Care Home: Highbury House Nursing Home

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What the care home does well The management responded to the previous inspection report with a number of improvements. Requirements and the majority of good practice recommendations required at the last inspection visit were actioned. There were good relationships with the local health care services, providing support for people living at the home. The waiting list for admissions demonstrated the good level of trust and professional respect between the home and primary care services. People were encouraged to treat the home as their own home and to be as independent as possible. People were encouraged to personalise their bedrooms with their possessions and furniture if they wished. We received positive comments from people living at the home which included, "Can get up and go to bed when want to"; "Food good"; and "the staff are friendly and helpful" People could generally make choices about their daily routines, activities and meals on a risk assessed basis. People knew how to raise concerns and make complaints and felt these would be dealt with. The home had a homely ambience and it was warm, very clean and comfortable. The staff were caring, committed, flexible, and well trained. The number of care staff with an NVQ (National Vocational Qualification) had increased so that 17 out of 21 carers had achieved the award. The acting manager, nurses and staff strive to keep themselves up to date with training to make sure people are cared for as well as possible. What has improved since the last inspection? There were additional staff allocated to developing a wider range of activities and opportunities for each person. There was an on going programme of redecoration and refurbishment, with improved lounge areas and flooring in many parts of the home. There were plans to grow fruit, vegetables and herbs, so that people could enjoy meals with home grown produce. Improvements had been made to staffing arrangements with increased numbers, skills and knowledge of staff to meet the needs of the people living at the home. The management had undertaken some quality assurance audits so that shortcomings could be pro actively recognised and actions taken to improve the service. What the care home could do better: Care plans need further development, so that they are person centred, include all assessed needs and show that each person and where appropriate their representative is involved and in agreement. Person centred care plans must include each person`s activity opportunities and goals that have clearly measurable outcomes. Some aspects of medication practices needed further improvement to make medication administration as safe as possible. Systems must be improved to provide adequate safeguards for every person and other agencies must be informed and involved at an early stage where there are risks of harm to any person at the home. The redecoration and maintenance programme needs to be completed so that the standards of the premises are pleasant and safe for people using the service. Notifications to us about any adverse event affecting people at the home must be made without delay. Improvements must be made to the security and safety of the premises, so that all persons are safeguarded from risks of harm. Key inspection report Care homes for adults (18-65 years) Name: Address: Highbury House Nursing Home The Old Rectory Parkfield Road Stourbridge West Midlands DY8 1HB     The quality rating for this care home is:   one star adequate 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: Jean Edwards     Date: 0 4 0 2 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 40 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 40 Information about the care home Name of care home: Address: Highbury House Nursing Home The Old Rectory Parkfield Road Stourbridge West Midlands DY8 1HB 01384354455 01384358309 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Rushcliffe Care Limited care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence past or present drug dependence mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 21. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental Disorder (MD) 21 Past or present Drug dependency (D) 21 Past or present Alcohol dependency (A) 21 Date of last inspection Brief description of the care home Highbury Nursing Home provides accommodation, support and nursing services for up to 20 younger men and women. The home is a converted Georgian building in its own grounds with secure perimeters. It has gardens, which provide recreational areas and gardening opportunities for people using the service. There is limited car parking in the Care Homes for Adults (18-65 years) Page 4 of 40 Over 65 0 0 0 21 21 21 1 4 0 1 2 0 0 9 Brief description of the care home grounds. It is situated in a residential area of Stourbridge near to shops and other local amenities. The majority of bedrooms are single occupancy and have en suite facilities. There are two shared bedrooms. There are bathing, showering and toilet facilities throughout the home. There are communal lounges, dining areas and a designated smoking area in a conservatory. The home has a range of aids and adaptations to meet the needs of people accommodated. The organisation has not published the range of fees in the service user guide and people are advised to contact the home for up to date information about fees charged. Care Homes for Adults (18-65 years) Page 5 of 40 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: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection took place on 14 January 2009. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. We monitored the compliance with all Key National Minimum Standards at this visit. Two Inspectors visited the home for 10 hours on 26 January 2010 and a Pharmacy Inspector visited the home on 4 February 2010. The range of inspection methods to obtain evidence and make judgements included discussions with the acting manager, area manager, nurses and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the Commission. We looked at a number of records and documents. The acting manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to the inspection visit. Care Homes for Adults (18-65 years) Page 6 of 40 We looked around the premises, including communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. We did not receive any responses to CQC surveys circulated prior to this inspection visit. Care Homes for Adults (18-65 years) Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Adults (18-65 years) Page 8 of 40 Care plans need further development, so that they are person centred, include all assessed needs and show that each person and where appropriate their representative is involved and in agreement. Person centred care plans must include each persons activity opportunities and goals that have clearly measurable outcomes. Some aspects of medication practices needed further improvement to make medication administration as safe as possible. Systems must be improved to provide adequate safeguards for every person and other agencies must be informed and involved at an early stage where there are risks of harm to any person at the home. The redecoration and maintenance programme needs to be completed so that the standards of the premises are pleasant and safe for people using the service. Notifications to us about any adverse event affecting people at the home must be made without delay. Improvements must be made to the security and safety of the premises, so that all persons are safeguarded from risks of harm. 