Care Home: Pirton Grange Nursing Home

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What the care home does well The home has a new manager who has started to improve all areas of the home. People living at the home have a lifestyle that suits their needs and interests, with opportunity to develop their interests and independence. People have good quality meals and snacks. What has improved since the last inspection? Staff are receiving appropriate training and support which has led to improvements the quality of care and support throughout the home. There have been improvements in care planning, supporting risk taking, meeting health and personal care needs, medications, and complaints and safeguarding. What the care home could do better: As new people move to the home and new staff are recruited, the home must be able to sustain the improvements it has made and adapt to suit new people. This is particularly important in the areas of assessment, personalised care planning, recording of activities, health care and complaints for monitoring, use of the communal areas, staffing levels and training. Key inspection report Care homes for adults (18-65 years) Name: Address: Pirton Grange Nursing Home The Grange Pirton Grange Nursing Home Pirton Wadborough Worcestershire WR8 9EF     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Emily White     Date: 0 2 1 2 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 32 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 32 Information about the care home Name of care home: Address: Pirton Grange Nursing Home The Grange Pirton Grange Nursing Home Pirton Wadborough Worcestershire WR8 9EF 01905821544 01905821257 admin@pirtongrange.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Pirton Grange Limited care home 58 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence past or present drug dependence dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 58. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 58 Mental Disorder, excluding leaning disability or demetia (MD) 58 Past or present drug dependent (D) 58 Past or present alcohol dependent (A) 58 Date of last inspection Brief description of the care home Pirton Grange has extended the home and provided a purpose built unit. The original home is a heritage listed building and is in the process of being modernised and Care Homes for Adults (18-65 years) Page 4 of 32 Over 65 0 0 0 0 58 58 58 58 2 4 0 9 2 0 0 9 Brief description of the care home upgraded. Pirton Grange is situated near the village of Pirton in beautiful countryside south of Worcestershire. The home is two storeys with a lift to assist people with mobility problems to mobilise throughout the home. The new unit provides accommodation for people in single en - suite bedrooms which are well equipped for people with physical disabilities. In addition to the bedrooms the home provides lounge and dining room, and specialist bathing facilities. The spacious landscaped gardens are accessible for people to use and provide a pleasant outlook from the home. The home provides 24-hour nursing care for people under the age of 65 years. There assessed health needs include Huntingdons Disease, Acquired Brain Injuries and other physical and mental health problems. People can be accommodated on long term and short term placements. Information regarding the home can be obtained from the Statement of Purpose and the Service Users Guide, which are available in the home. The home is part pf the European Care Group who have other homes throughout the country. The home have appointed an acting manager who is applying for registration with the Care Quality Commission. Information about the fees are not included in the Service User Guide, for up to date information about the fees please contact the home direct as the fees are based on individual needs and assessments. Additional charges are made for cigarettes and holidays. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: Before we visited the home we looked at the information we had about the home. This included that last key inspection report, the last random inspection report, the improvement plan sent to us by the home, notifications we had been sent, reports from other health professionals, and information from families, representatives and other professionals who know the home. Two inspectors visited the home on a weekday and met the new manager, staff and people who live at the home. We spoke to people, observed daily life and looked at records such as care plans and staff training. Care Homes for Adults (18-65 years) Page 6 of 32 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 32 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 8 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has not been able to meet the needs of all the people who have lived there, but improvements are being made. The assessment procedures, statement of purpose and guide to the service must be accurate and reflect the aims of the home so new people can be confident the home is the right place for them. Evidence: Following the last key inspection a requirement was made that the preadmission process must be made more robust to ensure that only people whose care needs can be met are admitted to the home. This had been repeated from previous inspections because no new people have moved to Pirton Grange. This requirement will be repeated again with an extended time frame as no new people have moved to the home or been readmitted from hospital since the last key inspection. Following concerns and complaints received in the past twelve months, concerns have been raised that some people with challenging behaviour and mental health needs did not have these needs met by the home. Some people who lived a Pirton Grange have now moved to more appropriate accommodation. The improvement plan sent to us by Care Homes for Adults (18-65 years) Page 9 of 32 Evidence: the home in September 2009 states that they have identified a new preadmission assessment tool and a new health Needs Assessment to ensure the home is the right place for new people moving in. No new people have