Care Home: Nicholas House

What the care home does well Prospective users of the service are thoroughly assessed prior to admission are given the opportunity to visit the home to ensure it meets their needs. The home`s arrangements for support plans are thorough and promote the organisation of effective care and support for each user. Users have a varied and active lifestyle which takes account of their interests and provides opportunities for learning new skills and being involved in a range of activities in the community. The health and personal care needs of users are well met, promoting health and wellbeing. The home liaises well and effectively with health and social support agencies in the community. In particular it maintains good liaison with local community mental health services. The management and administration of the home promotes continuity of care for users and aims to ensure that risk is safely managed to reduce the likelihood of injury or harm. What has improved since the last inspection? The service has strengthened its working relationship with Bucks County Council through a manager regularly attending joint agency meetings. This facilitates communication between the home and a key statutory service. It should also ensure that the home is continuing to meet the needs of users in the context of changes in the wider environment. The format of support plans has been modified and the home has developed a more `person centred` approach. This promotes greater user involvement in support planning. The home has supported a number of users to learn practical skills (including one service user training as a plumber and electrician, and others taking up employment with a `Workskills` group), develop computer skills, and take up voluntary jobs in charity shops. A new washing machine, sofas and armchairs have been purchased. A number of areas of the home have been redecorated by the Workskills Group. Security has been improved through the installation of CCTV. A number of changes in organisation and staffing have taken place over the last two years and the effects of these had more or less settled by the time of our visit. Users expressed a high level of satisfaction with the staff in post at the time of this inspection. Hightown Praetorian and Churches Housing Association have published their plans for the redevelopment of the service and have discussed these with users. These should lead to significant improvements in the range and quality of accommodation in future years. What the care home could do better: The schedule of cleaning and maintenance for the bathrooms, shower and toilets on the first floor must be reviewed by managers to ensure good standards of hygiene and a pleasant and safe environment for users. Key inspection report Care homes for adults (18-65 years) Name: Address: Nicholas House The Broadway London Road West Amersham Buckinghamshire HP7 0EZ     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: Mike Murphy     Date: 2 1 0 8 2 0 0 9 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 35 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 35 Information about the care home Name of care home: Address: Nicholas House The Broadway London Road West Amersham Buckinghamshire HP7 0EZ 01494433788 01494433788 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Hightown Praetorian & Churches Housing Association The registered provider is responsible for running the service care home 12 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 12. The registered person may provide the following category 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 category: Mental Health- not falling within any other category (MD) Date of last inspection Brief description of the care home Nicholas House provides care for up to twelve adults who have experienced or are experiencing mental health problems. The service aims to be a short term rehabilitation service and works towards providing service users with a safe environment in which people can develop the emotional and practical resources needed Care Homes for Adults (18-65 years) Page 4 of 35 12 Over 65 0 Brief description of the care home for independent living in the wider community. The service is located within Old Amersham and is close to shops, pubs and transport links. Care Homes for Adults (18-65 years) Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out by one inspector in August 2009. It included an unannounced visit to the home on Friday 21 August 2009. The inspection included consideration of information provided in the homes Annual Quality Assurance Assessment (AQAA) which was completed by the registered manager in advance of the inspection. The inspection included meetings with three current users of the service. We also spoke to one ex-user and to a healthcare professional who happened to be visiting at the time we were in the home. The inspection included discussion with staff, with the registered manager and with the team leader. It also included examination of the homes current statement of purpose and service users guide. Other documents examined included user support plans, medicines administration records, communications with health and social services in the community, plans by Care Homes for Adults (18-65 years) Page 6 of 35 Hightown Praetorian and Churches Housing Association for redevelopment of the service, and internal documents such as summaries of documents on file pertaining to the recruitment of staff appointed since the