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 40 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 40 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 home has information about the service, though this is not entirely accurate. All persons admitted to the home have their needs assessed and reviewed with multidisciplinary health care professionals. The home actively encourages introductory visits and people are given ample opportunity and time to make decisions, which are right for them. Everyone has a contract with terms and conditions of residency. Evidence: The information contained in the homes AQAA about what it did well stated, Through our admission procedure the manager ensures that the home can adequately meet individuals needs before admission. The manager visits the potential resident during assessment and we encourage relatives and potential residents to visit before making their choice. The home presents a warm, friendly environment. Where possible we give residents a choice and if this is not possible we seek to solicit the views of relatives about general choices the individual was likely to have made. Where choice has not been possible due to external circumstances we ensure that the individual is offered their first choice as soon as this becomes an option. Where reasonable we offer a choice of room and areas within the home and where this is not possible (due Care Homes for Adults (18-65 years) Page 11 of 40 Evidence: to lack of vacancies) we support use of preferred choice of communal areas to access social support. We accommodate requests to move rooms internally, where possible, as soon as practicable. We discourage emergency admissions but where necessary in the best interests of the potential resident we work closely with the social worker to ensure that all relevant information, equipment and facilities are available to the home. All residents or relatives are provided with a written contract that clearly states terms and conditions and costs, where appropriate. The manager or nursing staff explain the details of the costing and any additional payments etc. prior to the resident being admitted. In this environment funding is usually arranged via social services or the PCT as complex arrangements are in place. The AQAA also cited the following improvements over the last 12 months, Highbury has improved our community access activity team. Interventions now encompass the rehabilitation philosophy that is fundamental to Highbury Houses continued success. All residents have their own personal community portfolio that is individually geared toward promoting residents development both internally and externally. Referred clients are allocated a (RMN) clinical leader who liaises with the previous care provider to ensure the seamless transition of services. The clinical leader is responsible for their own team to ensure effective communication, in-depth knowledge of the clients allocated in that group thus improving the dissemination of information around the home. Develop a new service profile that details more clearly the changes in service provision, as the residents often remain at Highbury so long that preadmission information becomes less relevant. We looked at copy of the homes statement of purpose, which had review dates July 2008 / 18/2/09. The document contained comprehensive information but the information about the registered manager, who had left the service, was out of date and there was no information about the range of fees. We discussed this omission with the acting manager and area manager who told us that the fees charged were based on each persons individual assessed needs and were paid by the Primary Care Trusts or Local Authorities. We recommended that information about the range of fees should be included in the service user guide. The AQAA told us about the planned improvements for the next 12 months, which included the redevelopment of the brochure and revision and updates for the statement of purpose and service user guide. We saw that peoples needs had been assessed to provide a sound basis for planning their care and support. However, the principal focus of assessment appears to be clinical need and was not very person centred. Also, it was important that documents Care Homes for Adults (18-65 years) Page 12 of 40 Evidence: should be properly signed and dated, so that it would be clear when they were written, and due for review. We saw a written contract on file dated 21 November 2008; the room allocated was not specified. It is recommended that contracts be updated to include all of the information specified in National Minimum Standard 5, so that all parties are clear about their responsibilities. Care Homes for Adults (18-65 years) Page 13 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are care plans and risk assessments to support people to lead as an independent life as possible. Evidence: We looked at a sample of care files containing care plans, risk assessments and held discussions with people and staff about how each person was supported and given assistance to meet their daily needs. We saw that people had detailed care plans in place, and records showed that these had been kept under review. It was recommended that care plans should be developed to make them more user-friendly and person centred. The language used in each person plan seemed to be geared rather more towards the professionals reading them rather than the person whose plan it was for example, promote (Ns) capacity to sequence and clarify understanding by summarising statements and requests. Records of review were limited to comments such as care plan remains appropriate to (Ns) individual care requirements. Care Homes for Adults (18-65 years) Page 14 of 40 Evidence: It