Care Home: Lotus House

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What the care home does well People living in the home told us in their surveys that: `I decide what I do to make decisions about my life`, `I`ve always got a choice`, `I have a complaint procedure form in my bedroom`, and `I like Lotus House and all staff`. Staff told us that: `the manager and one of the team leaders works hand in hand and will support us staff so well in regards care plans and risk assessments`, ` our manager operates an open office policy where the staff can talk to her freely`, `care plans are up to date and reviewed on a monthly basis according to need`, `thehome is always very clean and have a good working atmosphere. The service users are supported a lot and staff always listen to the service users`, Health professionals told us that the home `seeks professional help when necessary` and that they `ensure that activities/socialisation outside of the home (happen) as much as possible`, `always accompany and support clients in visits to the surgery and allow them to communicate their own concerns as much as possible`, and `clients (are) always appropriately dressed and appear relaxed and comfortable with carers. Good rapport`. Relatives told us: `majority of staff understand (our relatives) problems and I believe work really well with all the different types of problems they have within the home`, `have always found home is able to work out any problems`, `all the residents at Lotus House have different health needs and problems and they do care well for them - they are providing a good family atmosphere`. What has improved since the last inspection? A new manager has been appointed who appears to be having a positive impact on the home. She has introduced different ways of working and new paperwork to show that she and the staff understand the individual needs of the people living at the home. What the care home could do better: The home needs to focus more on supporting people living in the home to take responsible risks. They must also ensure that the current number of restrictions placed on people living at the home are properly reviewed so that people can be helped to reach their potential with regard to independent living skills.Staff and health professionals told us that staff would benefit from further training in medication (we would support this) and training to meet the assessed needs of the people living at the home such as autism, challenging behavior and mental disorder. People also told us that they would like more support to meet the different needsof people at the home - specifically with regard to race and sexuality. Some people did not think that they received enough information or support from head office and were unhappy that they did not receive certificates following training. The home`s medication practices do not always meet company policy or good practice guidelines and must be reviewed. The manager needs to apply for registration with the Care Quality Commission (CQC). Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Lotus House 34 Lansdowne Road Bedford Bedfordshire MK40 2BU The quality rating for this care home is: one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Rachel Geary Date: 0 4 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. They reflect the things that people have said are important to them: 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 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 Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 37 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (20092008) Commission for Social Care Inspection (CSCI). 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 CSCI 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 37 Information about the care home Name of care home: Address: Lotus House 34 Lansdowne Road Bedford Bedfordshire MK40 2BU 01234350600 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): noemailjuly07 www.mentauruk.com Mentaur Limited Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 7 Number of places (if applicable): Under 65 Over 65 7 0 learning disability Additional conditions: No service users who need the assistance of a mobility aid shall be admitted to the home. Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 37 A bit about the care home Lotus House was first registered in April 2004 to provide care for up to seven adults with learning disabilities. The purpose of the home is to provide care to people with complex needs, which may include those who have a mental health need and/or behaviours that challenge, in addition to their learning disability. Due to the physical environment, the home is not able to take people who have any mobility difficulties. The home aims to provide a 24-hour package of care, including day activities where necessary. The accommodation is in a converted Victorian semi-detached house in the centre of Bedford. The accommodation is arranged over three floors and all service users have their own bedroom with en-suite facilities. There are three communal areas, one on each of the floors, and bathing facilities on each floor. The home has a small patio to the side of the house. Mentaur Ltd, who also owns a number of other similar homes in Northamptonshire and Leicestershire, owns the home. Care Homes for Adults (18-65 years) Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 37 How we did our inspection: This is what the inspector did when they were at the care home A key inspection is a thorough type of inspection when we look at all of the key aspects of a service. For this key inspection, we looked at all the information that we have received or asked for since the last inspection of this service on 23rd November 2007. This included surveys which we sent to the home to give out to people who live there and their relatives, staff and health professionals. We received 6 surveys back from people living at the home, 6 from members of staff, 2 from health professionals and 2 from relatives. We looked at notifications that we received from the home. This is information about the service that the home has to tell us about by law. We also looked at information that we asked the home to send us following our visit. Some of this never arrived. We carried out an unannounced visit to the home on 4th August 2009 which lasted nearly 8 hours. During the visit to the