last inspection, staff training records and a recent report of a proprietors visit. The visit to the home included inspection of parts of the building including the garden, shared living accommodation on the ground floor, the laundry room, kitchens, and bathrooms, showers and toilets. The inspection of the bathroom, shower and toilets included an on-site discussion with the domestic assistant in the morning and later in the day with the registered manager. We did initiate a survey of stakeholders as part of this inspection. We did not receive any completed forms back by the time of writing this report. However a summary of forms received after publication of this report will be recorded and will inform the next inspection of the service. Care Homes for Adults (18-65 years) Page 7 of 35 What the care home does well: What has improved since the last inspection? The service has strengthened its working relationship with Bucks County Council through a manager regularly attending joint agency meetings. This facilitates communication between the home and a key statutory service. It should also ensure that the home is continuing to meet the needs of users in the context of changes in the wider environment. The format of support plans has been modified and the home has developed a more person centred approach. This promotes greater user involvement in support planning. The home has supported a number of users to learn practical skills (including one service user training as a plumber and electrician, and others taking up employment with a Workskills group), develop computer skills, and take up voluntary jobs in charity shops. A new washing machine, sofas and armchairs have been purchased. A number of areas of the home have been redecorated by the Workskills Group. Security has been improved through the installation of CCTV. A number of changes in organisation and staffing have taken place over the last two years and the effects of these had more or less settled by the time of our visit. Users expressed a high level of satisfaction with the staff in post at the time of this inspection. Hightown Praetorian and Churches Housing Association have published their plans for the redevelopment of the service and have discussed these with users. These should Care Homes for Adults (18-65 years) Page 8 of 35 lead to significant improvements in the range and quality of accommodation in future years. 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 35 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 35 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. Prospective users are thoroughly assessed prior to admission and are given the opportunity to visit the home beforehand to ensure it meets their needs. Evidence: The statement of purpose (updated in July 2008) sets out the values of Hightown Praetorian and Churches Housing Association (referred to in some documents as HPCHA and in conversation as Hightown) and the aims and objectives of Nicholas House. It outlines the facilities in the home, its staffing, referral criteria, moving in process, activities, consultation with users, fire precautions, protection from abuse, the arrangements for dealing with complaints, and a statement on privacy and dignity. The service users guide was updated in July 2008. This is presented in booklet form. It lists the aims of the home, an outline of the approach to support planning (Your Care Programme), a description of the home and its facilities, the weekly programme, details of the staff in post at that time, key contacts, some quotes from users, and a list of ways of providing feedback (comments, complaints and compliments) to the organisation. Care Homes for Adults (18-65 years) Page 11 of 35 Evidence: The home has good and well established systems for assessing the needs of prospective users. The home works closely with the community mental health team (CMHT) and only accepts referrals from that source. It has clear referral criteria which are set out in its statement of purpose. Both documents will require updating to take account of changes since July 2008 both within the home and with the establishment of the Commission in April 2009. Before referral the prospective user will have been involved in an assessment carried out by a member of the CMHT under the care programme approach (CPA). This includes an assessment of needs and an assessment of risk. With the prospective users consent this information is shared with the home. The information is taken into account as part of the homes own assessment of the persons needs and its consideration of whether it can meet those needs. The home provides information to the person as required. The process includes a visit to the home. Should all parties agree to admission then an initial plan of support is drawn up in consultation with the user. Progress is reviewed with the user as required but more formally, at the end of the first month. The key to success is good communication between all of those involved - the user (and in many cases their family), the CMHT (in particular their care manager), and the home. The service achieves this and maintains a very good standard of practice in this most important aspect of a users experience of the home. Care Homes for Adults (18-65 years) Page 12 of 35 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. Comprehensive and detailed support plans are in place for each user which support the organisation of effective care and the participation of the user in