was recommended that plans should be developed to include some clear goals with outcomes that could be measured. These should be evaluated on a regular basis, and it might be that the regular key worker meetings already in place could provide the ideal opportunity to do this. Care plans we saw included some goals but these seemed to be more for staff than the people using the service, for example, promote respect and dignity while sustaining a level of independence and provide clear and concise feedback to promote understanding relative to his needs. Care plan goals should include clear statements of the aspirations and wishes of the individuals concerned, so they receive the support they need to achieve the things that they say are important to them. Each persons goals should also provide clear direction to the planning of activity opportunities. We saw that risk assessments were in place. Some of these were generic in nature and focused on clinical needs. It was difficult to make clear links between risk assessments and care plans. It is recommended that simple indexing and crossreferencing of plans and risk assessments would make important information easier to find. We noted that people were offered the opportunity to manage their own money if they wished and if it was appropriate. The home provided facilities to help keep funds safe. We looked at a random sample of balances and records of monies held in temporary safekeeping on behalf of people living at the home, which were accurate, with generally satisfactory records of transactions. We saw some transactions without two signatures. We recommended that there should be two signatures for all financial transactions of peoples funds held in temporary safekeeping and one signature could be the person involved, where they had capacity to understand. We saw that one person had several receipts for taxi fares. The acting manager told us that these were payments for times when the person absconded from the home and was found at a relatives home. The person was charged for the fare as a consequence for their behaviour. This person was under a Guardianship Order and we were told that a taxi was used for return journey to the home as an alternative to requesting a Police escort. We were concerned that it was unclear whether the person understood the use of their money as a consequence of this behaviour. There was no evidence these actions had been discussed and agreed with the multi-disciplinary team. We also discussed this persons risk assessments, which indicated the need for ratio 2:1 staff supervision in the community. The acting manager confirmed that there were high risks for this person to be unsupervised in the community for him and for the public. We requested that the acting manager make safeguarding referral and request a review so that agreed arrangements could be put in place to ensure the Care Homes for Adults (18-65 years) Page 15 of 40 Evidence: person was safe. We were informed a review would take place with the persons consultant within days of this inspection visit. Care Homes for Adults (18-65 years) Page 16 of 40 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. Some people are able to take advantage of socially stimulating opportunities. Good contact is maintained with family and friends for the majority of people living at the home and there is evidence that they are supported to exercise control and make decisions about their lives where this is possible. Food available offers people a choice of choice of a well-balanced and varied diet, which meets their tastes and preferences. Evidence: The homes AQAA stated what they do well, In order to promote a social environment in keeping with the age range and cultural mix of our residents we have an activity senior in the home, to organise a programme for residents after clinical liaison with RMNs. Staff are supportive during activities or any events in home and ensure a wide participation from the whole of the resident group. Assistance to access activities is provided at a level appropriate to the individuals needs. Care Homes for Adults (18-65 years) Page 17 of 40 Evidence: We provide group activities to facilitate interaction where possible. Where this is not possible we provide quality time on a one to one basis where the resident is willing or requests interaction. We review and alter our activity provision on a regular basis to stimulate interest and maintain participation levels. We ensure a balance is struck between social, leisure, recreational, educational and therapeutic activity to promote personal development within the context of a slow stream rehabilitation process. Menus are varied and reflect the preferences of the residents. Where residents have requirements for culturally specific meals these are prepared on the advice and guidance of the residents, relatives or independent advocates. Snacks are available on request at any time and in accordance with the wishes and needs of the residents. Residents are provided with an opportunity to go on holiday and an allowance is provided to facilitate this. The homes AQAA cited what had improved in the last 12 months, Cooking clubs and teaching sessions are now regularly undertaken to provide life skills development in a social context; this also enables staff to build a good rapport with residents. Residents are encouraged to purchase the produce involved in the formulation of a menu. This promotes increased knowledge of the financial aspects as well as health promotion regarding a balanced diet. We have undertaken a survey of residents to ensure that our plans for a new menu reflect the likes and tastes of our resident group. The acting manager told us about improvements planned for the next 12 months, such as, individualised menus for each person, and more individual involvement in the development of individual health action plans with a more visible focus on health promotion. We were not able to verify all the claims made in the homes AQAA. We looked at peoples records to see how their activity opportunities were planned and managed. Recording of the things people had done was very limited. There was a system in place for allocating codes to activities. These included relaxation, life skills, educational, spiritual, recreational activities, and those promoting health. Entries about what people had done were limited to things like Stourbridge shops, Merry Hill, music session and ride to Leasowes. Another persons activities were centred on walks and going to the pub in Stourbridge. There were records, which detailed conversations with this person and their in depth knowledge of the locality and interests in woodwork and being creative with their