Care Home: Langdown House

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What the care home does well The home`s admission procedure is underpinned by an inclusive and comprehensive assessment process to ensure the needs and aspirations of people using services can be met. Those who responded to our survey said they had a choice of home. Both the YMCA London South West and Surrey County Council have robust equality and diversity policies and procedures. These are embedded in the home`s culture and all activities, ensuring equality of access to services and non - discriminatory practice. Daily life at the home promotes independence and informed risk-taking, enabling people using services to be in control of their lives and to self-direct services, within individual levels of capacity. They are involved in domestic routines, taking responsibility for their own rooms and menu planning. Some people are allocated budgets and cater for themselves, purchasing food and cooking their own meals, with staff support. Though care plans are not produced in a person-centred, accessible format, observations concluded the approach to care planning is inclusive, personcentred and holistic. People using services have agreed individualised programmes of daily activities. Systems are in place to make sure staff unfamiliar with the home know the needs and wishes of the people they support. People using services participate in age, peer and culturally appropriate activities and are part of their local community. They are enabled to make choices about their lifestyles and supported in developing life skills. Staff demonstrate an understanding of and commitment to the social model of disability and principles of inclusion.They support people using services to maintain family links and friendships inside and outside of the home. The atmosphere on the houses was observed to be friendly, warm and welcoming. Health care needs are met ensuring access to routine health checks and specialist services. Staff work in partnership with health and other professionals. The management of medication is safe and principles of respect, dignity and privacy are put into practice.The houses were all clean and tidy and observations confirmed staff respect the privacy and autonomy of people using services. The expert by experience commented positively on the control they evidently have over their lives and personal space. Those who invited him to view their bedrooms clearly had them arranged how they wanted them. They had furnished them out of their personal money to their personal taste. The service complaint procedure is clearly written and easy to understand. It is available in a suitable pictorial format and displayed prominently in each house. People using this service said they knew how to make a complaint and their concerns and complaints are listened to and mostly acted upon. Survey feedback and discussions with people using services confirmed most were overall satisfied with services though there were some things they would like to be different. Comments included, "I like living here", "The home does everything well", "Staff treat me as a human being and not like a child and make sure I`m happy". "1 like it here and I am not going to move for nothing". We were informed by a social care professional that staff always supports people using services to live the life they choose, responding to their diverse needs. The professional commented, "There is a relaxed, homely atmosphere. Staff know service users and their needs well after working together for many years. Staff and service users are anxious about the future and could be better informed. This creates anxiety for all, including families". Relatives concerns regarding the home`s future were evident in their response to our survey, however most expressed satisfaction with service provision. Their comments included, "The home cares for people well, they can do nothing better"." Generally all aspects of my relatives care are met"."My relative is happy in the house environment and I know she is well looked after. I would like to receive her annual assessment". What has improved since the last inspection? A home manager has been appointed and registered in the past twelve months. The scope of individual and environmental risk assessments has been extended and health and safety monitoring systems are more robust, enhancing the safety of people using services. The recording and reporting of incidents and accidents has improved, enabling a more proactive and timely response to any significant change in needs and in making safeguarding referrals. The statement of purpose and service users guide have been updated and are now two separate documents. People using services were afforded opportunities for holidays and outings this year, which they helped choose and plan. Observations confirmed some redecoration had taken place, predominately in communal areas, dining chairs had been reupholstered and some items of furniture and equipment replaced. Malodorous carpets had also been replaced in a small number of bedrooms. Whilst staff recruitment remains suspended since June 2007 the home has benefited from the transfer of two staff from other care services, replacing two staff no longer in post. What the care home could do better: Two relatives felt communication could be improved also the home`s response to complaints. Attention is necessary to record keeping practices relating to care and complaints.The service users guide, care plans, review records and menus would be more accessible to people using services if produced in formats to meet their communication needs. It is necessary to plan and commence implementation of a renewal programme for stained, well-worn carpets. A more robust system is necessary to ensure agency staff are suitably vetted and trained. Staff training shortfalls must also be addressed. The expert by experience felt more could be done to make the houses look and feel different.Some people using services were upset about shortages of permanent staff and described how this adversely affected their lives. Key inspection report Care homes for adults (18-65 years) Name: Address: Langdown House 1-4 Yeend Close West Molesey Surrey KT8 2NY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Patricia Collins     Date: 1 4 0 1 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 33 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Langdown House 1-4 Yeend Close West Molesey Surrey KT8 2NY 02089794561 02089798901 jane.gupta@surreycc.