the process. Evidence: A Care Programme (plan of support) is drawn up for each user. A key worker is responsible for the co-ordination of each users care programme.There are three main files for each user. A red file includes correspondence, copies of CPA reviews and other material which is not used on a day to day basis. A green file includes current risk assessments, the person centred plan (PCP), key CPA information, monthly summary notes written by the key worker in consultation with the user, and other information which is relevant to the users care and support. A third file contains information which is used each day. This includes essential information (photograph and key contacts), key information (diagnosis, signs of decline in mental health, current medication), monthly and weekly activities, and daily notes. In broad terms personal care plans include sections on, daily living, health, lifestyle, Care Homes for Adults (18-65 years) Page 13 of 35 Evidence: matters of particular concern or relevance to individual users, and risk assessments. Personal care plans have a practical orientation and include space for action plans. They also include a section for recording the users comments and for the signature of both the user and the key worker. According to the service users guide the role of the key worker is to ..assist, support and guide.... users throughout their stay in the home. Users seen during the course of the inspection visit described the staff as brilliant, really decent and said that they respect users views. Users said they felt involved in their care programmes. Users are involved in the day to day running of the home through the daily meeting which we attended on the day of the inspection visit. Staff do not attend the meeting on one day a week so that users can have a discussion without staff participation or influence. There is also a monthly house meeting. Details of a local independent advocacy organisation, Peoples Voices, are available if required. To date an advocate has attended the monthly house meeting on alternate months. The home has good procedures for assessing and managing risk. Staff work closely with individual users and key staff from the CMHT in identifying, assessing and managing risk. The home takes account of the outcome of CMHT risk assessments with regard to harm to self, harm to others or of self-neglect. The homes own risk assessments were noted to address risk with regard to decline in mental health (in particular signs of decline such as withdrawal or other change in behaviour), noncompliance with prescribed medication (and its potential consequences), illicit drug use, alcohol or substance misuse, risks associated with smoking (fire), and health and safety in the kitchen. Users were aware of these risks. Users acknowledged that alcohol and substance misuse can have an adverse effect on mental and physical health. They valued the efforts of staff in supporting them on occasions where such risks were increased. One said that if it wasnt for the staff he might just watch TV all day. Another said the home made him feel safe and helped him to deal (positively) with his illness. A visiting health professional valued the supportive environment of the home and the good liaison staff maintained with the CMHT. In particular the person acknowledged the personal qualities and experience of the staff. At the same time however, we heard from a member of staff of the frustration staff Care Homes for Adults (18-65 years) Page 14 of 35 Evidence: experienced on occasions when crises arose. It was felt that local mental health services were under resourced and were unable to provide specialist intervention and support on such occasions. Instead, the home was refered to the users GP, which out of hours may mean an agency doctor with limited knowledge of the user and perhaps of the specialty. Care Homes for Adults (18-65 years) Page 15 of 35 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Users lead a varied and active lifestylewhich takes account of their interests and provides opportunities for learning new skills and being involved in a range of activities in the community. Evidence: The ethos of the home includes an expectation that users will participate in activities.The home offers a mixed programme of activities across the week. Users, in consultation with their key worker, may select the activities in which they are interested. At the same time, the programme allows free time for users to pursue their own interests. We received positive comments from users on this approach. Many users said they appreciated the structure which the activity programme gave to the week - for some, it helped to avoid the danger of sitting around doing nothing all day. In the opinion Care Homes for Adults (18-65 years) Page 16 of 35 Evidence: of a health professional the programme helped restore users confidence and prepared them to move on to more independent accommodation when they were ready. The daily meeting allows users and staff to discuss the key issues of the day e.g daily chores, cooking arrangements, and main activities of the day. On the day we visited all users attended the meeting and there was good participation. Users are supported in pursuing college courses if they wish. One user had successfully completed a City and Guilds course in plumbing and was currently attending an electricians course. One user had completed a preparation for work course at an employment centre in Buckinghamshire. Two