hands. It was difficult to establish clear links between peoples care plans and goals, and their activity opportunities. We Care Homes for Adults (18-65 years) Page 18 of 40 Evidence: saw questionnaires completed by (or on behalf of) people showing some preferred activities, but these did not appear to feature greatly in the things they actually did. A client questionnaire stated would like to go bowling, to the library and to the Crystal Leisure Centre. These preferred activities had not been provided for this person. Peoples activity opportunities should be a prime indicator of their quality of life and there should be clear links between their personal goals and aspirations, and the things they actually do, subject to appropriate risk assessments. Person centred care plans are important for this reason and must include goals that have clearly measurable outcomes. A persons activities plan included budgeting, banking, shopping, travel, cooking classes but these did not feature in progress reports for community activities. It was difficult to see how peoples life skills and independence were being promoted by the activity opportunities they currently enjoy. Records provided evidence that people were supported to keep in touch with other people important to them, where this was possible. Example were: one person was supported to make visits to their family home and another person, recently admitted to the home, had an improved relationship with his parents, who regularly visited the home. We also saw evidence of a range of in house activities provided including a Christmas event, X-factor night, and cooking club. We saw that one persons had support to meet his spiritual and cultural needs through visiting the Sikh temple with his parents, and going out for Asian food. Members of staff took turns to prepare meals based on peoples preferences. We saw food records, though these did not demonstrate that an approach to healthy eating was always followed, examples of one persons food consumed on outings consisted of sausage rolls and Belgian bun. We saw that the majority of food was ordered and purchased from a central budget. There were plentiful supplies of a wide range of dried, frozen and fresh foods. We were told about the cookery club involving a small number of people residing at the home but we did not see evidence of shopping and budgeting on an individual basis. Care Homes for Adults (18-65 years) Page 19 of 40 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health needs of people living at the home are generally met with evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication do not always ensure each persons medication needs are met. Evidence: The homes AQAA cited the following evidence for what they say they do well, Highbury works collaboratively with residents to inform, educate and clarify what their specific needs are. Detailed plans are in place for the care of residents following a period of assessment. Programmes are in place to promote the psycho-social development of residents, bolstering their self-esteem and confidence. We provide detailed care plans which are evaluated and updated on a four weekly basis or when needs change. We access support, advice and guidance from a wide range of professionals; to ensure that the care provided is relevant and evidenced based. The home has a close relationship with the local district nursing team and they work closely together to ensure that needs are met in a timely manner. All of our residents are registered with a GP and most have specialist services including Consultant Psychiatrists, Psychologists etc. Our nurses are trained and supported through their Care Homes for Adults (18-65 years) Page 20 of 40 Evidence: requirements to meet their continuing professional development standards. Staff are encouraged to participate in evaluation and review processes to ensure that a full picture of the care of individuals is recognised. Families and residents are asked for their opinions and their suggestions and ideas are incorporated into the care plans as far as possible. Independence is promoted wherever possible and all staff assist in a manner that provides for the development of skills. Resident involvement in the planning, implementation and evaluation of their own care plans is a key element of the philosophy of the home to ensure maximum rehabilitative opportunity is achieved. The homes AQAA cited examples of how the home had improved in the last 12 months, Community and activity team has been revamped to ensure that the psychosocial needs of all residents are assessed and implemented thus ensuring that Highbury House utilises a holistic approach to improve care provision within the service. We saw that people were generally well dressed in clean clothing of good quality and had received the support they needed with their personal care. Interactions between people using the service and staff were generally warm and friendly, and both appeared at ease in each others company. We saw that a person recently admitted as an emergency had improved with the level of personal care they were able to do for themselves, with a recent evaluation stating now only requires minimal prompting. However as reported above, care plans needed some development to make them more person-centred, so that staff have clear guidance about how to give support in the ways that each person liked best. Records provided evidence of involvement of a range of professionals in peoples care, showing that the service sought advice and support appropriately. These included consultant psychiatrist, psychologist, occupational therapist, social worker and dentist. It was recommended that the service developed Health Action Plans for each person, in keeping with the aspirations of the Government White Paper Valuing People (2001). The focus of health action planning is the proactive promotion of good health and healthy lifestyles, as opposed to reactive support (i.e. only doing things in response to problems as they arise). It is recommended that the local health facilitation team be contacted to gain support and advice for this. We looked at the care of a person with diabetes and we found that the care planning for this condition was not holistic in approach and information relating to health checks for nutrition, foot care, dental care, and eye care were kept in separate files. We were told that baseline observations were checked if there were any concerns. The Care Homes for Adults (18-65 years) Page 21 of 40 Evidence: nurses told us they had not received specific diabetic care training but would be interested to learn more about the condition. We recommended that the specialist diabetic nursing