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): YMCA London South West Name of registered manager (if applicable) Mrs Gemma Rose Stubbs Type of registration: Number of places registered: care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 28. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) Mental disorder, excluding learning disability or dementia (MD). Date of last inspection Brief description of the care home The home is owned and operated by YMCA London South West and staffed by employees of Surrey County Council. Langdown House is located in the centre of the local Molesey community and benefits from good access to transport, shops, banks and other community facilities. It comprises of four detached, purpose built two-storey houses, providing small group living accommodation in which people using services can Care Homes for Adults (18-65 years) Page 4 of 33 Over 65 0 0 28 28 2 3 0 2 2 0 0 9 Brief description of the care home enjoy maximum independence. The houses have a sitting room and combined dining/kitchen area and a utility room on the ground floor. Bedrooms are all for single occupancy, arranged on both floors near to bathroom and toilet facilties. There is no lift access to the first floor. The houses have secluded, enclosed gardens and car parking spaces. Surrey County Council currently block purchases all placements. Weekly fees are £765 pounds 25 pence per person. Additional charges include some transport costs, for holidays and for holiday escorts, toiletries, hairdressing and clothing.A reduced television license fee is payable by people using services who have televisions in their own rooms. They can arrange for satellite or cable connections at their own expense. Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The unannounced inspection visit formed part of the key inspection process using the Inspecting for Better Lives (IBL) methodology. The inspection visit was undertaken by one inspector over nine hours.The report will say what we found as it is written on behalf of the Care Quality Commission (CQC). Engaging with people using services is an integral part of the inspection process. For this purpose we involved an expert by experience, one of a range of stakeholder involvement methodologies we use. Experts by experience are recruited and trained by support organisations and visit homes with inspectors. Because of their shared experience of using services and/or ways of communicating, they help inspectors form a picture of what it is like to live in or use services. The expert by experience and his personal assistant spent five hours at this home and his observations are included in this report. Care Homes for Adults (18-65 years) Page 6 of 33 The inspection visit was facilitated by the registered manager and an assistant team manager. All available information has been taken into account when forming judgments about how well the home is meeting the National Minimum Standards for Adults. This includes cumulative assessment, knowledge and experience of the home since its last key inspection. The inspection process involved discussions with some people using the service and staff, sampling records and a range of other documents. We visited all three houses currently operational and looked at their gardens.We have taken account of all information received about the home since its last inspection including concerns of a relative. Also survey feedback from fifteen people using services, eight relatives, six staff and a social care professional. Each year providers registered with the Care Quality Commission CQC) must complete a self assessment called an Annual Quality Assurance Assessment (AQAA) and send this to the CQC. It provides quantitative information about their service; also requires assessment of services against the outcome areas of the National Minimum Standards for Adults (NMS), demonstrating both areas of strength and where improvements can be made. The content of the homes AQAA was clear, validated by evidence and this information also informed judgments about the service. Care Homes for Adults (18-65 years) Page 7 of 33 What the care home does well: The homes admission procedure is underpinned by an inclusive and comprehensive assessment process to ensure the needs and aspirations of people using services can be met. Those who responded to our survey said they had a choice of home. Both the YMCA London South West and Surrey County Council have robust equality and diversity policies and procedures. These are embedded in the homes culture and all activities, ensuring equality of access to services and non - discriminatory practice. Daily life at the home promotes independence and informed risk-taking, enabling people using services to be in control of their lives and to self-direct services, within individual levels of capacity. They are involved in domestic routines, taking responsibility for their own rooms and menu planning. Some people are allocated budgets and cater for themselves, purchasing food and cooking their own meals, with staff support. Though care plans are not produced in a person-centred, accessible format, observations concluded the approach to care planning is inclusive, personcentred and holistic. People using services have agreed individualised programmes of daily activities. Systems are in place to make sure staff unfamiliar with the home know the needs and wishes of the people they support. People using services participate in age, peer and culturally appropriate activities and are part of their local community. They are enabled to make choices about their lifestyles and supported in developing life skills. Staff demonstrate an understanding of and commitment to the social model of disability and principles of inclusion.They support people using services to maintain family links and friendships inside and outside of the home. The atmosphere on the houses was observed to be