits the home. Care Homes for Adults (18-65 years) Page 32 of 37 Evidence: Frequent changes in the management of the home have been difficult for residents and staff, and a relative and a social worker involved are concerned that consistent management is achieved quickly to provide the home with consistency and leadership. Staff morale was a concern at the last inspection and it has noticeably improved during this inspection where staff spoke about improvements in the running of the home. All spoken with said if they had any concerns or supervision needs that they felt confident to raise them with the current managers. The staff and residents were observed to use the managers open door policy and they came to the office frequently for a chat. The managers also spend time with the residents and assist with care when necessary. This provides staff with good role modelling and helps reduce the negative impact of frequent management changes. The registered provider has appointed a consultant to undertake the monthly inspection visits under Regulation 26. The reports of these visits are detailed and cover all of the areas required and involve discussion with both residents and staff on duty. These reports are sent to the provider and to the home manager so that action points can be followed up. Copies are available in the managers office. The registered provider has also appointed a specific quality assurance team and they are involved in the safeguarding and monitoring meetings with the local authority. They have helped staff to develop care plans of a higher quality with the residents. The annual quality assurance audit says that the quality team will be monitoring the service on a weekly basis from February 2010 and they will also produce an annual assessment that will include resident satisfaction surveys analysis and feedback. The annual quality assurance audit shows that systems are in place to promote health and safety. This includes policy and procedure, staff training and regular recorded checks by staff of the physical environment. There are professional checks of fire detecting and fire fighting equipment. Accidents and incidents are recorded and reported appropriately and the registered provider has demonstrated appropriate action to safeguard residents. All thirteen requirements made in our last report have been actioned. Care Homes for Adults (18-65 years) Page 33 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 34 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 1 1 The cost of extras, for example, use of the house vehicle, should be added to the service users guide. Prospective residents should be given a copy of the most recent Commission inspection report when they receive a copy of the service users guide. The views of the current residents should be added to the service users guide. The agenda of the residents house meetings should be increased to allow for discussion about house issues. Staff should check that there are no old prescribed items of medication, for example shampoos and creams, in bathrooms or bedrooms. The agenda for residents house meetings should include concerns and complaints. The ground floor kitchen should be adapted so that residents who use wheelchairs can use kitchen equipment and the communal garden should be wheelchair accessible. The first floor lounge should have better ventilation during 3 4 5 1 8 20 6 7 22 24 8 24 Care Homes for Adults (18-65 years) Page 35 of 37 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 warm weather to keep the temperature from being uncomfortably high. 9 33 Whilst the home is under occupied and fewer staff are on duty there should be daily review of the staffing levels to ensure that sufficient staff are on duty at all times to ensure the health and safety of all residents. There should be a staff team training needs analysis to ensure that each member of staff receives specific training in meeting the specific needs of residents that they are working with. 10 35 Care Homes for Adults (18-65 years) Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. 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