moved to the home or been readmitted from hospital since the last key inspection. For this reason we did not look at the new preadmission assessment tool. We spoke to the manager about how he would manage new admissions to the home. The manager told us that decisions relating to new people would be a team decision, and they would assess the appropriateness of the decision, for example whether the person would fit in. The manager also said the home will plan for the persons care before they arrive. The home is currently employing therapists from ARCOS (a charity which provides information, advice and support for people with communication and swallowing problems). The manager hopes that this organisation will have an ongoing involvement with new admissions to the home. The manager states that he considers Pirton Grange able to provide a specialist service because there is a high level of therapeutic input, a high level of training for staff, and newly appointed staff have a specialist background. It would be good practice as part of the improvements to the home that the statement of purpose and information for people interested in the home is reviewed to ensure that it meets the current and future aims and objectives of the home, and provides an accurate description of the service for new people. As part of our key inspection we looked at the health needs assessment for two people. This fitted with their care plan and will be mentioned in more detail later in this report. Care Homes for Adults (18-65 years) Page 10 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made so that people are supported to make decisions about their life and to take risks to enable them to stay independent. Staff now have appropriate information on which to base decisions. Improvements need to be made so that plan for peoples care are available in a personalised and accessible way. Evidence: Following the last key inspection two requirements were made: 1. Care plans should be comprehensive and reflective of the individuals care needs. 2. When a risk is identified to a persons health, safety or wellbeing, a risk assessment must be completed that provides clear guidance and instruction to the staff about minimising the potential risk. Following this key inspection we found that improvements have been made and these requirements have been met. Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: The home sent us an improvement plan in September which told us that the home hopes to use an Essential Lifestyle Approach in peoples Person Centred Care Plans. It also tells us that they have completed a Risk Screen for all individuals and each persons file has a Risk Management Plan if necessary.The manager tells us that the Essential Lifestyle Approach will take some time as the the home has been focused on improving health care needs in the plans. The operations manager has been working with some of the staff on health action plans and essential lifestyle plans. The manager has started case presentations with the lead nurses, which involves asking them to discuss a person and talk about their knowledge of their needs. So far two nurses have been involved in this. The manager also plans to use getting to know you questionnaires for people living at the home. Now that improvements in care planning are being made, it will important for the home to provide a more personalised way of planning peoples care. This will help staff to understand individuals better and ensure they are able to meet their needs in the way they prefer and want. We looked at the care files for two people living at Pirton Grange. We note that monthly care plan reviews are more detailed since June 2009 which shows that peoples support is being monitored regularly. Many of the people who live at Pirton Grange communicate and express their decisions in different ways. We saw that people have communication care plans which give clear directions for staff about peoples speech and meaning. People also have plans related to their behaviour which is another way people may express themselves or show decisions they have made. Peoples plans describe the behaviour they might use and tell staff the best way to respond to this. For example,When I scream and shout I want something, listen to me and act on my wishes, allow time to settle, providing reassurance, refer to agitation and maintaining safety care plan, utilise observation chart, tends to bang on the table for attention requesting a cup of tea. We saw that people were sitting or acting as described in their care plans. One persons plan says they like a quiet environment. We observed this person spent the day in their room, with the door open so they could interact with staff passing by. We observed another person interacting with staff and other residents in a demanding way. We observed staff assisting this person to join in the craft activities at the table. New risk screening tools have been completed which identifies risks such as risk of verbal and physical aggression, self harm and fearfulness of walking. One person had a agitation and maintaining safety care plan which links to their risk assessment. We saw that people had relevant risk assessments in place including one relating Deprivation of Liberty. Where risks related to behaviour people had behaviour Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: monitoring charts in place. We spoke to several nursing and care staff during the day. Staff say they are getting involved in all activities as this is part of their learning about how to get to know people better. Staff say they have time to talk to people living at Pirton Grange, which helps them to understand their preferences better. Staff tell us they believe people are supported to do the things they want to. Staff show a good understanding of making agreements, setting boundaries and expectations, monitoring activity and the importance of choice. We observed staff using a communication chart with one person, speaking calmly, starting again when they have not understood. Care Homes for Adults (18-65 years) Page 13 of 32 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. The service is improving so that it can show how it treats each person as an individual, supports people to follow personal interests and activities in the community and at home, keep in touch with family, friends and representatives, and maintain independence in daily living. People have healthy meals and snacks at times to suit them. The home must be able to sustain this so that new people moving to the home can maintain the lifestyle they choose. Evidence: Following the last key inspection a requirement was made that the service must consult and enable people using the service to maintain and develop appropriate social, emotional, communication and independent living skills, and take part in fulfilling and meaningful activities, as part of their daily routines and interaction with family, friends and wider community. Following this key inspection this requirement has been met. Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: The home sent us an improvement plan in September 2009. It tells us people living at Pirton Grange have a high quality of lifestyle. Examples include, two activity coordinators who cover seven days a week; individual holidays, musical sessions, gardening, films, supported access to local pubs, community facilities, the library, college, the zoo, swimming and hydrotherapy, art and the Body2Soul organization who provide therapies such as massage, reiki, and aromatherapy. We looked at some records and observed the lifestyle in the home during the day. Finance records show that people have been having pub meals, trips to the cinema, pub drinks, trips to the garden centre, and shopping. People have had an activities assessment carried out by the coordinator, which is used to set up an activity care plan. This gives a good social history which helps staff to build a picture of the person. Staff record in the persons care plan to monitor what they have been doing that day. One persons records showed daily entries including reading, daily walks, make up, massage, and games. Another persons records showed seven entries for November. It is important that records for occupation and daily activities are recorded consistently so staff can monitor whether peoples needs and preferences are being met and met and quieter individuals do not experience isolation. During our visit we observed Body2Soul therapists doing one to one hand treatments, some people went to the cinema in the afternoon and other were involved in crafts during the morning. Upstairs people were watching TV and talking to staff, and downstairs people were able to walk about freely, watch TV or have the paper read to them. We observed a friendly relaxed atmosphere which was calmer than on previous inspections. The new manager tells us he is trying to encourage an activity based culture and to raise awareness of daily routines as activities. Although there are two activity coordinators all staff are involved. We also met one of the activity coordinators and spoke to staff about the lifestyle in the home. Staff tell us the atmosphere in the home have improved, and all staff are involved in activities. Some people have one to one support but everyone gets some input dependent on their needs. The activity coordinators have a timetable for suggested activities and people living at Pirton belong to small activity groups with people they get on with or who have the same interests. People are encouraged to go out and staff say people usually go out at least once a week. Staff understand the importance of daily activities and routines such as going to the bank, not just providing entertainment. Staff also show a good awareness of peoples individual likes and dislikes. The activities coordinator has requested a cooker that people can use to help improve some of their daily living skills. We also noted that people do not have access to computers, games consoles or the internet. It would be good practice for the service to consider the use of appliances and computer Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: technology to encourage independence and skills suitable for peoples ages and needs. We observed breakfast and lunch times at the home. During 8 AM to 10 AM there are two care staff whose role is to support breakfast and ensure that everyone has had their choice and support to eat if needed. We saw daily records which show that people are getting the meals and drinks they need as part of their plan of care. People have the food and drink preferences recorded. During lunch time we observed people in the dining room or other rooms of their choice being supported to eat. We observed that food looks appetising and people were finishing their food. We observed staff sitting appropriately and working in a calm and supportive manner. The lunchtime appeared much less chaotic than on previous inspections. We met the chef and kitchen staff. There is a large choice of food with high calories for those who need it. The kitchen is open all day and staff tell us people can have food at any time. There is a large choice for breakfast such as cooked breakfast, porridge, cereals, and two choices for the cooked meal at lunch time, for example turkey or beef. There is a four week rolling menu which is seasonal. For tea people can have sacks such as soups or sandwiches, and fresh fruit and yoghurt is available. The kitchen staff understand the different needs of people for example whether they need high calorie food, have diabetes, swallowing difficulties, or changes to their weight. The kitchen has recently received a four star certificate from the environmental health officer, and all food is stored and transported safely and at the correct temperatures. Care Homes for Adults (18-65 years) Page 16 of 32 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. Improvements have been made to the way people receive personal support, and their physical and emotional health needs are now being met. People are getting the medications they need and medications are being managed safely. The home must be able to sustain this so that new people moving to the home receive good