service should be contacted to provide training, support and advice. The pharmacist inspector visited the home on 4th February 2010 to check the management and control of medicines within the service. We looked at medication storage, all medicine records and the care plan for one person. We spoke with one nurse who was present during the inspection. We were in the home for two hours. We saw that medication was stored securely in a locked clinic room with locked cupboards. This meant that medication was safe and therefore the people who live in the service were protected from harm. We looked at the medication administration record (MAR) charts, which were handwritten by staff. We saw one MAR chart for a person, which did not include their date of birth or the name of their GP and another MAR chart did not include the month or the year. We saw one handwritten MAR chart which was confusing and it was not possible to determine exactly how much medicine needed to be given and there was an increased risk of a medication error. All the MAR charts were documented with a staff signature to show when medication had been given to a person or a reason was recorded if medication was not given. This meant that staff were recording and documenting what medicine was given to a person, however there was no system to ensure that the handwritten MAR charts were accurate. We found that counts and checks made on the majority of medication were accurate; however it was not always possible to complete accurate checks. For example, the date of opening of some medicines was not always recorded and two boxes of the same medicine were in use for one person, which meant that accurate checks could not be made. We found that other medication records were generally up to date. For example, we saw current records for the receipt and disposal of medication. Overall, the medication records helped to ensure there was a clear audit trail of medication and people who live in the service were being given medication as prescribed by a medical practitioner. We found information relating to medication available in the care plans for individual people living in the service. For example, we looked at one person who was prescribed five different tablets. One of the tablets was to be given when required for anxiety. We were shown a monthly behaviour graph which recorded the dates when the tablet was given in order to see if there was a pattern to the persons behaviour. We saw written information in the care plan to explain the reason why the tablet was given. There was Care Homes for Adults (18-65 years) Page 22 of 40 Evidence: also internal reviews undertaken, which documented any medication changes. The written information was clear, up to date and ensured that staff could access the information at any time. Care Homes for Adults (18-65 years) Page 23 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints system with good evidence that peoples views are listened to and acted upon and people are supported to exercise their rights as citizens. The systems do not always provide adequate safeguards for every person. Evidence: We saw copies of the complaints procedure displayed in the home and included in the statement of purpose. The information telling people how they could raise concerns or complain had not been provided in alternative formats for people unable or read or understand the written information. Information in the Homes AQAA told us that the home had received two complaints in the past 12 months, which had been investigated and upheld by the provider within 28 days, with satisfactory resolutions implemented. We looked at the homes complaints log and noted that there were three complaints recorded, with information about investigations and actions for resolution. We also saw that Advocacy Information was readily available around the home. The homes AQAA told us, We have maintained our high standards in regard to our responses to complaints. We have introduced a more robust system to highlight the receipt of appropriate CRB and reference clearance. We were told that there had not been any safeguarding alerts or referrals made by the Care Homes for Adults (18-65 years) Page 24 of 40 Evidence: home in the past 12 months. However we had received a Regulation 37 notification about an incident involving a person admitted to the home on an emergency basis who had displayed physical aggression to a member of staff. There had been a safeguarding strategy meeting and measures had been introduced to monitor and manage the risks of repeated behaviour including, ABC (Antecedent Behaviour Consequence) charts and level 3 observations by staff at the home. This level of observation meant that a member of staff was designated to maintain sight of the person at all times in communal situations. We looked at the daily observation records and noted that these were being recorded hourly but many entries were the same and not all entries were signed. As highlighted earlier in this report we noted that a person at the home with a Guardianship order was absconding from the home on an increasingly frequent basis, posing risks to him and the public whilst in the community unsupervised. This situation should have been reviewed at an earlier stage, with revised risk assessments and measures to control the risks, including increased vigilance and alarms for the fire doors, where he was leaving the building unobserved. Safeguarding alerts must be made to the lead agency where vulnerable people are at risk of harm and Regulation 37 notifications must be submitted to us for all such incidents. The home had policies and procedures to inform staff about abuse and responsibilities for reporting suspicions or incidents. We spoke to some staff who told us that they knew where they must report allegations or suspicions of abuse. There was a copy of the multi-agency Safeguard and Protect procedure for the protection of vulnerable adults. Some staff had received safeguarding training, though this was not provided by the lead agency Dudley DACHS, which would be beneficial for familiarisation of the multi-agency procedures. We recommended that all staff should read and sign policies to demonstrate awareness of procedures to safeguard people at the home. We saw that there were significant numbers of reported incidents and accidents where staff had experienced physical aggression or assaults from people using the service. It is recommended that the organisation should review the policy and procedural guidance relating to violence and aggression towards staff and make sure all staff have received support and training to deal with the risks involved in this service. At the previous key inspection we