friendly, warm and welcoming. Health care needs are met ensuring access to routine health checks and specialist services. Staff work in partnership with health and other professionals. The management of medication is safe and principles of respect, dignity and privacy are put into practice.The houses were all clean and tidy and observations confirmed staff respect the privacy and autonomy of people using services. The expert by experience commented positively on the control they evidently have over their lives and personal space. Those who invited him to view their bedrooms clearly had them arranged how they wanted them. They had furnished them out of their personal money to their personal taste. The service complaint procedure is clearly written and easy to understand. It is available in a suitable pictorial format and displayed prominently in each house. People using this service said they knew how to make a complaint and their concerns and complaints are listened to and mostly acted upon. Survey feedback and discussions with people using services confirmed most were overall satisfied with services though there were some things they would like to be different. Comments included, I like living here, The home does everything well, Staff treat me as a human being and not like a child and make sure Im happy. 1 like it here and I am not going to move for nothing. We were informed by a social care professional that staff always supports people using services to live the life they choose, responding to their diverse needs. The professional commented, There is a relaxed, homely atmosphere. Staff know service users and their needs well after working together for many years. Staff and service users are anxious about the future and could be better informed. This creates anxiety for all, including families. Relatives concerns regarding the homes future were evident in their response to our survey, however most expressed satisfaction with service provision. Their comments included, Care Homes for Adults (18-65 years) Page 8 of 33 The home cares for people well, they can do nothing better. Generally all aspects of my relatives care are met.My relative is happy in the house environment and I know she is well looked after. I would like to receive her annual assessment. What has improved since the last inspection? What they could do better: 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 33 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 33 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. Admission processes are personalised and based on comprehensive assessment of needs.The homes statement of purpose and service users guide is up to date, containing all statutory information. The information however is not accessible to all people using this services because it is available only in a standard format. Evidence: The homes statement of purpose describes the provider organisation as a Christian movement, welcoming into its fellowship people of other religious faiths and those of none. It includes a clearly stated commitment to equality of opportunities for people using services and staff. This means people will be treated fairly regardless of race, colour, age, gender, disability or sexual orientation. The home manager told us that all the homes policies, procedures and practice support compliance with legislation promoting equality and diversity. An equality impact assessment had been undertaken for the home. There is a clear admissions criteria and admissions referral procedure. Services Care Homes for Adults (18-65 years) Page 11 of 33 Evidence: provision at Langdown House is block purchased by Surrey County Council. Admissions have been suspended for over three years since the decision was made to sell this home and two others operated by YMCA London South West. Previous inspections established evidence of a comprehensive, multi-disciplinary needs assessment process before admission, ensuring the homes capacity to meet individual needs. Lifestyle agreement plans (care plans) were generated from pre-admission assessments, using a person-centred, inclusive approach. This had involved prospective service users in the process, within individual levels of capacity, also their relatives/representatives. People using services who responded to our survey confirmed they were asked if they wished to move into the home. There had been a planned transition before they moved in, with opportunity to visit the home and for overnight stays. This enabled them to get to know other service users, staff and routines. Following admission the assessment process continued for a further twelve weeks. A formal review had taken place after six weeks so that any necessary adjustment could be made to care plans. Last year a decision was taken to close one of the houses to improve services. A transitional plan had been instituted for the service users affected. This incorporated tea-time visits but not overnight stays, stated to have been their choice by the home manager. We looked at the homes statement of purpose and service users guide, which have been reviewed and updated and are now two separate documents. Both contain all statutory information and copies of the service users guide stated to have been issued to all people using services. The information in this document however was found not to be accessible to some people using the service. It was suggested consideration be given to producing this in a range of formats to meet individual communication needs, to ensure this information is meaningful and interesting. Care Homes for Adults (18-65 years) Page 12 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using services are involved in decisions about their lives and play an active role in planning their care and support. Evidence: We visited all three houses to assess how well these standards are being met.Evidence was gathered through direct observation of activities and practice, discussions with people using services and staff, from records and surveys and feedback from the expert by experience. We found the social model of disability to be well understood by staff who try hard to overcome disabilities by reducing environmental and attitudinal barriers and to