home we met some of the people who live there. Some people were able to talk about what it is like to live at the home. Some people did not use words to communicate, so we observed Care Homes for Adults (18-65 years) Page 7 of 37 the way that the staff were supporting them. We also looked at some of the paperwork that the home has to keep such as care plans, risk assessments, medication charts, staff records, menus and health and safety records. What the care home does well People living in the home told us in their surveys that: I decide what I do to make decisions about my life, Ive always got a choice, I have a complaint procedure form in my bedroom, and I like Lotus House and all staff. Staff told us that: the manager and one of the team leaders works hand in hand and will support us staff so well in regards care plans and risk assessments, our manager operates an open office policy where the staff can talk to her freely, care plans are up to date and reviewed on a monthly basis according to need, the Care Homes for Adults (18-65 years) Page 8 of 37 home is always very clean and have a good working atmosphere. The service users are supported a lot and staff always listen to the service users, Health professionals told us that the home seeks professional help when necessary and that they ensure that activities/socialisation outside of the home (happen) as much as possible, always accompany and support clients in visits to the surgery and allow them to communicate their own concerns as much as possible, and clients (are) always appropriately dressed and appear relaxed and comfortable with carers. Good rapport. Relatives told us: majority of staff understand (our relatives) problems and I believe work really well with all the different types of problems they have within the home, have always found home is able to work out any problems, all the residents at Lotus House have different health needs and problems and they do care well for them - they are providing a good family atmosphere. What has got better from the last inspection Care Homes for Adults (18-65 years) Page 9 of 37 A new manager has been appointed who appears to be having a positive impact on the home. She has introduced different ways of working and new paperwork to show that she and the staff understand the individual needs of the people living at the home. What the care home could do better The home needs to focus more on supporting people living in the home to take responsible risks. They must also ensure that the current number of restrictions placed on people living at the home are properly reviewed so that people can be helped to reach their potential with regard to independent living skills. Staff and health professionals told us that staff would benefit from further training in medication (we would support this) and training to meet the assessed needs of the people living at the home such as autism, challenging behavior and mental disorder. People also told us that they would like more support to meet the different needs Care Homes for Adults (18-65 years) Page 10 of 37 of people at the home - specifically with regard to race and sexuality. Some people did not think that they received enough information or support from head office and were unhappy that they did not receive certificates following training. The homes medication practices do not always meet company policy or good practice guidelines and must be reviewed. The manager needs to apply for registration with the Care Quality Commission (CQC). If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Rachel Geary 33 Greycoat Street London SW1P 2QF 02079792000 Care Homes for Adults (18-65 years) Page 11 of 37 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 set out 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 12 of 37 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 13 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some useful information has been produced to help current and prospective users of the service make an informed choice about life at Lotus House. Evidence: A Statement of Purpose had been produced for the home. It contained some very clear and useful information. The manager told us that only three of the seven people living at the home could read, so we took this into consideration when looking at information that had been developed for people living there and prospective users of this service. Attempts had been made through the use of pictures to make information easier to understand. Some looked easier to understand than others. A Service User Guide incorporated pictures and written text. It included the required information plus additional information that would be interesting and of use to prospective users of this service. We found evidence to show that people are only admitted to the home following a full assessment of their needs. This information is kept under review and updated as Care Homes for Adults (18-65 years) Page 14 of 37 Evidence: required. The homes Statement of Purpose contained clear information about the range of needs that the home is able to cater for. Pictorial contracts were in place and there was evidence that these had been signed by people living in the home. One of the contracts that we looked at contained information about fees which appeared to include holidays, trips and leisure costs. However records and the manager confirmed that this was not the case, and that people living at the home cover their own costs for leisure activities. The reference to leisure facilities in the contract needs to be made clearer so that people know what is covered by the fees and what they will individually need to contribute towards. Care Homes for Adults (18-65 years) Page 15 of 37 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has developed some comprehensive care plans and risk assessments which contain a range of important information about people living in the home. Evidence: Attempts had been made through the use of pictures, to make individual care plans easier to understand for people who are not able to read. Individual risk assessments had been produced in the same way. The manager had recently written or reviewed the care plans for people living in the home. They were detailed, clear and provided important information for staff to be able to meet the individual needs and preferences of each person. Although references