identified improvements, which were needed to the recruitment processes so that vulnerable people living at the home could feel assured that all staff working at the home were suitable care for them. At this inspection we saw two out of three duplicate staff files had only one written reference, instead of two references required. It was recommended that the manager obtained assurances from Care Homes for Adults (18-65 years) Page 25 of 40 Evidence: head office that there were two satisfactory references available prior to employment commencing at the home. Care Homes for Adults (18-65 years) Page 26 of 40 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 living at this home are provided with a pleasant, comfortable environment. The systems do not always safeguard all persons at the home. Evidence: The home offers accommodation, support and nursing services for up to 20 younger men and women. The home was a converted Georgian building situated in a residential area of Stourbridge near to shops and other local facilities. We were told about plans to make better use of the gardens to provide recreational areas and gardening opportunities for people using the service. There was an area of decking, which had been risk assessed, in need of renovation to make it safe and was restricted until the warmer weather when the work would be carried out. The homes AQAA cited the following evidence about what the home does well, The home provides a comfortable and clean environment which is well maintained. The atmosphere is warm, welcoming and friendly and our residents are happy in their home. We have a regular programme of building maintenance and redecoration to ensure that all rooms and communal areas are upgraded as necessary. Our domestic team provides an efficient and effective service and the home is clean, neat and tidy whilst maintaining a homely atmosphere. We encourage personalisation of rooms for all residents and involve relatives in choices where appropriate. We undertake regular Care Homes for Adults (18-65 years) Page 27 of 40 Evidence: environmental audits to provide feedback regarding areas for improvement. We respond promptly to resident concerns regarding their personal space and the environment. The home is audited on a daily basis by senior support staff and feedback is provided to the management regarding comfort and environmental practises. We undertake hazard analysis, risk management and action planning with regard to fire safety and environmental practices. We internally audit health and safety service and action plans are created. This is undertaken by service manager and maintenance operative. All rooms are equipped with en-suite facilities. Communal bath room, allows access to shower for residents that have impaired mobility requirements The AQAA told us about what had improved over the past 12 months, We have encouraged residents to personalise bedrooms. Weekly building checks involving appointed staff and health and safety representative. Refurbishment of building (new floors and all communal areas decorated). On-site maintenance operative trained in PAT testing. A new kitchen floor has been laid. Extra domestic personal recruited to maintain high standard of cleanliness around the home. We briefly looked around the premises there was evidence that the home continued to be maintained with an ongoing maintenance programme. Generally secure systems remain in place to protect people living in the home, with a seven foot perimeter fence, and the main gates area opened with required actions and the pedestrian gates locked at night. We were told that people who wish to go out at night on a risk assessed basis had a key for access after the gates were locked. However as already highlighted earlier in this report one person was absconding posing risks to him and the public. Staff told us the person used fire doors, which were not alarmed, to leave the building. The acting manager informed us that the risk assessment in relation to the premises would be reviewed with improved control measures to minimise the risks. The fire doors must be alarmed as a minimum control measure to safeguard this person. The majority of people had their own bedroom and we viewed a sample of rooms with the persons permission where possible. Most bedrooms were furnished and personalised according to each persons preferences. However we saw a shared bedroom without comfortable chairs or individual bedside or over-bed lights; and in the en suite there was only one bathroom cabinet for toiletries, including toothbrushes, which were jumbled together. This was not hygienic. Additionally there was no written evidence that the two people had agreed to share bedroom accommodation. This did not demonstrate that each persons rights to choice, privacy Care Homes for Adults (18-65 years) Page 28 of 40 Evidence: and dignity were fully considered. Another persons bedroom had broken wooden flooring, which was not on the maintenance programme. This should be risk assessed, and renovated or replaced to control risks of an accident. The kitchen was well organised, with well maintained equipment, and a wide range of food stocks stored and prepared in generally good compliance with food safety. The acting manager discarded a small number of food items during the inspection. These were not stored in the fridge in accordance with manufacturers instructions. Laundry facilities were provided in the basement of the home. We reported at the previous inspection that the location of the laundry did not provide a safe environment for people accommodated to do their own laundry and the access for staff had not been risk assessed. The organisation must devise and implement a safe system of work for the laundry accessed via step cellar steps and secured with an external lock and key. There were good standards of cleanliness maintained and there were no discernable malodours during this visit. Care Homes for Adults (18-65 years) Page 29 of 40 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. Staffing levels in the home are sufficient and people benefit from being cared for by trained staff. Recruitment processes are not always sufficiently rigorous, which may result in insufficient safeguards for people using the service. Evidence: The homes AQAA cited the following as evidence of what the home does well, Residents are well supported by staff and the staffing levels and skill mixes are maintained to meet residents needs. All staff are competent in their job roles and trained to undertake the duties of their post. They are provided with all of their mandatory training requirements according to the identified needs of the home. We facilitate access to external