quality support. Evidence: Following the last key inspection we found serious concerns with how peoples medications and health care needs were being met. A random inspection was carried out in September which found that improvements had been made in how people received support with their health and personal care. A requirement was made that the service purchase and install a Controlled Drug cabinet that complies with the Misuse of Drugs safe custody Regulations 1973. This has been done which means this requirement has been met. The improvement plan which was sent to us in September states that all care files have been updated in consideration of the observations and comments from the previous inspection report. It also tells us that shift handover sheets are in use to Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: provide a clinical overview of each person, and a new Health Needs Assessment in peoples care files provides information for day to day needs and clear guidelines for what to do if this changes. The plan also says that training has been provided for staff in the areas of Epilepsy, Diabetes and Huntingtons Disease. During October the managing director of the organization that owns Pirton Grange also confirmed to us that the home has employed some specialist staffing including the ARCOS training team (an occupational therapist, physiotherapist, and speech therapist), an experienced pharmacist advisor, and new nurses with appropriate specialist backgrounds such as mental health nursing. During our visit we were able to see from observations that all of these improvements have been put into place. The manager tells us that the specialist staffing will continue while the home improves. We spoke to several members of nursing and care staff who confirmed that the specialist team have been available daily and time has been made for staff to work alongside them to gain specialist knowledge and skills, and get advice on sitting, communication, and feeding for example. The care and nursing staff we spoke to showed a good knowledge of the people they care for and were able to tell us about current problems or concerns that were being recorded in care plans, and also showed a good understanding of the emotional aspects of the care they provide. Staff confirmed that handover sheets are used, which include comments from day and night staff about each person, and staff find this information useful. Staff say that communication has improved and new staff have been given good support. We looked in detail at the health and support plans for two people living at Pirton Grange. The manager and staff have worked hard to improve the detail in these plans but the manager also understands the need for information that is more individualised and accessible to people living at the home and staff. During the day we observed that people were getting the support as described in their care plans. Both of the people appeared happy and communicating well with staff. People we saw during the day appeared well groomed, healthy and happy. People have had a health needs assessment completed which looks at issues such as communication, continence, diet, teeth, pain, psychological health, general health checks such as well woman. We saw that where the assessment identifies a need for further assessments or reviews by health practitioners, this had been done for the most urgent assessments, such continence, swallowing and psychiatry. We also noted that one persons assessment from August had highlighted a need for a well woman check and dentist appointment which had not been carried out by December. People had received assessments for management of pain and how this is Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: communicated, for example X will tell staff when she is in pain. We noted that there are now protocols in place for giving pain relief as and when required. People also have risk assessment in relation to their medications, and other concerns such as moving and handling, falls, agitation and physical aggression, and smoking. These are all being reviewed monthly, and where risks or concerns are identified such as mental health, weight gain or pressure care, these are being followed up with appointments with the GP, dietitian, tissue viability nurse or other relevant health professional. People are also having dependency assessments recorded which shows that peoples changing health needs are being monitored. Care plans, daily records and monitoring sheets all show that staff have an understanding of supporting independence, for example X can wash at her sink but requires assistance with turning the taps. Where issues have been identified with mobility or swallowing, records show that people are having regular input from the ARCOS physiotherapy team. Monitoring sheets for meals, weights and personal care are being completed. While we could see from records and from speaking to staff that concerns are being followed up and dealt with, we saw some areas of recording that were inconsistent. For example, one persons weight gain has been investigated and dealt with appropriately, however their MUST tool had not been completed in November. Where professionals such as dietitians had visited, their advice or guidance was not clearly recorded or accessible. In one area where someone was rightly receiving a soft diet, the care plan recorded a puree. Another person had been identified with sore pressure areas and bowel concerns. Staff were taking the right action to manage this, however an acute care plan had not been set up to provide information for staff who may not know the person. For another person who had had several concerns about their mental well being, staff had not recorded any communications with their family. The home currently has a specialist pharmacist advisor working for them. She has changed the dispensing chemist and made some of the paperwork easier to follow. She has completed medication audits and is currently assessing competencies for staff, observing their practice as necessary. We observed two medication round which were being managed safely and