some degree, communication barriers. Staff were evidently committed to supporting and enabling people using services to lead purposeful and fulfilling lives as independently as possible. Routines are reasonably flexible, affording choice in times of getting up and going to bed and activities of daily living. Days are predominately structured by individualised programme plans. Most of those sampled detailed how individual Care Homes for Adults (18-65 years) Page 13 of 33 Evidence: assessed needs, preferences and goals are being met. They were mostly comprehensive, the approach to care planning putting the individual at the centre of service delivery. There are opportunities for personal development and growth and to learn and use practical life skills.People using services are supported to make informed decisions within individual levels of capacity. Rights to take risks in their daily lives are respected, within a risk management framework. The scope of risk assessments had been extended since the last inspection. The expert by experience said conversations with staff identified their concerns about shortfalls in their training. Several mentioned the need for person centred planning training. They also acknowledged the need for a pictorial care planning formats to make them more user- friendly. The care plan shown to the expert by experience was not written from the point of view of the individual, though containing information of use to the individual and staff. Staff mentioned another service users care plan review meeting attended by a lot of people who knew that individuals needs.The expert by experience felt consideration should be given to limiting the size of review meetings,particularly for individuals with limited communication skills which make it difficult to have your say in such a large group of people. Observations confirmed people using service access day services and educational institutions. They engage in meaningful occupation and leisure pursuits and integrate in community life. There is a choice of meals and of mealtimes, of what they wear and spend their money on and of friendships and relationships. Their wishes for their future and where they live have been explored at review meeting and individuals are on the housing register. Positive comments were received about the home and staff from people using services, most relatives and a social care professional. Care Homes for Adults (18-65 years) Page 14 of 33 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. People using this service are offered a healthy diet. They participate in age, peer and culturally appropriate activities and are part of their local community. They are able to make choices about their lifestyle and are supported in developing life skills. Evidence: The expert by experience said people using services were mostly very satisfied with service provision, though there were few things they would like changed.Those consulted said they liked living at Langdown House.They felt staff gave them good support with the things they needed, whether it be help with the dishwasher or with things they were upset about. One person spoke about staff shortages and how this adversely affected their lives. He cited this as the reason for the closure of House 2 last year, necessitating people having to move to other Houses. Also the reason for service users meetings being irregular. Another person spoke about not being able to Care Homes for Adults (18-65 years) Page 15 of 33 Evidence: get a lift in the homes car on Mondays anymore due to it being used for community appointments, for example visits to the doctor. The expert by experience said people using services frequently referred to going out and about in the community, mostly shopping, using local bus services with staff support though some were more independent.They and staff spoke about the impact of the home no longer having its own minibus, stating service users are now spending a lot of their personal money on taxi fares. One individual said that the loss of the minibus had limited what people using services do. The home manager however said there is shared access to a minibus used by The Summers, another care home on the same site operated by the provider. It was understood that staff prefer to use a vehicle belonging to a day centre which they have access to evenings and weekends. The home also has a car for approved staff drivers use. Of the remaining nine permanent staff however there are only five approved drivers. Observations confirmed an individualised approach to planning individual education, training and leisure activities based on assessed needs,interests, hobbies and personal aspirations.The expert by experience was informed of a range of opportunities available for integration in community life. People using services are supported to lead their chosen lifestyles.One person said they usually stay home, not wishing to go out. Whilst staff encourage this individual to try out various activities they respect this individuals wishes not to do so. People using services consulted were reported not to speak much about going to pubs and clubs but more about shopping trips for personal items and for food and their attendance at day services. The expert by experience acknowledged this could be a reflection of the small group of people available to talk to as many were not at home. Records confirmed individuals are members of various clubs, affording opportunities to socialise with friends. Individuals spoke about holidays they had enjoyed and chosen.Last year a group went to Cornwall and there was a holiday organised to Lourdes, another person visited a relative in America, travelling by air independently and another enjoyed a family holiday in Germany. One person spoke about a holiday in America some time ago and said it was his goal save up and go again. A staff member supported another person last year who wished to visit and stay overnight in Brighton. She had past connections with the town and the trip provoked happy memories. Other activities people spoke about enjoying included BBQs in the garden, visits to Brooklands museum and horse racing.There is regular use of community leisure facilities, for example gyms