regarding independent living skills were included, plans would benefit further from identifying specific areas to work on with each person in order to develop these skills. For example, one persons plan made reference to them not being able to use complicated equipment and that help would be given to acquire skills to use such equipment more independently. However the plan didnt say how this would be achieved. PCPs (person centred plans) were in place but these were locked in the office. When Care Homes for Adults (18-65 years) Page 16 of 37 Evidence: asked why people living in the home didnt hold these themselves, we were told that one person would destroy the information and other people just wanted them held for them. It was discussed that supporting people to take more ownership of their individual plans might be one way of helping them to take more control over their lives. We looked at the PCP for one person which contained some positive statements about them and included their likes/dislikes. It also stated that the person wanted to get a job and have their own flat and be more independent. Comprehensive risk assessments had been written in conjunction with care plans. The emphasis however was on keeping people safe rather than enabling them to take some responsible risks as part of a more independent lifestyle. For example risks assessments that we looked at referred to people needing supervision in the kitchen. We observed staff locking themselves in the kitchen after dinner without anyone who lives in the home. Three people who live in the home were in the lounge at the time watching a DVD. One person did not appear interested in watching the DVD. The manager told us that there was a risk of people absconding from the home and as such, the exit doors were kept locked. There was a sign near the front door which told people to ask a member of staff if they wanted to leave the building. Risk assessments were in place regarding this but these should be reviewed to ensure people are not having their liberty restricted without proper justification and records relating to this. The manager told us that she was in the process of arranging a review of each persons care package. Care Homes for Adults (18-65 years) Page 17 of 37 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. More could be done to support people living in the home to develop their skills including independent living skills. The home must ensure that the rights of the majority are not restricted by the behaviours of the minority. Evidence: The Service User Guide states that the home has its own day care opportunity. This is based in Northampton and staff from the home transport people to and from this facility during the week. The manager told us that she was looking into courses at a local college to provide some alternative options for people. It was also said that people can choose not to go out to day care at all and can stay at home. People are supported to access community facilities and leisure activities. At the time of this inspection we were told that none of the people living in the home were able to access the community independently. Care Homes for Adults (18-65 years) Page 18 of 37 Evidence: In the 3.5 months prior to the inspection, activities that had been organised included bowling, cinema, drives out, shopping, Woburn Safari Park, Rookery Open Farm, Dinosaur Adventure, a meal out, walks, Warwick Castle, and the Black Country Living Museum. For each trip there was a diary entry written by staff with leaflets and other memorabilia providing a keepsake for the person attending the trip. There was evidence that people were supported to maintain regular contact with their families. And a key worker checklist had been devised to ensure that this was not forgotten. The home is able to support people to seek specialist guidance around personal relationships if this is needed. Observations and records seen during the inspection, indicated that the daily routines within the home do not promote independence and freedom of movement. It appeared to us that staff do a lot of things for the people who live at the home such as cooking and laundry, rather than enabling people to do more things for themselves. A number of restrictions were also in place to prevent people from independently leaving the building, or accessing areas within the home - including the kitchen, a lounge, the garden, bathrooms, some bedrooms and the laundry area. The manager told us that people did not yet have ability to do things independently such as accessing the community and putting on their laundry. And that one person living in the home had significant behavioural issues which included causing damage to property. To this end, areas of the home were being kept locked to prevent this person from causing damage throughout. This meant that during our inspection, some people only had free access to one lounge and the hall/stairs. One person was seen during the inspection asking for a shower room to be unlocked. This was done immediately by the manager. We were told that the person had their own key for the shower but had mislaid it. None of the other people living in the home had a key for this room. The manager did say that it was an aim of the home to support people to become more independent including accessing the local community on their own. We were also told that 2 people living in the home hoped to move onto more independent living. A unit run by the company in Northampton had been identified as a possibility The manager told us that the home was looking into providing a special type of lock that could be used by one person living in the home to access their bedroom. The person could not use a key and so was dependent on asking staff if they needed to access their bedroom. The room could not be left unlocked because there is a risk of it being damaged by another person living in the home. The manager was looking into providing some assisted technology - a communication system - for the same person. The person was not able to communicate verbally and it is hoped that the new system will enable them to communicate through some pre recorded messages. We were told that none of the people currently living at the home smoked although information about this was included in the homes Service User Guide for prospective Care Homes for Adults (18-65 years) Page 19 of 