appropriately. Peoples medication care plans show their medications and a description of possible side effects. We saw no gaps in the administration charts and saw that peoples creams are kept in their rooms and administered appropriately. Medications are stored and audited safely. Care Homes for Adults (18-65 years) Page 19 of 32 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. Improvements have been made to communication records so that if people have concerns with their care, they or people close to them, know how to complain and 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. The home must be able to sustain this as new people with different needs move into the home. Evidence: Following the key inspection in December 2008 several serious concerns and complaints have been raised about the quality of care at Pirton Grange. A large number of these concerns were raised about the homes ability to support people with challenging levels of need including mental health and behavioural problems. Some people have moved to more appropriate accommodation and since June 2009 the number of concerns has reduced, and efforts are being made to improve the quality and safety of the home. We are aware of one safeguarding concern and one complaint from a staff member that are still outstanding, and are confident that the home is addressing these through the appropriate channels. As new people move to the home it will be important that standards to monitor complaints and safeguard people are maintained. This will be achieved through ensuring that thorough assessments are completed, staff are trained and are aware of safeguarding procedures, and people living at the home are able to communicate Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: appropriately, The improvement plan sent to us in September 2009 says that a full day extensive Adult Protection Training has been carried out and is ongoing to cover all staff including new starters. We looked at the training records which show that the majority of staff have received this training from June 2009 onwards. Safeguarding vulnerable adults is part of the e-learning induction that all new staff must complete. We were not able to view the current complaints file however the manager states that there have been no complaints since the last inspection. The manager is aware of the importance of keeping a complaints log and of having measures in place to record communications from people who live at the home. Care files show that communication support plans are in place and staff know people well. Accident records are audited monthly by the manager who tells us that no patterns are emerging. One person who had a number of falls is being assessed by the physiotherapist for footwear. Care Homes for Adults (18-65 years) Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People stay in a safe and well-maintained home that is clean and hygienic. Consideration should be given to making the large communal areas more homely and suitable for the different activities that happen in them. Evidence: The improvement plan sent to us by the service tells us that improvements have been made as follows: Window restrictors are in place The company has a policy and procedure for the reporting of hazards with the induction of the new Home Manager these will be fully implemented. A number of discreet clinical waste bins have been ordered and will be sited in key areas. The home is introducing a coloured system for clinical aprons and gloves. During our visit we saw that the home was free from odours and infection risks. Staff were carrying out their jobs safely. We spoke to the maintenance person who is responsible for some the health and safety aspects of the home, and is keeping up to date. The home has two domestic staff and two laundry staff during the day. Prior to this key inspection we discussed the environment of the home with a specialist in Huntingtons disease who has visited Pirton Grange. She told us that work has been done to personalise some peoples rooms. She advised that some areas for Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: improvement might be to the large communal areas, and consideration of noise, for example music, TV volume peoples sensitivity to noise. During our visit we observed a calmer, quieter atmosphere than at previous inspections. People have freedom of movement around the home and appear comfortable there. We noted the rooms had all been decorated with Christmas trees and peoples bedrooms were personalised. The small rooms that have been recently decorated are not used during the day at present, and most people use the large communal areas. For example the large lounge next to the reception has a small number of seats in it with a TV on one wall, and extra space which is not used. The room is used as a corridor which means that sometimes staff and other people walk in front of the people who are watching TV. As new people move into the home, consideration should be given to the use and layout of these large rooms with consideration for noise and different activities that might take place within them, and creating a more homely atmosphere. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made so that people living at the home have safe and appropriate support by competent, qualified staff. Checks have been done to make sure staff are suitable. Peoples needs are met because staff get the right training, supervision and support they need from their managers. The home must be able to sustain this as new people with different needs move into the home and new staff are recruited. Evidence: Following the last key inspection requirements were made that 1. Staff must attend appropriate training so that they are able to demonstrate they have the knowledge, skills and confidence needed to ensure residents health and emotional needs are met. 2. The home must show that the staff have the necessary knowledge, skills and competencies to meet the assessed needs of people using the service. Following this key inspection we saw that improvements have been made so that the requirements have been met