users had completed computer training courses. One user had regular voluntary jobs at two charity shops. Fours users were working with a Work Skills group which offers a gardening and decorating service in the area. Activities in the weekly programme include (among others): Gym, Swimming, Cookery, Badminton, Indoor Football, and Practical Skills. Users may also go walking in the local area (there are a number of footpaths in the local Chiltern hills), play golf or putting, ten pin bowling, or visit local cinemas in High Wycombe or Hemel Hempstead. Much of the programme is planned in advance with users. At the time of this inspection users and staff were planning outings for October 2009. Other trips have included visits to a model village in Beaconsfield, to towns on the Thames such as Marlow and Henley, and circular walks in the area with a stop for lunch in a pub. The manager had recently organised a visit for users and ex-users to a Wycombe Wanderers vs Leeds United football match. Many users maintain contact with their families and join them for holidays. The registered manager said that earlier in the year a group had taken a one week break in Devon. Menus are planned with users on Mondays. Meals are prepared with users. On some days of the week some users self-cater. The home has a separate self-catering kitchen when required. The home encourages healthy eating. A cookery group takes place every Wednesday. About once a month staff and users have a themed evening in which food plays a central part. To date these have included Caribbean, Thai, German, and American evenings. Users help themselves to breakfast. Lunch is usually a snack such as sandwiches. Groups of users may cook lunch together for themselves on occasions. The evening Care Homes for Adults (18-65 years) Page 17 of 35 Evidence: meal is the main meal of the day and is planned at the beginning of the week. Light desserts such as yoghurts and fruit are encouraged. Some medication in this field can lead to significant weight gain by, perhaps, affecting appetite, metabolism and activity. This is monitored by the home in liaison with the CMHT. Care Homes for Adults (18-65 years) Page 18 of 35 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 needs of users of the service are well met and promote health and well-being. The homes arrangements for the storage and administration of medicines are generally satisfactory and aim to ensure that users receive medication in a safe and consistent manner. Evidence: Support is provided in consultation and negotiation with users. There is a good level of flexibility with regard to user preferences. All users are registered with a local GP practice and with the local multidisciplinary community mental health team (Central East CMHT). Together, those provide access to GPs, psychiatrists, community psychiatric nurses (CPNs), and social workers. Psychologists and dieticians may also be accessed through the CMHT. Other services, such as NHS dentists are accessed locally as required. Care Homes for Adults (18-65 years) Page 19 of 35 Evidence: Support plans included evidence of regular contact with healthcare professionals. The home has devised a colour coded system for recording such contacts. The manager said that the GP surgery offers a good holistic annual health check. Medicines are prescribed either by the GP or the users psychiatrist and are dispensed by a local pharmacy. Most medicines are dispensed in monitored dosage blister packs except those which cannot be dispensed in such form. The latter includes medicines frequently used in this specialty and of which the home holds moderate amounts. The stock balance of such medicines are checked after each administration. Medicines requiring cool storage are kept in a plastic container in the kitchen refrigerator. At the time of this inspection eye drops were being stored there. Such medicines should be stored in a lockable container and the home undertook to obtain one. Systems are in place for recording receipt of drugs in the home and their return to pharmacy. Medicines records include a photograph of each user, the persons medicines administration record (MAR chart), a protocol for prescribed as required (PRN) medicines, and a homely remedies policy (for paracetamol to be administered as required). The homely remedies policy is signed by a pharmacist - a good practice. The homes procedures are checked twice a year by a pharmacist. A check was scheduled for September 2010. The reports of checks carried out in April and October 08 were on file. That for April 09 was not available at the time of the inspection visit. Care Homes for Adults (18-65 years) Page 20 of 35 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. Complaints and protection are effectively managed and protect the interests and wellbeing of users. Evidence: The home is required to conform to the complaints policy and procedures of Hightown Praetorian and Churches Housing Association. The procedure is summarised for users in the service users guide under the section entitled HPCHA Feedback. The procedure outlines a process for communicating comments, questions, compliments or complaints to staff in the organisation - from ..any of our staff to the Chief Executive. It includes contact details for CSCI (the former regulatory body) at its Oxford office (now closed). Records of compliments and complaints are retained. Two complaints have been recorded since the last inspection and appear to have been