and swimming pools, horse riding, cafes and churches. Staff spend time promoting personal development, independence and life skills training. Individualised support is a new development this year, empowering people using services to have greater control over daily routines. They are actively involved in keeping their home clean and tidy and in undertaking personal laundry. They receive assistance with budgeting and managing their finances Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: and to use their mobile phones.To prepare people to this level of independence the home has produced risk assessments and various training programmes, for example to develop skills in cooking, road safety and to learn about stranger danger.Pictorial prompts were noted to support independence in respect of a range of daily living activities. The home seeks information encouraging and supporting people with capacity to do so, to access paid employment. Despite the challenging economic climate a person using services was stated to have gained employment in the last twelve months. Observations confirmed staff support people using services to maintain family links and friendships, inside and outside the home. People using services engage in individual and group menu planning activities.Photographs of food are used to support individuals in making informed menu choices. Menus were displayed in the houses including those for individuals who receive a food budget and cater for themselves. Menus sampled indicated a varied diet and records confirmed special dietary needs and preferences are met.Early morning observations identified individuals making their own breakfasts, some independently and others with staff support.The evening meal on the two houses observed, were prepared for the group mostly by staff with limited input from people using services. Staff were also supporting individuals catering for themselves.Mealtimes were observed to be flexible, relaxed and social occasions, allowing individuals the time they need to finish their meals. Care Homes for Adults (18-65 years) Page 17 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care people using services receive is based on their individual needs and preferences and medication practice is safe. principles of respect, dignity and privacy are put into practice. Improvement is necessary to record keeping. Evidence: Direct observations confirmed staff encourage people using services to dress appropriately and attend to their personal appearance. Personal support was evidently responsive to the diverse needs and preferences of each individual. On each house a file is maintained containing current risk assessments, care and support notes and current photograph for each service user. This system together with weekly shift planners supports safe practice and continuity of support and routines.The homes policy requires staff to produce a monthly summary of daily records about each individual. These include information about activities, health, mood and behaviours and any significant incidents or events. The summaries are audited by management and filed on personal files. Observations identified significant shortfalls in the standard of record keeping practice on house 4. Across all houses record keeping specific to people using services was fragmented and record audit trails difficult to Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: follow. On house 4 this difficulty was further compounded by care records for the previous two months for each service user being filed together in yet another binder, waiting to be checked by a manager. We found staff on that house had not produced monthly summaries for the past two months. There were also gaps in weight monitoring records. Discussions with staff confirmed the home does not operate a key worker system and staff accountability for record keeping was unclear. It is acknowledged that this house had particular staffing issues. In addition to having a very depleted staff team, in common with the other houses, changes had taken place within the team and a staff member was on long term sick leave. Record storage on house 4 was also noted to be at a premium and the shift planner incomplete. Care and support records and review notes sampled on all the houses demonstrated service users involvement in the care planning process. Individuals had signed their care plans and monthly care summaries. Record formats mostly did not meet the individual communication needs of the majority of people using services, however. It is acknowledged essential lifestyle plans are pictorial and include symbols. People using services are registered with a general practitioner (GP) and have health action plans. They have access to their GP and National Health Services (NHS) including dental, opthalmic and chiropody services. Those in need of frequent chiropody also use private chiropody services which they pay for themselves. Staff support people using services to attend health care appointments, their health needs being closely monitored. Feedback from a social care professional confirmed staff seek advice and act on it and observations confirmed staff work collaboratively with other professionals. The complex health needs of one individual are managed with input from the district nursing service and one to one staff support when attending hospital three times a week. Survey feedback confirmed most relatives were satisfied with health care arrangements. Also with communication from the home informing them of important information about their relative using the service. One respondent however said they were never informed and another said only sometimes. Care plans, guidelines and protocols were in place for the management of various health conditions, including dementia, diabetes and epilepsy. Staff and agency workers training records evidenced gaps in training on health care topics specific to the health conditions of people using this service. Risk management plans had been produced, based on assessment of risks specific to various medical conditions. Special equipment was in use to alert on-call staff sleeping on the premises at night to indicators of medical emergencies. Record evidence was