37 Evidence: users of the service. Survey feedback prior to this inspection, raised concerns about there being inadequate money available each week for costs such as food. The manager told us that £245 a week was available for food - for the seven people living in the home and staff. We looked in the cupboards and the fridge/freezer and found that there was sufficient food to provide a nutritious meal for that evening plus more frozen food, cereals, fruit, vegetables, salad and pack up items. We were told that the home was due to do the weekly shop in the next couple of days and a member of staff went out during the inspection to buy a few more items to keep them going until this time. The meal for the evening of the inspection was chicken curry and vegetables and this was made by a member of staff. Ample portions were provided and people who ate it said that they had enjoyed it. We were told that people living in the home sometimes helped to prepare food but not for every meal because of concerns about poor hygiene amongst other things. We were told that people tended to help out more with cooked breakfasts at weekends. Weekly menus were seen. These are decided during weekly meetings for the people living at the home - should they wish to attend. A main meal had been chosen for each day with alternatives recorded below. The alternatives were often convenience food options such as pizza, hot dogs and burgers. The manager said that these were rarely chosen. The menu on the day of the inspection recorded an apple pudding as afters but this did not happen and people were seen eating what appeared to be tinned peaches. It is a regulatory requirement that homes maintain a detailed record of the food provided, so if changes are made, in agreement with people living in the home, these must be recorded. Care Homes for Adults (18-65 years) Page 20 of 37 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes medication system does not always follow company policy or good practice guidelines. Evidence: Monthly key worker checklists were in place which included things to remember for each person living in the home such as personal care needs, health checks and contact with family. Some files that we looked at contained a lot of paperwork and there was evidence that this was not always being completed. For example a weight chart had not been completed for 5 months for 1 person. We queried whether weight charts were actually necessary for everyone living in the home if there were no current concerns about their health or weight. A bath inspection form also appeared a little intrusive as records indicated that not everyone needed staff supervision whilst bathing or having a shower. The government paper Valuing People sets out plans for making the lives of people with a learning disability better through a number of things including individual health action plans (HAPs). It is the responsibility of the medical or clinical services to which the person is entitled, usually through the persons GP, to make sure that each individual has a HAP. This has not happened so far for the people living at Lotus House Care Homes for Adults (18-65 years) Page 21 of 37 Evidence: so the company has introduced their own plans as good practice. Records showed that people are supported to attend health care checks and appointments as required. We received some feedback from some health care professionals involved with this service which was generally very positive. However we were told that staff do not always attend appointments with enough information to enable the health professional to make a decision or a diagnosis. The manager told us that she was now trying to attend all appointments to improve this situation. We were told that none of the people living at the home managed their own medication. Consent forms and medication profiles, including photographs and information about possible side effects, were in place. These had been signed by the manager and the person to which the medication related. Appropriate storage was in place for medication and the home was using a Monitored Dosage System (MDS). We saw some compliance aids and were told that these were used to send medication into day care or when people visited family. They were also used at times for administration purposes within the home. On the day of our inspection we saw a member of staff with a small unlabelled container with a tablet in it. This had been taken from the original container and was being taken to one of the people living in the home. We referred the manager to our guidance about leave medication and secondary dispensing. The guidance states that there are concerns about the use of compliance aids in the home because if the person administering the medication does not have the container with the original medication label, they cannot be sure that each person receives the right dose of the right medicine at the right time, as prescribed. The guidance does say that there could be exceptional circumstances when the practice of secondary dispensing may be acceptable. For example when people go on social leave from a care home and do not wish to take all their medication with them. The guidance states that in these cases, placing sufficient medicines in a compliance system would be helpful if the care home was unable to obtain a labelled supply solely for the period of leave. Exceptional cases such as these need a robust risk assessment and written procedure. Details should include, which staff are permitted to do this, what containers the medicines are to be put in, how the containers are to be labelled and what other information is to be given. A clear record should be kept of all staff involved in each stage of the procedure and the actions taken. In usual circumstances when leave is planned, the homes supplying pharmacist should be asked if they can provide a separate supply of labelled medicines for the duration of the leave. The supplying pharmacist might also be able to help by providing a separate container for periods of regular attendance at a Day Care Centre. We were told that 2 staff administer medication within the home however, we noted some gaps in the medication administration records where there was no signature or only 1 signature. The medication was not in the MDS container, so the manager Care Homes for Adults (18-65 years) Page 22 of 37 Evidence: thought it was likely that it had been administered but not signed for correctly. We were told that the home had taken medical advice about bringing forward evening medication for one person as they liked to go to bed early and could become agitated if woken. The persons PCP (person centered plan) confirmed that they liked to spend time alone in their room and that this helped them to feel calm if they were feeling angry. Care Homes for Adults (18-65 years) Page 23 of 37 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although there are systems in place to protect people from abuse and harm, there is a limited understanding around restraint issues. The practice of using locks throughout the home focuses on keeping people safe or protecting the property, and does not focus on managing the identified risks and promoting the individual human rights and opportunities of the people living at Lotus House. Evidence: A complaints procedure was in place and attempts had been made to make this easier to understand for people who cannot read. There was evidence that this had been distributed to people living in the home and only 1 person told us that they didnt know what to do if they had a concern or a complaint. A complaints folder had been set up but there was nothing to review as the manager confirmed that no complaints had been received since the last inspection of this service. Services such as Lotus House are required by law to tell us about certain things involving people who live at the service. Since the last inspection of this service, we have received a number of notifications from the home. The notifications included several incidents of aggression - between people living in the home. We were concerned about the number and type of notification and wanted to know if these had been managed appropriately by the home. We contacted the local funding authority for this service who also have a safeguarding role in relation to the people living in the home. It appeared that they were aware of some of the notifications. The funding authority carried out their own visit to the home following our inspection. They found Care Homes for Adults (18-65 years) Page 24 of 37 Evidence: evidence that safeguarding of vulnerable adults (SOVA) referrals were being made appropriately when incidents occurred. We looked at records too during our inspection and found that where incidents had occurred that these had been reported appropriately to us and/or the safeguarding team. On the day of the inspection, people went out bowling in between coming home from day care and having dinner. The manager explained that the home tries to keep people busy and active to reduce the number of incidents when factors such as boredom may be a trigger for aggressive behaviours. There was evidence that staff were receiving SOVA and NAPPI (non-abusive psychological and physical intervention) training. People who were spoken to were clear about the use of intervention techniques with people living in the home and that these should be the least restrictive possible. The notifications received by us verified this. We were concerned about the number of restrictions in place for people in relation to the locked doors. Although it is acknowledged that appropriate use of restrictions to prevent serious harm is not a deprivation of liberty, it is hard to see how the blanket restrictions that are currently in place are applicable to all 7 of the people living at the home particularly when we were told that 2 of those people were looking to move onto more independent living. We contacted the local funding authority for this home and they carried out their own visits to the home and found that (Mental Capacity Act) Deprivation of Liberty/Capacity assessments had not been carried out in respect of anybody living in the home. They suggested that the manager spoke to a Mental Capacity Co-coordinator, who could provide advice about whether these assessments would be appropriate. Arrangements for this to happen were underway at the time of writing this report. We received information before the inspection that told us that the company was controlling peoples monies. We looked at records and found that each person had a financial management agreement form in their file. The form gave a number of options about money management but all the ones that we saw had been signed by people living at the home to say they did not wish to manage their benefits and other financial concerns and would feel safer if Mentaur Ltd staff did this on their behalf. Money that was kept in the home for each person was stored securely and separately accessible by senior staff only. It was not clear how much work had been done with each person to enable them to look after their own monies and financial affairs. The manager indicated that this was something the home intended to work towards in the future. At the time of this inspection, if a person wanted to get their money, they would need to make a request through the manager and this would be arranged on their behalf and picked up from the company head office on a weekly basis. Individual bank accounts had been set up and records of these accounts were available. Care Homes for Adults (18-65 years) Page 25 of 37 Evidence: We looked at one persons finances and found them to be in order. Care Homes for Adults (18-65 years) Page 26 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and safe but people living there do not have free access in and around their own home. Evidence: On arrival at the home it was noted that the exterior of the home looked in need of attention. The manager said that she was in the process of obtaining quotes for cleaning, painting and re paving and hoped that this work would be completed by the end of September. We found the home to be clean and tidy inside. Some areas would benefit from redecoration and some of the carpets required cleaning. The manager said that there was a regular programme for carpet cleaning and that this was in hand. One person showed us their bedroom which included an ensuite toilet and sink facility. The room was personalised and we were told by the person that they were planning to purchase a new personal CD player the following day. We observed the person talking with the manager about finances for this. We were told that one person had a tendency to damage property including their own room. We