dealt with appropriately. We have not received any complaints about this service since the last inspection. Seven compliments have been recorded, six of which were accompanied by donations to the homes amenities fund. The statement of purpose (SOP) includes a section headed Protection From Abuse. This outlines the organisations approach to the subject of safeguarding vulnerable adults. The organisations policy and procedure is reinforced by staff training. Training Care Homes for Adults (18-65 years) Page 21 of 35 Evidence: is provided during induction and at update sessions at the head office in Hemel Hempstead. It is noted that the statement of purpose says that Staff are also required to read and understand the requirements of Bucks interagency policy on the protection of vulnerable adults. A copy of the current Buckinghamshire policy was not readily accessible at the time of our visit. The manager undertook to obtain a copy of the policy and associated material from the relevant office in Buckinghamshire Social Services. The home reports that in June 2009 two staff delivered a two hour workshop on Bullying for all residents. The workshop included role play, a quiz and discussion. There have been no safeguarding referrals since the last inspection. Staff training on responding to challenging behaviour is provided through the organisations training department at its head office. All staff receive training during their induction. The home does not manage monies on behalf of users. Arrangements can be made on a temporary basis for safe keeping and support but users are required to make their own arrangements otherwise. This is usually with their families according to the manager. Care Homes for Adults (18-65 years) Page 22 of 35 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 generally provides an acceptable standard of accommodation for users of the service. It is well located for the amenities of the local area. However, standards of cleaning and maintenance in some areas may compromise the otherwise good standards of the service. Evidence: The home is conveniently located for the Amenities of Old Amersham. Amersham rail and underground station is about a mile or so from the home. Amersham is well served by buses. There is limited parking to the front of the home. The home is well located for local services such as day centres and drop in facilities. It is also convenient for country walks in this part of the Chiltern Hills. The accommodation is on two floors. the home does not have a lift and is not therefore suitable for a person in a wheelchair. The ground floor accommodation comprises offices, two kitchens, two lounges (of which one is a designated smoking area), a meeting room, computer room, laundry, staff sleep-in accommodation, and wc. Stairs at either end of the building lead to the first floor. The first floor accommodation comprises bedrooms, bathrooms, shower and wc. None of the Care Homes for Adults (18-65 years) Page 23 of 35 Evidence: bedrooms have en-suite facilities. There is a moderately sized garden to the rear of the property. This comprises an area of lawn, patio, and a number of areas for seating, barbeques and other events. Part of the garden, between the car park and that used by the home, is used by the Workskills Group (which employed at least four users at the time of this inspection). There is a commercial property to one side of the garden and views of open country to the rear. The standard of the accommodation on this inspection was variable. Most of the ground floor accommodation was in an acceptable condition. The carpet in the nonsmoking lounge was showing signs of wear and tear and should be considered for replacement. Some of the furniture in the smoking lounge was scheduled for replacement. The main kitchen was in quite good order although the freezer appeared due for defrosting. The rehabilitation kitchen was in a satisfactory condition. The laundry was in good order. The accommodation visited on the first floor was generally satisfactory. A significant exception however, was the state of the shower room, bathroom and wc. There were two issues: standards of cleanliness and standards of maintenance. Both wcs were in an unclean and quite unhygienic condition. The detail was discussed with the registered manager on the day of the inspection. The problem of maintaining good standards of cleanliness in communal toilets are acknowledged. It was noted that by lunch time - after the domestic assistant had cleaned those areas - standards had greatly improved. However, the state of those toilets when first inspected was unacceptable and managers must consider what changes are required to ensure that good standards of cleanliness are maintained in those parts of the home . The other issue on that floor appeared to be concerned with maintenance. Ventilation in the shower room seemed to be exceptionally poor. This seems to lead to a warm and humid atmosphere which remains for longer than one would expect. This may contribute to the discolouration of the tiles and grouting in that room. This point was also noted in the report of the previous key inspection of August 2007. The bathroom is also in need of attention. The seal between the bath and the wall was damaged. Tiles were loose. The decor was dowdy. The home is due for redevelopment within the next two years. This may have a Care Homes for Adults (18-65 years) Page 24 of 35 Evidence: bearing on management decisions with regard to