Care Home: Katherine House

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What the care home does well People have a care plan that is kept up to date and tells staff how their needs should be met. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Everyone has their own bedroom. People can put things that are important to them in their rooms so they are personal and comfortable. People’s family can visit the home when they want to and they are made to feel welcome so people maintain relationships that are important to them. People are supported to do things they enjoy, go on day trips and holidays so they live fulfilled lifestyles. Safety checks are completed so the home is safe for people to live in. What has improved since the last inspection? Lots of improvements had been made since our last visit so the home is a nicer place for people to live. There is not so many people living in the home so it is a calmer and a more relaxed place to live in. The lounge, dining room and hall have been painted so the house looks nice and welcoming for people. There is a sensory garden for people to enjoy, if they choose to. People are being supported to make more choices about the food they would like to eat. Improvements have been made to how information is communicated to people so they feel more involved in decisions that are made. People are going out more and doing things they like to do. Staff have had training so they know how to meet people’s needs. Regular visits are being done by the owner to make sure that the home is being run well for people. What the care home could do better: The medication management must improve so people receive their medication safely.Katherine HouseDS0000068481.V378245.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Katherine House Katherine House 91 - 93 Sutton Road Erdington Birmingham West Midlands B23 5XA Lead Inspector Donna Ahern Key Unannounced Inspection 17th November 2009 11:00 Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. 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 home adults 18-65 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. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Katherine House Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Katherine House 91 - 93 Sutton Road Erdington Birmingham West Midlands B23 5XA 07834977180 Pharos Care Limited Ms Sheila Claybur Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of care only Care Home only to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability 10 The maximum number of service users to be accommodated is 10. Date of last inspection 10th March 2009 Brief Description of the Service: Katherine House is a large detached house and provides twenty-four hour care and support for ten people with Learning Disabilities, Autism and behaviour that can be difficult to manage. Eight people were living at the home at the time of the Inspection. The home is close to the centre of Erdington where there are a variety of shops, restaurants, transport links and leisure facilities. There are seven single bedrooms and two flats all bedrooms have an en-suite bathroom with either a bath or shower. One of the bedrooms is on the ground floor and is accessible to a person with limited mobility. All other bedrooms are on the first floor and second floor. There is no lift so people would need to be fully mobile to access the first and second floor. There are two large lounges on the ground floor a large dining room, conservatory, extended kitchen, office and a separate laundry. To the rear of the Home is a large garden with lawned area and patio, and to the front of the Home there is off street parking. Since the last inspection one of the bedrooms on the first floor has been made into an office reducing the number of bedrooms from ten to nine. The statement of purpose seen stated fees range from £1,700. Toiletries, personal clothing, electrical items and some activities are not included in the fee. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 5 Previous inspection reports were available in the hall for people to read. The date of the previous inspection is March 10th 2009. SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star adequate service. This means the people who use this service experience adequate quality outcomes. This inspection was carried out by one inspector over one day. The home did not know we were going to visit. This was the homes key inspection for the inspection year 2009 to 2010. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and an Annual Quality Assurance Assessment (AQAA) completed by the owner. This provides information about the home and how they think it meets the needs of the people living there. We case tracked the care received by three people living there. This involved establishing individuals experience of living in the care home by meeting and talking with them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked at parts of the home and a sample of care, staff and health and safety records. The people living there who were able to communicate their views, the manager, four staff on duty, three relatives visiting and two professionals were spoken with. As some people were not able to communicate their views, time was spent observing care practices and interactions from staff. We sent out eight surveys to people who live at the home and their relatives. We sent eight to staff. Seven were returned from people living there one from a relative and five from staff. The surveys ask people about their views of the home, comments we received are included in the report. What the service does well: People have a care plan that is kept up to date and tells staff how their needs should be met. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 6 Everyone has their own bedroom. People can put things that are important to them in their rooms so they are personal and comfortable. People’s family can visit the home when they want to and they are made to feel welcome so people maintain relationships that are important to them. People are supported to do things they enjoy, go on day trips and holidays so they live fulfilled lifestyles. Safety checks are completed so the home is safe for people to live in. What has improved since the last inspection? What they could do better: The medication management must improve so people receive their medication safely. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 7 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. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):1 and 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people and their relatives would have the information they need to know so they can make an informed choice about whether they want to live at the Home. EVIDENCE: There had been no new admissions since our last visit so it was not possible to assess the pre admission process. We saw that a detailed pre admission procedure is in place and if followed should ensure that full assessments are completed prior to admission. The service user guide and statement of purpose tell people what they can expect from the home and had been written in a style that is easier for the people living there to understand. Eight people were living there at the time of the visit. The manager told us although the home is registered for ten people, they are only accommodating Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 10 up to eight people and this is stated in the statement of purpose. One of the bedrooms has been made into an office reducing the number of bedrooms to nine. This does not reflect what is on the homes registration certificate. The owner needs to confirm to us how many people they want the home to be registered for so the statement of purpose and registration certificate is consistent and accurate. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):6, 7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the information they need and a good understanding of how to offer care and support to each person, which should ensure peoples needs are met in a way they prefer. EVIDENCE: We looked at three care plans. Care plans explain what each persons needs are and the care and support they require to make sure these needs are met. A lot of work had taken place to improve care plans so that staff have the information they need to support people. People have two care plan files and an essential lifestyle plan. There is a lot of information for staff to read about people. We found that the files looked at gave information about how staff should support the person in order to meet their individual needs in relation to Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 12 personal care, communication, health care , social activities and likes and dislikes. Information was written in a way that reflected personalised care. This should ensure that people receive support in a way that they prefer. We spoke to four members of staff who support each of the people we also observed people being supported by staff. The staff demonstrated knowledge of people’s individual needs which was consistent with the information on peoples file. This indicates that staff know how to provide care and support to people so their needs are understood and met. One of the people was supported to move bedrooms and a lot of work went into making their new bedroom suitable for their individual needs. However there was no documentation on their care plan to support how and why the decision to move rooms was made. We saw a number of risk assessments on people’s files. These generally detail the support people need to be safe whilst still being enabled to be independent. We spoke to the manager about giving consideration to what needs to be risk assessed instead of doing a risk assessment for everything in the persons care plan. This could make risk assessments more people focused and reduce some of the written information that staff need to read before they can support people to be safe. Behaviour management plans were in place and had been reviewed. We noted from talking to people, reading files and observing during the visit that incidents where behaviour may become challenging, had reduced significantly. The home felt relaxed and we saw staff responding promptly to people needs. A lot of work had been done to improve communication systems for people living in the home. Pictures and photographs are used to provide visual information. We saw that staff photographs are placed alongside the person they are supporting for the day. We saw in a person’s bedroom that they had activities for the week displayed in a visual format so the person who is autistic has the information they need to know in a format they can follow. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):12, 13, 15, 16 and 17. This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People experience a meaningful lifestyle that promotes their independence and is reflective of individual needs. EVIDENCE: We looked at care plans and daily records to establish that people are leading meaningful lifestyles and taking part in activities that they enjoy. We also spoke to four staff members and observed care and support on the day. We could see from reading daily notes that people go out to the shops, for walks, to places of interest, snoozeland and out for meals. On the day of the visit one person was at college and then went swimming. One to one staff Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 14 support was provided so that the person got the support they require to take part in the activities. One of the people told us they enjoy doing jobs around the home, going to the shops and playing bingo. We saw that another person is regularly supported to attend a temple so the person’s cultural and religious needs are met. People told us in the surveys “The home lets me do what I want to do each day” and “I think the home could have more drivers and team leaders should go out with service users more” One of the people’s relatives told us that things have really improved in the home. Their relative is now going out more on activities including swimming, going to the park and out for meals. They told us that their relative has enjoyed the trips to the caravan. People seemed relaxed and freely accessed all areas of the home choosing to go to their own bedroom, the kitchen or sitting in the communal lounge. The home has a caravan in Wales that is used by people living at Katherine House and other homes owned by the provider. Two people were preparing to go there for a weekend visit with two staff. Staff told us that the use of the caravan has been very beneficial to people and has enabled small groups of people to get away on short breaks. People are supported to maintain contact with relatives and friends and staff spoken with demonstrated that they recognise the importance of maintaining relationships that are important to people. During the visit we met with three relatives. They all spoke positively about the home. We saw that they were made welcome by staff and other people living in the home. We saw that one of the people had their evening meal with their family. We saw staff asking people if they would like a drink and supporting people to get a drink or snack. A lot of work has been done around meal times and supporting people to make real choices around what they would like to eat. Individual records are in place and photographs and pictures are used to support people to make the choices. One of the people wanted liver for their evening meal and was supported to go to the butchers to buy the meat so it could then be prepared for their evening meal. Beef stew and chicken curry were also prepared on the evening of our visit. People ate at different times some people choose to eat their meal in their room. One of the people told me they prefer to eat their meals in their own bedroom. We saw care plans had information about peoples food likes and dislike’s. One of the people told us in the survey they completed that they would like more branded foods bought. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 15 We saw records of tests in place for food and storage safety checks, which means food is stored and prepared in a hygienic and safe manner. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):18, 19 and 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements in place are not always effective in meeting people health care needs. EVIDENCE: Care plans that we looked at had good detail about how to meet peoples personal care needs. The range of needs of people living at the home is diverse and complex. These include difficult to manage behaviours, autism, aspergers mental ill health and additional medical conditions. There was information about how much support people required from staff and what people could do for themselves in order to maintain their independence. We saw that people were dressed in age appropriate clothing and people were well groomed, this indicates that people are supported to maintain a good selfimage. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 17 We met all of the people who live in the home and saw throughout our visit that staff were prompt to offer personal care or support as needed. We saw that changes in peoples needs had been made to people care plans so staff knew how to meet their health care needs. We had the opportunity to speak to a visiting professional who told us the manager works well with them and “Will go out of her way to do things for the people living in the home”. We saw that detailed protocols are now in place for managing people’s epilepsy. An epilepsy specialist nurse works closely with one of the people. Protocols are kept up to date and the person’s epilepsy is well managed. We saw that referrals had been made to different professionals so that specific health care needs are met. We saw that people are supported to attend medical appointments. We saw that outcomes of appointments are recorded so people’s wellbeing can be monitored and any follow up required can be actioned. Medication is stored in a locked cupboard off the dining room. The storage of medication was clean, tidy and well ordered. Copies of prescriptions are retained so that staff can check the right medication has been received from the chemist. None of the people self-administered their medication. When we checked the medication administration records (MAR) we saw that morning medication for one person had not been signed for the previous nine days however the medication had been administered from the blister pack. This indicates that staff are not checking the medication with the MAR chart before it is given to people which could put people at risk of harm. When one of the people went to stay with their family the procedure for signing over their medication had not been followed. Protocols were in place for the administration of medication on an as required basis. However more information is needed so it is clear in what circumstances this medication would be given. We saw information leaflets detailing what the different medication is for and their possible side effects had been retained on people’s files for reference but had not been written up on peoples care plans. The manager told us that staff are assessed annually and receive external training on the safe administration of medication. However the above practice does raise concern about staffs skills and knowledge to administer medication safely to people. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22 and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to listen to and respond to complaints about the service. Arrangements are in place so people should be protected from harm. EVIDENCE: The complaints procedure is available in an easy read format so it is more meaningful for the people who live there. It was really positive that the complaint policy is now available on audio and has been produced in English and Punjabi. Some of the people living at the home would require considerable support to raise a complaint or concern. We received one complaint about the home the day after our visit. It raised concern about staff care practice and the availability of food. We asked the owner to investigate this matter using their own procedures. People told us “staff are really good if I am not happy about something I talk to them and they sort it out”. Relatives told us “very happy with the home if there is a problem I go to the manager and it will be sorted”. Staff we spoke to demonstrated a general understanding of their duty to safeguard people and how to report concerns on to senior managers. We looked at training records to determine that training in safeguarding vulnerable adults had been provided. This should ensure that they know how to identify different types of abuse and what to do if abuse is happening so they can Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 19 protect the people living there. Safeguarding procedures and a whistle blowing policy was available for staff to refer to. At previous inspections we had been concerned about the domino effect that different peoples behaviour has on each other. At this visit the home was calm and relaxed for most of the day. We saw that staff were quick to respond to people when they became agitated and were able to manage the situation. We saw that behaviour management plans were in place, which tells staff how to support people to keep safe. Systems are in place for the recording of accidents and incidents to the commission this should ensure that notifiable incidents are reported to us. We saw that systems are in place for the recording of peoples personal money and a risk assessment was in place to inform staff about how to support people and ensure their money is handled safely. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):24 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a spacious home which is safe and comfortable and meets their needs. EVIDENCE: Katherine House is located near to local shops with public transport routes close by. There is limited off road parking to the front of the house. To the rear of the home there is a garden that people have direct access to. A lovely sensory garden has been developed and a range of garden seating is provided so people can enjoy the garden. The home is furnished and decorated in a homely and comfortable way. Since our last visit the internal communal areas including hallway and stairs have been painted. A conservatory and kitchen extension provides additional Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 21 communal space for people to pursue their interests. Three people showed us their bedroom. They had lots of their personal items to make it feel homely. One of the people has moved bedrooms and their room had been refurbished to a very good standard and is spacious and well laid out. A carpet in one of the bedrooms had recently been cleaned however this did not remove marks and stains. There is one bedroom on the ground floor, which would be suitable for a person who may have some mobility difficulties. All other bedrooms are on the first and second floor and are accessed by steep stairway and would not be suitable for people with mobility difficulties as there is no lift. A first floor bedroom has been made into an office and ensures a suitable room is now available for meetings to take place in private. There is a separate laundry room, which was clean and organised. We saw substances such as cleaning products that could cause harm to people had been locked safely away. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):32, 33, 34, 35 and 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a staff team who can meet their needs. Recruitment practice is robust and should protect the people living there. EVIDENCE: We watched the way that people interacted with staff on duty, which indicated that good relationships exist between people living there and the staff supporting them. We looked at the staffing rota for the week of the visit and the previous week. These showed that there is usually seven staff on duty during the day. We spoke to four staff during this visit who demonstrated that they had a good understanding of peoples individual needs. We spoke to staff about the training they had received and they said that they had completed training in mandatory areas including safeguarding, medication, Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 23 health and safety, first aid and fire. We looked at the staff training plan which confirmed mandatory training had taken place. In addition training specific to meeting peoples individual needs had taken place including epilepsy, sensory awareness and makaton. Training from an external trainer on autism awareness was taking place on the day of the visit at a venue near to the home. This should ensure that staff continue to have the up to date knowledge and skills required to meet peoples individual needs. One of the staff who had recently been employed told us they had a very good induction and shadowed experienced staff for several shifts. We looked at staff recruitment records for the two most recently employed people. We saw that Criminal Records Bureau checks (CRB) had been completed. Application form and details of references were on their file. This should ensure that people are protected from the risk of having unsuitable staff work in the home with them. Regular staff meetings take place, which provide an opportunity for staff to discuss good practice and development issues. The minutes of meetings seen were detailed and informative and we saw that in a recent meeting risk assessments and keeping good care records had been discussed. Staff who completed and returned the surveys to us indicated that they get the support they need to do their job and there is usually enough staff on duty. Staff told us in the returned surveys “The home provides a lot of choice for people. It is a happy and warm place to be with a great staff team”. “I have seen a great improvement over the last eighteen months”. “The home has improved drastically in every area. I have no concerns at present”. “The home works well as a team and pulls together to help each other provide the best service for our service users”. “I like the support I get from my manager and other senior staff. Training is always been done regularly to make sure we do our job professionally”. The AQAA informed us that only 7 of the 22 staff have achieved a National Vocational Qualification (NVQ) in care however it stated that staff are being supported to achieve NVQ which should contribute towards ensuring that the staff team have effective knowledge of social care. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):37, 39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements in place ensure the health, safety and wellbeing of the people living there. EVIDENCE: The manager assisted us with the inspection process. She was open and welcoming and demonstrated a commitment to continue to improve standards for people. The requirements we made in the last inspection report had been met which demonstrated a commitment to comply with the regulations. The visit established that improvements have been made across a number of areas including care planning systems, risk assessments and the monitoring of Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 25 accidents and incidents. However we identified shortfalls in the management of medication which could impact of the wellbeing of people. The manager wrote to us following the visit and advised us of the systems she has put in place since our visit to address the concerns we identified. There are quality assurance systems in place including an auditing system. The operations manager carries out monthly visit to the home to monitor and report on standards. Reports seen were detailed and should ensure that the provider takes responsibility for monitoring the home. An improvement plan is displayed in the office for people to see. This provides a focus for improving standards across all areas of the home. Staff spoken with and records looked at confirmed that staff have completed training on health and safety, fire, first aid, manual handling and basic food hygiene so a safe environment is provided for people. We looked at some health and safety records including fire records, gas appliances safety certificates and water temperatures checks. All are checked and serviced regularly. Monthly safety audits are completed which should ensure peoples health and safety is promoted. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000068481.V378245.R01.S.doc 3 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Katherine House Score 3 3 1 x 3 x 3 x x 3 x Version 5.3 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement Arrangements must be in place so that medication is administered safely so people are protected from the risk of harm. Timescale for action 14/12/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The provider should confirm to CQC the number of people the home is to be registered for so the registration certificate reflects the statement of purpose and the facilities provided in the home. The pre-admission assessment should be reviewed to ensure this is comprehensive, and that findings are kept under review. Previous recommendation. Not assessed at this visit as no new admissions. Decisions made on peoples behalf should be recorded so it is clear why and how these decision were made and in whose best interest. The side effects of people’s medication should be recorded on their file so staff can monitor people’s wellbeing and take action if needed. DS0000068481.V378245.R01.S.doc Version 5.3 Page 28 2. YA2 3 4 YA7 YA20 Katherine House 5 YA20 6 YA24 Protocols in place for medication taken on an as required basis for pain management or when a person has become agitated. These need more information so it is clear to staff when they would administer. The carpet in one bedroom should replaced so it is hygienic for the person. Katherine House DS0000068481.V378245.R01.S.doc Version 5.3 Page 29 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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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