training provision to update current practices and to enhance specialist knowledge. Key staff are encouraged to look at a variety of accredited courses to provide quality care in all areas of practice. We provide a number of internal development packs at a variety of levels to ensure that all staff have the opportunity to reach their full potential. We provide regular supervision to all staff and undertake at least annual appraisals. We develop action plans as a result of these to meet the needs of all staff. All staff attend interviews and are subject to the required CRB checks as part of our selection process. Upon commencement all staff complete an induction programme and support is Care Homes for Adults (18-65 years) Page 30 of 40 Evidence: offered to those who are having difficulty adjusting to their roles in the early stages. Where the required standards are not met after support the probationary period is not extended to reduce the risk of employing staff that are not able to meet the needs of the residents. Utilise buddy system in house to ensure that roles and responsibilities relating to positions are fully understood. Ensure that staff are fully conversant with the expectations of the national care standards act. From assessment of staffing rotas, observations and discussions there were adequate staffing levels, including an additional team of staff employed to support people with activities. Staff told us there were some concerns with the changes introduced by the organisation but people generally felt more settled. Staff felt there were generally enough staff on duty but occasionally there were not sufficient to provide all the individual activities, outings and in house supervision for people with very different needs. Staff told us some days were difficult when people are on top of each other and things can kick off. As reported at the last key inspection the management should keep staffing levels under review to make sure that sufficient numbers of staff are on duty at all times. This will help to ensure that every persons care needs can be met safely at all times. The AQAA told us that six staff had left the homes employ in the last 12 months. We were told that new staff had been employed, including a male carer to meet the needs of males accommodated. Two nurses who had left to pursue other career opportunities were retained as bank nurses. We spoke to a bank nurse and it was evident that good relationships were maintained with the nurses who were retained bank workers. We were told of improvements since the last inspection, such as retention of the majority of the newly appointed staff throughout the year. There was an increased number of staff with an NVQ 2 award, so that there were 17 out of 21 care workers with the award. We looked at staff files to see how the service selects and recruits people to work in the home. The acting manager told us that personnel files were held at the organisations main office, and that the files in the home were duplicates. The files we looked at contained completed applications with full employment histories. However, two of the three files we sampled only contained one written reference, not two, as required. Only one contained a job description or statement of terms and conditions. All three contained evidence of checks with the Criminal Records Bureau, as required. We saw that a training schedule was in place. The Manager told us that the organisation operated a rolling programme of training. Staff were divided into teams, Care Homes for Adults (18-65 years) Page 31 of 40 Evidence: and completed their allocated training each month. It was recommended that the manager produce a training and development plan in spreadsheet format. This would show, for each member of staff, training completed and qualifications gained (with dates) and show when refreshers are due, and the dates these were scheduled. This should provide an instant overview of the staff teams training and development needs, and a useful tool for planning and scheduling future training. We saw that a schedule had been introduced in recent months (October 2009) for managing staff supervisions. These were allocated to senior staff and the record showed these were now being completed regularly. It should be acknowledged that training and supervision were currently works in progress. It is anticipated that these standards will be fully met in due course. Care Homes for Adults (18-65 years) Page 32 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an effective management team providing good leadership and direction, which ensures continuity. There are systems for consultation with people living at the home. The systems for safeguarding people in their environment are not sufficiently robust. Evidence: The homes AQAA cited what the home does well, The manager is a qualified nurse and is undertaking his NVQ 4 Leadership and Management. He works closely with the senior manager and the company to maintain the smooth running of the home in a financially viable manner. Our staff work well as a team to provide for the needs of the residents and follow the policies and procedures provided in the home. The manager is proactive in issuing reminders to staff who do not operate in accordance with expected standards. Policies and procedures are updated regularly and the staff and manager contribute to this process through the staff representative meetings, managers meetings and via internal reports. The manager is supported by the company senior management structure to achieve negotiated goals and targets and accesses supervision himself to assist in maintaining personal growth and development. The Care Homes for Adults (18-65 years) Page 33 of 40 Evidence: new manager is currently in the process of applying for registered manager. He has eight years experience in community, acute and forensic work. Training needs are clearly documented and reflect the national and organisational requirements of the support team. RMN team responsible for the formulation of educational/activity plans to promote residents development. During discussions there was evidence of an open, approachable ethos, which encouraged good communication with people living at the home, their relatives and staff. There were clear lines of accountability within the home, and through the management structure. We saw evidence that a representative of the organisation visited the home regularly. We spoke to a senior manager and looked at the Regulation 26 Reports held at the home, which were comprehensive and constructive. We were told that the improvements included, working closely with senior management to develop key skills and strengths in leadership. The senior