refurbishment, redecoration and the replacement of furniture and other items. However, there is a need to maintain good standards in the environment for users. The state of the bathroom, shower room and toilets on the morning of the inspection fell well short of acceptable standards and need to be addressed by managers. Care Homes for Adults (18-65 years) Page 25 of 35 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. Good standards are maintained in staff recruitment, training and development which ensure that users are supported by staff with appropriate qualities and skills. Questions on whether changes in the organisation and in staffing since the last inspection have led to a reduction in the amount of staff time available to users should be considered by managers in consultation with users and staff. Evidence: At the time of this inspection the staffing consisted of the following: 8 am to 9 am one staff member; 9 am to 9 pm - two members of staff; 9 pm to 11 pm - one member of staff; 11 pm to 8 am - one sleep-in staff member. There is always a manager on call. In addition to care staff there is also one part-time domestic assistant and eight hours of admin support per week. Since the last inspection the staffing structure had changed. The registered manager had been promoted to service manager. This entailed taking on additional responsibilities for a group of services, including Nicholas House. The registered manager told us that he was currently able to spend around four days out of five in the home. In keeping with a wider restructuring the organisation had appointed a team leader for the home. The team leader was soon to assume the responsibilities of Care Homes for Adults (18-65 years) Page 26 of 35 Evidence: the registered manager. The position of deputy manager had been replaced by a senior support worker. We received some expressions of concern about staffing. These centred on increased pressures on staff time and potentially less time available for users. Firstly, we were told that the amount of administration had increased with more time now spent on paperwork and computer work and that this reduced the amount of time available to users. Secondly, with just two staff available between 9 am and 11.30 am, a period of peak activity, there was little free time for staff to spend with users. Thirdly, staff told us that they were frequently unable to take their break, particularly in the morning, and were discouraged from accruing time off in lieu. There was a concern that staff did not have enough time to get to know users and more particulary perhaps, to monitor subtle changes in mood or behaviour. One person said that it was as if the home was around one staff member short.These concerns were raised with the registered manager on the day of the inspection visit. This inspection includes a recommendation that the registered persons explore these matters further with staff and users. Users seen were complimentary about the staff and based on observation on the day of the inspection visit, staff and users seemed to have a comfortable relationship. There is a varied range of experience among the staff group and all of those seen appeared to have the qualities necessary for this field of work. Staff spoke highly of both the registered manager and the team leader. These positive views were echoed by a health professional seen during the inspection visit. The home has appointed four staff since the last inspection. It is supported in appointing new staff by the organisations Human Resources (HR) department at head office. HR staff process applications and advise on any technical aspects of recruitment. The home holds a summary of the information held on each personnel file in the HR department. The summary forms were examined in the presence of the team leader and were considered satisfactory. Staff have access to a comprehensive programme of training. This includes induction, update, specialist, and NVQ training. Each member of staff maintains a personal portfolio which includes a schedule of training and certificates of attendance or attainment. New staff undertake induction training which includes completion of a workbook and attendance at some sessions at head ofice. Reviews are held at three and six months (the latter usually noting the end of the persons probationary period). Care Homes for Adults (18-65 years) Page 27 of 35 Evidence: In addition to the organisations general programme staff also attend a two-day Mental Health Awareness course and training on responding to aggression and violence. Staff have also attended joint training with the CMHT on Dual Diagnosis and Schizophrenia. The registered manager said that further joint training is likely to take place. This is a positive development because the service forms an important element of the local network of mental health services. Such events, apart from the benefits of training, also facilitate communications between services. Mixed views were expressed on the use of E-Learning (computer based training) which it was said is increasing across the organisation. Eight of nine staff have acquired NVQs at level 2 or above. Supervision is well established in the home and sessions normally take place on a six weekly basis. Sessions are planned, are confidential and records are maintained. Care Homes for Adults (18-65 years) Page 28 of 35 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 management and administration of the home promotes a good quality of