were shown the persons en suite facility where we noted significant damage to the fixtures and fittings. There was mould in this room and we were told that this was because the shower was left on for long periods of time. There was evidence within regulation 26 reports and a health and safety report that this was an ongoing Care Homes for Adults (18-65 years) Page 27 of 37 Evidence: situation, and that the area was due to be refurbished again. Because there was a risk of the person causing similar damage throughout the home, many areas of the home were being kept locked - preventing other users of the service from having free access around their own home. We questioned whether or not this situation was having a detrimental effect on the majority of people living at Lotus House. There was a small second lounge on the first floor of the home. This contained storage for the person who was causing the damage because they did not want their clothes/belongings stored in their own bedroom and would throw things away. The lounge was locked to prevent the person from accessing this area and throwing the clothes/belongings away. But this would be an ideal quiet area for other people to use if they wanted a bit of privacy or to watch something different on the television. The manager did say that they were looking to fit new locks on the storage items so that these could be kept locked and the lounge area opened up for use by people living in the home. In addition there was a small enclosed garden. This was not accessible to people living in the home because it was accessed through the kitchen. In order to access this area, they would need to be supervised by staff. There was evidence that people liked to use this facility. Care Homes for Adults (18-65 years) Page 28 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate systems are in place to ensure people living in the home are supported by safe recruitment practices and competent staff. Evidence: Survey feedback told us that staffing levels were affecting opportunities for people living at the home to engage in outdoor activities and that not enough effort was made to improve staff turnover. We were also told that new staff often lacked experience. We did find that there were a number of new staff and the homes Annual Quality Assurance Assessment (AQAA) received by us in January 2009, recorded that 8 members of staff had left in the previous 12 months. We were told by the manager at this inspection however, that there were no staff vacancies at the current time. We looked at staff files including some for people who had not been working at the home for long. We found on the files that we looked at that people did have relevant experience and that new staff completed a 2 week induction during which they were not included in the numbers of staff on shift. Evidence of recruitment checks for one member of staff was not available. The manager said that this was because the person had only started working at the home in June, so the information was still at head office. This information must be available for inspection. We did see evidence of appropriate recruitment checks for other staff working in the Care Homes for Adults (18-65 years) Page 29 of 37 Evidence: home. We looked through a sample of files for people living at the home and found that in the 3.5 months leading up to the inspection, that people had been on a number of external excursions. The manager told us that there are 4 staff on each morning and afternoon/evening shift and that she is always supernumerary. The rota that we looked at verified this. There is 1 waking night staff and 1 sleeping in staff at night. We were also told before the inspection that the home needed more male staff. However, records showed that at the time of the inspection 6 of the 14 staff employed were male. A number of male staff were on duty on the day of the inspection and the manager said that 3 of the male staff had worked at the home for over a year. People told us that staff would benefit from increased training in medication, and specific training to meet the assessed needs of people living in the home such as autism, challenging behaviour and mental disorder. We looked at the training plan for the home for May - Dec 2009 and found evidence of planned training in all these areas and more for a number of the staff. There was also evidence on staff files that a number of staff had already attended this training fairly recently. The manager told us that they were looking to access different medication training for staff and felt that the company was open to requests for relevant training. We were told that staff never received certificates following training courses. We looked on staff files and found that there were minimal certificates but training was recorded year by year on company paper. There was evidence that staff supervision was being monitored through the provider (regulation 26) visits and that the manager had a system in place to ensure that supervision sessions were carried out on a regular basis. We saw a notice for staff about a staff meeting planned for August. Care Homes for Adults (18-65 years) Page 30 of 37 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has a clear understanding of the key principles and focus of the service. But more work is needed to support people who live in the home to take control of their lives including the right to take some risks. Evidence: A new manager was in post who had been working at the home for around seven months. She told us that prior to working at Lotus House she had had 10 years experience as a clinical psychologist and 5 years experience working in management with older people. She had not previously worked with people with a learning disability. Despite this, observations during the inspection showed that the manager was familiar with all of the people living at the home and was sensitive to their individual needs. She was well organised and appeared to have a good understanding of what her role entailed. She told us that she was in the process of applying for registration. The manager said that she had completed some induction training with Mentaur and was planning to undertake further training through BILD (British Institute of Learning Disabilities) including training about autism. She said that she had booked to start the NVQ 4 in Management as well. Care