manager told us she visited the home on a weekly basis as part of the quality assurance arrangements and provided the acting manager with formal supervision sessions, support and development. We were informed that the acting manager would submit an application to us for registration within a week. We noted that staff meetings were taking place and there was a structured formal supervision system. The development of staff knowledge and skills had evident benefits for people living at the home. We looked at records relating to health and safety. We saw that regular checks were carried out on essential equipment around the home. This helped to ensure that people living and working in the home are supported to stay safe. As highlighted earlier in this report there were recorded incidents relating a person frequently absconding. The acting manager was reminded that any event adversely affects people at the home must be notified to us without delay. We looked accident records and noted that there were 22 recorded accidents since February 2009 relating to persons living at the home and 25 recorded accidents and incidents related to staff for the same period. There should be a regular documented analysis of all accidents to evaluate any trends and minimise risks as far as possible. Care Homes for Adults (18-65 years) Page 34 of 40 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 35 of 40 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 9 13 Identified risks must be kept 01/04/2010 under review and minimised with control measures. There must be proactive responses to any changes with prompt referrals and notifications to appropriate agencies in relation to unexplained absences. This is to safeguard people using the service. 2 20 13 To make arrangements to ensure that medication administration records are accurately maintained. This is to ensure that the care service maintains accurate records of medicines administered to people. 01/04/2010 3 23 13 Safeguarding referrals must be made to the lead agency where vulnerable people are at risk of harm and Regulation 37 notifications 01/04/2010 Care Homes for Adults (18-65 years) Page 36 of 40 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 must be submitted to the CQC for all such incidents. This is to safeguard each person using the service from risks of harm. 4 24 13 Risk assessments for entry and egress to the home must be reviewed and fire exits must be alarmed as a minimum control measure. This is to safeguard all persons for risks of harm. 5 42 37 Systems must be 01/04/2010 implemented to ensure any event, which adversely affects people at the home is notified to the CQC without delay. This is to safeguard the health and well being of people living at the home. 6 42 13 The organisation must 01/04/2010 devise and implement a safe system of work for the laundry accessed via step cellar steps and secured with an external lock and key. This is to provide safeguards for all persons at the home. 01/04/2010 Care Homes for Adults (18-65 years) Page 37 of 40 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 Information about fees should be included in the service user guide to give people comprehensive information about the service. Contracts should be updated to include comprehensive information and to reflect the guidance from the Office of Fair Trading related to Care Homes contracts, so that all parties are clear about their responsibilities. Simple indexing and cross-referencing of plans and risk assessments would make important information easier to find. Care plans should be developed to make them more userfriendly and person-centred, should be developed to include some clear goals with outcomes that could be measured and should be evaluated on a regular basis. There should be two signatures for all financial transactions of peoples funds held in temporary safekeeping and one signature could be the person involved, where they had capacity to understand. Person centred care plans must include each persons activity opportunities and goals that have clearly measurable outcomes. There should be clear links between each persons personal goals and aspirations, and the things they actually do, subject to appropriate risk assessments. The specialist diabetic nursing service should be contacted to provide training, support and advice. The service should develop Health Action Plans for each person, in keeping with the aspirations of the Government White Paper Valuing People (2001), and the local Health Facilitation Team should be contacted for support and advice. Information telling people how they can raise concerns or complain should be provided in alternative formats for people unable or read or understand the written information. All staff should read and sign policies to demonstrate awareness of procedures to safeguard people at the home. The organisation should review the policy and procedural 2 2 3 6 4 6 5 7 6 12 7 12 8 9 19 19 10 22 11 12 23 23 Care Homes for Adults (18-65 years) Page 38 of 40 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 guidance relating to violence and aggression towards staff and make sure all staff have received support and training to deal with the risks involved in this service. 13 24 The broken wooden bedroom flooring should be risk assessed, and renovated or replaced to control risks of an accident. There should be documented agreements in place where two people have agreed to share a bedroom and the should be sufficient furniture and fittings, such as comfortable chairs, independent lighting and cupboards, so that each person can exercise their individual rights to choice, privacy and dignity. There should be assurances that two satisfactory written references have been received for all members of staff prior to commencing employment at the home. This is to ensure staff are suitable to work with vulnerable people using the service. It is recommended that a training and development plan should be produced in spreadsheet format, which would provide an instant overview of the staff teams training and development needs, and a useful tool for planning and scheduling future training. An application should be made to the CQC requesting the registration of the home manager. This will support the running of the home in a way that supports and benefits people living in the home. This was an unmet previous good practice recommendation. There should be a regular documented analysis of all accidents to evaluate any trends and minimise risks as far as possible. 14 25 15 34 16 35 17 37 18 42 Care Homes for Adults (18-65 years) Page 39 of 40 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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