viewed of systems to ensure the equipment is working and all staff instructed in their use. At the time of this inspection four people were stated to have dual conditions of learning disabilities and dementia. Risk assessments had been carried out for these individuals to ensure their safety, Care Homes for Adults (18-65 years) Page 19 of 33 Evidence: including risks at night when on-call staff are asleep. The storage, recording, administration and disposal of medication was found to be in accordance with statutory requirements. Improvement in medication procedures since the last inspection was reported in the AQAA. There are robust medication audit systems and staff adhere to the policy for two staff to engage in medication administration practice. These staff are required to have completed the homes medication training which includes a practice assessment element. Only regular agency staff who have completed the homes medication training are permitted to administer medication. Trained permanent staff support other houses with medication administration practice where agency workers are deployed who have not had this training. The practice of secondary dispensing in exceptional circumstances was discussed and observed to be subject to robust risk assessment. The homes management was noted to be making changes to this practice to minimise risk. Care Homes for Adults (18-65 years) Page 20 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an effective complaint procedure however attention is necessary to records of complaints to ensure these are accurately maintained. Policies and procedures safeguard people using services from abuse and respect their rights. Evidence: Survey feedback from people using services confirmed all were aware of how to make a complaint and had someone they can talk to if they are not happy. One person commented, Staff understand if I am not happy and help with any problems. The homes complaint procedure is clearly written and easy to understand. It is produced in an accessible pictorial format a copy of which is displayed prominently in each house. The need to update the CQC contact details on the copy in house 3 was discussed. Though complaints were stated to have been received from four people using services in the past twelve months and action taken, these were not recorded in complaint records or reflected in the Annual Quality Assurance Assessment ( AQAA) submitted to the CQC. The importance of maintaining accurate complaint records was discussed. A number of complaints received in the past twelve months did not go through the complaint procedure but were sent direct to the provider who dealt with them.The homes complaint records should also cross-reference these complaints, issues and outcomes.These complaints from a relative were predominately about staffing, maintenance of the environment and regarding the potential impact to the safety of people using services specific to fire safety precautions. Of the eight relatives Care Homes for Adults (18-65 years) Page 21 of 33 Evidence: who returned surveys five said they knew how to make a complaint. Four relatives told us the home always or usually responded appropriately to complaints, one said sometimes and one said never. This information was followed up with management at the time of the visit. A relative commented, The home manager and permanent staff do their best to resolve complaints. 100 of people using services who completed our survey said they felt safe at the home and that staff treat them well. Policies and procedures for safeguarding adults are available, giving clear specific guidance to those using them. There is a system for staff to report concerns about colleagues and managers. The home has a copy of the latest edition of Surreys safeguarding procedure and have followed these procedures making two safeguarding referrals in the past twelve months. Both were fully investigated and one is still ongoing. Staff training records sampled confirmed staff and agency workers receive safeguarding adults training. Care Homes for Adults (18-65 years) Page 22 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people using the service to live in a comfortable, safe environment that promotes independence. A planned renewal programme for carpets is required. Evidence: The houses on this site are designed to provide small group living environments in which people using services can enjoy maximum independence. Observations confirmed staff respect the privacy and autonomy of people using services. People with capacity to use them and who wish to have one were issued with front door keys and keys to their bedrooms.Bedrooms are all for single occupancy and arranged on both floors. The expert by experience commented positively on the control people using services evidently had over their lives and personal space. He was shown several bedrooms by people using services who clearly had them how they wanted them. Many had furnished them at their own expense and all were personalised, reflecting individual taste and interests. The expert by experience commented on the design of houses being all the same and felt this worked against people having their own distinct place. He felt more could be done to make the houses look and feel different. Since the last inspection one of the houses had been decommissioned.The inspection Care Homes for Adults (18-65 years) Page 23 of 33 Evidence: process incorporated a tour of the three houses still operating, viewing all communal areas and sampling bedrooms by invitation of people using services. All of the houses were domestic in style and character, warm, light and adequately ventilated. They were also clean and tidy and odour control satisfactory. Staff were working within the homes policy to reduce risk of cross-infection. The houses were generally comfortably furnished though some furniture showing signs of wear and tear and in need of replacement.On house 1 some staff expressed disappointment that people using services were not afforded a choice of settee when this was recently replaced. The colour of the settee received does not coordinate well with other furnishings in the lounge. Some improvements had been made to the home environments