Homes for Adults (18-65 years) Page 31 of 37 Evidence: Staff that were spoken to confirmed that they felt well supported by the new manager and we noted a good rapport between her and people living in the home. We asked for a number of documents to be sent electronically to us following the inspection but we needed to chase these on several occasions as they had still not arrived a week later. The manager explained that these were being sent from the companys head office as there was no Internet facility within the home. During the inspection, we saw an annual report for Lotus House for 2008/9 which included sections on Regulation 26 reports, progress reports for people living in the home, an Environmental Health report for 2007 (which recorded excellent standards within the home), Quality Assurance, management, human resource, training, health and safety and inspection. We asked for a copy of this to be sent to us so we did not have to spend time looking at it in the inspection. We did not receive it though because after the inspection, we were told by head office that it was a draft version and it needed to be approved by the director who was on leave. A separate request was made to head office for the homes latest Quality Assurance report, but this had also not been received three weeks after the inspection. However, we did receive a copy of the homes annual quality assurance assessment (AQAA) and copies of the Regulation 26 reports for March - June 2009. The AQAA was sent to us on 23.1.09. It had been written in a person centered way and gave us most of the information we needed. The regulation 26 reports were very thorough and included a monthly action plan for improvements to be made, with timescales. We also received a copy of the homes aims and objectives for 2009 which included objectives for the people living in the home and for the staff. It included aims to help people to achieve their personal dreams and goals and to provide a wider range of in house activities. Aims and objectives for staff included team building and training as well as specialist training. We felt that this combined information showed that the company and the manager know about some of the improvements that need to be made for the people living at Lotus House. We were advised by the manager that there were no people living at the home who were subject to a deprivation of liberty authorization under the Mental Capacity Act, at the time of this inspection. However we had some concerns about whether some peoples liberty was being deprived due to restrictions that were in place to manage the behaviours of at least one of the people living in the home. It is a regulatory requirement that a record of any limitations agreed with people as to their freedom of choice, liberty of movement and power to make decisions is maintained. Although there was some evidence of this, it will require further work to ensure the detail of every restriction currently in place is reviewed, agreed with each person living at the home and recorded. This review should take into account compatibility of people living at the home and the impact of the restrictions in place on each persons potential for developing their independent living skills. We received information prior to the inspection from an anonymous source and also Care Homes for Adults (18-65 years) Page 32 of 37 Evidence: from a number of surveys. We spoke about this with the manager during our inspection and have also referred to it throughout this report. We had some concerns about some of the information, which we shared with the local authority (Bedford Borough Council) who have a safeguarding role in relation to the people living at Lotus House. They were already aware about most of the information that we had because they had been told about it too. As a result they had visited the home earlier in the year and again following our inspection. The majority of the concerns raised, which sometimes lacked detail, were not substantiated. During the inspection we found that the health, safety and welfare of the the people living in the home was being promoted through a number of practices. This included COSHH (control of substances hazardous to health) items and kitchen equipment being locked away. Staff wearing protective clothing to administer medication and whilst cooking. The manager had also recently written some comprehensive risk assessments for a wide range of safe working practice topics and a health and safety folder was in place which showed us that there were systems in place for carrying out regular health and safety checks within the home. Care Homes for Adults (18-65 years) Page 33 of 37 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 34 of 37 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description 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 Description Timescale for action 1 5 5 Contracts for people living in 30/09/2009 the home must contain clear information about the fees charged, what they cover and any services that are not covered by fees. So that people can be clear about any costs that they may be liable for. 2 20 13 Arrangements for the safe 30/09/2009 administration of medication in and out of the home must be reviewed and changes made to reflect company policy and good practice guidelines. To ensure that people living in the home are protected by the homes policies and procedures for dealing with medicines. Care Homes for Adults (18-65 years) Page 35 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Care plans and risk assessments should contain specific information to show how the home supports people living in the home to take responsible risks and develop their independent living skills. The daily routines of the home should promote independence, individual choice and freedom of movement. Please update the Commission (CQC) once advice has been sought about whether or not Deprivation of Liberty/Capacity assessments are required in relation to the restrictions currently in place within the home (see protection section of this report). 2 16 Care Homes for Adults (18-65 years) Page 36 of 37 Helpline: Telephone: 03000 616161 or Textphone : or 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) Commission for Social Care Inspection (CSCI). 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. 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