service to users and in particular supports their participation in the running of the home and in activities in the wider community. Evidence: The registered manager is well qualified and experienced for the position. Since the last inspection the manager has taken on additional responsibilities for other services, having been promoted to the position of service manager. A team leader has been appointed. The team leader is appropriately experienced and is currently pursuing further studies in health and social care management. At the time of this inspection her application to be the registered manager was being processed by our registration service. Staff working in the home are accountable to the team leader. The team leader is accountable to the service manager. The ethos of the home seems fit well with the needs of users. Its aims include: To support service users to be as involved as possible in decisions about their lives, To Care Homes for Adults (18-65 years) Page 29 of 35 Evidence: consult service users about the running of the home, For service users to be as involved as possible in the practical side of running the home, and To ensure the culture of the service promotes equality and welcomes diversity. From what weve seen and heard on this inspection the home is generally achieving these aims. It seems to have an open culture which encourages users to express their views. Within a broad structure which encourages participation there is scope for individuals to pursue their own interests. At the time of this inspection the registered manager told us that the home was conducting its stakeholder survey for 2009. This includes seeking the views of users of the service, their families, and of health and social care professionals. The organisation carries out monthly proprietiors visits (sometimes referred to as Regulation 26 visits). These are thorough and comprehensive and detailed reports are filed of each visit. The report for June 2009 was examined at inspection. We were informed that the July 2009 report had not yet been printed off from the computer. The home is due for major redevelopment within the next two years. This is part of a reconfiguration of Hightown Praetorian and Churches mental health services accommodation in the area. When completed the Amersham complex will consist of eight shared supported living flats and four independent supported living flats. The plans have been discussed with users. The actual timing of the development is dependent upon a number of factors, including progress on related developments elsewhere in Buckinghamshire. We carried out a survey of stakeholders for this inspection. We had not received any completed forms by the time of writing this report. We will note the content of those we receive and record a summary report on the services file. This information will inform future inspections of the service. Arrangements for maintaining safe working practices appear satisfactory. There are a number of policies governing health and safety matters. The organisation provides a range of training on health and safety, fire safety, moving and handling, first aid, food hygiene, responding to aggression and violence, and the safe handling of medicines. The registered manager has provided us with with information on the most recent checks on the homes electrical wiring, portable appliance testing, fire detection and alarm systems, fire fightin equipment, emergency lighting, and the homes heating system. It is noted that according to information provided by the home gas appliances were last checked in October 2007. Arrangements are in place for the safe Care Homes for Adults (18-65 years) Page 30 of 35 Evidence: management of COSHH materials. The monthly proprietors visits includes checks on some matters of health and safety. However, the registered persons should review the cleaning and maintenance schedule for the toilets and bathrooms on the first floor for reasons outlined elsewhere in this report. Care Homes for Adults (18-65 years) Page 31 of 35 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 32 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 It is recommended that the registered persons review and update the statement of purpose and service users guide to take account of changes both within the home and in health and social care regulation since the last edition in July 2008. It is recommended that the registered persons ensure that medicines stored in the refrigerators in the kitchens are kept in a lockable container. It is recommended that the registered persons obtain a copy of the Buckinghamshire joint agency policy of Safeguarding Vulnerable Adults and associated material and to ensure that it is readily accessible to staff. It is recommended that the registered persons take action to ensure that all areas of the home to which users have access are clean and adequately maintained. It is recommended that the registered persons conduct a review of staffing levels taking account of changes in the home and in the organisation of work since the last inspection. 2 20 3 23 4 24 5 33 Care Homes for Adults (18-65 years) Page 33 of 35 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 6 42 The registered persons should ensure that the safety of gas applianciances is checked by a competent person at recommended intervals. Care Homes for Adults (18-65 years) Page 34 of 35 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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