this year. Communal areas including stairways and corridors had been redecorated, dining chairs reupholstered, carpets cleaned and a small number replaced in bedrooms owing to malodour. Items of furniture and some appliances had also been replaced. The need for further investment in a planned renewal programme for carpets was discussed with the home manager based on observations in all three houses of well-worn, stained carpets. Attention is necessary also to the kitchen floor covering in house 4. Whilst this had been repaired ideally this should be replaced. Kitchen cupboards in some houses were in poor condition and the seals on some fridges are worn. The home continues to experience delays in receiving attention to non-urgent maintenance work. Bathrooms and toilets were clean and hygienic. Provision includes wheelchair accessible toilets, specialist shower and bathing facilities and suitable aids and equipment to meet individual needs.First floor accommodation is accessible by two flights of stairs and includes office facilities. Beds are provided for staff on-call at night in offices. Staff facilities include lockers, toilets and showers. Staff lockers on house 4 are in need of attention so staff can secure their money and valuables.Each house has an emergency call system and pay phone. The gardens were tidy for the time of year. Care Homes for Adults (18-65 years) Page 24 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels appear adequate however staffing arrangements can affect continuity and stability of staff support. Shortfalls in staff training were identified. Evidence: The home has a small core group of permanent staff employed by Surrey County Council(SCC). Contractual staffing arrangement exist between SCC and the YMCA London South West.No new staff have been employed since the decision to sell the home was announced in June 2007. Previous inspections have established full compliance with statutory staff recruitment vetting and induction procedures for permanent staff. The home manager said SCC monitors criminal record bureau checks (CRB) for permanent staff and requires these to be repeated every three years. Changes within the team since the last inspection include the resignation of two staff and transfer to the home of two staff from other homes. Since 2007 the staff team had been depleted by staff taking up other posts and retirements. At the time of this inspection only six full time and three part-time permanent care staff were in post.The homes operation depends on high use of care bank and agency workers. Since the last inspection SCC has changed the company with contract responsibility for ensuring agencies on the approved provider list only supply workers to the home that are fully vetted and trained.Discussions with staff confirmed this change initially affected service continuity as former agency workers, some of whom had worked at the home Care Homes for Adults (18-65 years) Page 25 of 33 Evidence: for many years, had to be replaced by workers new to the home.The disruption this initially caused was understood to have lessened. Numbers of agency staff used also reduced by the closure of house 2 as permanent staff are less thinly spread across the three remaining houses. Managers confirmed the homes reliance on agency workers remained at times problematic and time-consuming. They said agency staff sometimes failed to turn up when booked and conversely turned up when not needed.Every effort is made to use regular agency staff who know the home and the people who live there,however this is not always possible. It was stated that some people using services had been very vocal and assertive last year in their objection to being supported by non-permanent staff. This was stated to have been the catalyst for the closure of house 2. People using services told us they enjoyed positive relationships with most staff, though continuity and stability of staffing was a concern for individuals. Their comments included, Staff look after me, They help us, I like the staff because they help me with problems, Staff treat me like a human being and not like a child. They look after me and make sure Im happy. Staff look after me well but they need to sort out holidays. I would like to go to Spain with regular permanent staff because I know them.They need to employ more permanent staff. I feel with more permanent staff in the summer more outings could be arranged. Another form of transport would be useful. A relative who has repeated complained about the decision to recruit permanent staff strongly expressed concerns about the impact this was having on the welfare of people using services and on staff morale. The responsible individual has informed this relative of assurances received from SCC that staffing arrangements are safe. During the inspection visit staff did not raise this as a major issue; though some acknowledged time spent on inducting and directing new agency staff sometimes detracts from time available for administrative responsibilities. Discussions with staff confirmed their opinion that mostly staffing levels were adequate. Agency staff wear identity badges with photographs and are issued with a code of conduct by management. They receive a formal induction which covers systems and key procedures, individual risk assessments and risk reduction plans, instruction on answering the phone and transferring calls to other houses. They are shown how to use equipment and made aware of wrist or bed alarms. There are strategies in place to support continuity of practice, which include shift planners, various notices and reference binders referred to earlier in the report in the personal and healthcare section.We were informed that regular agency staff are invited to attend house and team meetings and are included in the staff supervision structure. Most undertake the range of duties of permanent staff, with the exception of medication administration and care planning. Care Homes for Adults (18-65 years) Page 26 of 33 Evidence: Systems include checks by assistant team managers on agency workers vetting and training. During the visit an omission in these checks established an agency worker on duty without record evidence of a CRB disclosure having been seen and recorded.The home manager took immediate appropriate action.We also found incomplete training records specific to mandatory training for a number of agency staff. It was not clear, following discussions with management whether the shortfall was in their training or the system for verifying training. The need for these checks to be more robust was discussed. Also for compliance with the registered person(s) obligations to ensure at all times suitably qualified, competent and experienced staff on duty. Discussions with permanent staff confirmed their frustration with training and development constraints, though some training has been received since the last inspection. The home manager is aware that some staff require refresher mandatory training and the team in need of other essential service specific training. Examples given were person centred planning, dementia awareness, autism and learning disability awareness. The high reliance on agency staff was stated to be a barrier to sending staff on courses. The need for a creative approach to meeting these training shortfalls was discussed.The AQAA confirmed all nine permanent care staff have national vocational qualifications or equivalent in health and social care at level 2 or above. Care Homes for Adults (18-65 years) Page 27 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by a competent, experienced management team. Even though these are challenging circumstances relating to the homes pending sale, the home overall runs in the best interest of people using services promoting and protecting their health and safety. Evidence: Since the last inspection a full-time qualified home manager has been appointed and registered. The assistant team manager and acting assistant team manager remain unchanged and also work full time. The acting assistant team manager who has a national vocational qualification (NVQ Level 3) in health and social care and is an NVQ assessor was noted to be working towards an NVQ level 4 management qualification. The home manager and acting assistant team manager share an office in house 3 and the assistant team manager has an office in house 1. The inspection visit was facilitated by the home manager and acting team manager. Discussions with them confirmed their clear understanding of the key principles and focus of the service, based on organisational values and priorities. Improvements in the last twelve months include work undertaken with the staff team at team meetings, developing awareness Care Homes for Adults (18-65 years) Page 28 of 33 Evidence: and understanding of their roles and responsibilities; also on incident reporting and recording requirements and systems. There has been continuous development of guidelines and in-house procedures and improvement in medication practices. The homes Annual Quality Assurance Assessment (AQAA) received after the visit contained clear and relevant information supported by a range of evidence. It let us know about changes at the home, where they still need to improve and how this is to be achieved. The homes management was observed to promote equal opportunities and demonstrates commitment to person centred care. The service has sound policies and procedures however the AQAA shows a number of these require review. The rights and best interests of people using services are mostly safeguarded by record keeping practices though some shortfalls were identified.Quality assurance and quality monitoring systems seek the views of people using services. The home has clear health and safety policies and we found improvement in health and safety monitoring practice on this occasion.There is also evidence of organisational monitoring of the homes conduct and of health and safety audit systems. Discussion again took place with management regarding the need to amend the hot water temperature audit forms. This will ensure staff are accurately informed of maximum hot water temperatures and take action if exceeded, for prevention of scalds.At the time of the visit the home manager confirmed the report of a recent fire safety inspection had not yet been received. We discussion observations of potential risk of falls for individuals with mobility difficulties whilst negotiating heavy fire doors in corridors. The home manager agreed to consult the fire officer for expert advice on the suitability of fitting a device to hold these doors open, also bedroom doors of individuals. Since the visit the home manager has reported the advice received was these devices are unsuitable for corridor fire doors. Other devices were approved by the fire officer however to maintain bedroom doors open for two service users. The home has access to Surrey County Councils policies and protocols for compliance with the Mental Capacity Act 2005 deprivation of liberty safeguards and its code of practice. The home manager had undertaken this training and is aware of the need for the assistant managers to have the same. Team meetings were stated to have been used to raise staff awareness to their duties and responsibilities under this legislation. At the time of the inspection visit none of the people using services were being deprived of their liberty. Care Homes for Adults (18-65 years) Page 29 of 33 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 30 of 33 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 24 23 The registered person must 10/06/2010 ensure a planned renewal programme for carpets in all the houses. This will ensure adequate private and communal accommodation provided for people using services. 2 35 18 The registered person must 10/06/2010 ensure staff employed by the home receive training appropriate to the work they are to perform; and at all times workers at the home are suitably trained. This will ensure people using services receive appropriate care to meet their needs. Care Homes for Adults (18-65 years) Page 31 of 33 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 Care Homes for Adults (18-65 years) Page 32 of 33 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. Care Homes for Adults (18-65 years) Page 33 of 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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