with regard to people who currently live at the home and current staff. The improvement plan sent to us by the home in September 2009 told us that formal training is certified and signed by the staff and put onto a training matrix which Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: includes induction and core Training. Secondary training is provided on a rolling programme. There are also six weekly supervisions and regular team meetings. The managing director of the company who owns Pirton Grange also tells us that the specialist staffing mentioned earlier in this report is to remain while the service improves. He also says that staff have undergone major comprehensive retraining regardless of team experience or earlier training, introduced a new e learning system to cover mandatory training. During our inspection we discussed staffing and competence with the new manager, staff and observed staff practices and records completed by staff. This confirmed that the above changes have taken place. As well as the e learning, staff have had some additional specialist training by St Richards Hospice and the Huntingtons Disease Association. Not all staff have attended this training, however all staff having significant input from the ARCOS specialist team. At present the different forms of training are logged on different spreadsheets, for example mandatory training is logged separately. As the service improves, the specialist teams will become less involved, new people will move to the home and new staff will be recruited. As a specialist service specialist training should be made available to all staff and a means to monitor this should be developed to monitor future training needs. Staff tell us they feel they have a good understanding of peoples physical health needs but would like more training on specialisms such as Huntingtons disease particularly around the psychological and emotional aspects. Staff are able to discuss the needs of people living at the home and records show they are acting appropriately to deal with concerns. The new manager has put in a new structure which staff say is working. There are two teams with a lead nurse who supervises the care staff. Staff report that communication between staff has improved, and care planning has improved because the nurses have ownership of the records. They also say it is better for people living at the home because they see the same staff and get to know them better. Staff morale has improved. There has been a lot of staff recruitment, records show that this has been managed safely with the appropriate checks being carried out. Staff say very few agency staff are now used, rotas support this although some agency staff are used at night. Currently there is one staff member between three or four people living at the home, with managers and activities coordinators on top of this. As new people move to the home it will be necessary for the manager to regularly review the staffing levels according to peoples needs and abilities. Care Homes for Adults (18-65 years) Page 25 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A new manager has been recruited so people living at the home can have confidence in how it is run and managed. The environment is safe for people and staff because health and safety practices are carried out. The home will benefit from having stable management as new people move to the home. Evidence: The home has appointed a new experienced manager who intends to become registered with CQC. The home has also appointed a new deputy manager and retains their clinical nurse lead. Staff tell us that already the home has improved due to these changes. Staff tell us that the new manager is very supportive with an open door policy. We were pleased to note that the manager has moved his office into the ground floor of the building where he is accessible by staff and people living at the home. Since the last key inspection all of the relevant requirements have been met and improvements have been made to the provision of health and personal care and staff competence and we have received fewer concerns and complaints. The new manager tells us he is supported by his organisation and has been given freedom to make changes. Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: Following the last key inspection a requirement was made that the home should establish and maintain a system for reviewing the quality of care and service provision in a format suited to the needs of the people using the service. This requirement has been met. The improvement plan sent to us in September tells us that people living at the home are to be more involved in the care planning and review process. There are relatives meetings and a suggestion box locate in the reception area that is checked weekly. Questionnaires will be sent out annually and the Senior Clinical Operations Manager will carry out the mandatory quality assurance visits. The manager tells us he is using the CQC Annual Quality Assurance Assessment as a live document to record improvements as they are made. The manager is in the process of introducing a new system of quality review based on the methodology of inspections. At the moment the manager reviews peoples care plans weekly, attends all staff handovers, reviews the rotas, gets feedback from reviews, and has started case presentations with staff, when staff present the needs of someone who lives at the home. Due to the improvements being made at the home, we are satisfied that the manager is reviewing the quality of the service on a regular basis. We checked a random sample of health and safety records and spoke to the maintenance person who is responsible for keeping records up to date. We saw that staff have had recent updates in safe working practices. Care Homes for Adults (18-65 years) Page 27 of 32 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 28 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 12 The pre-admission process must be robust to ensure that only people whose care needs can be met are admitted to the home. This will ensure new people moving to the home can be confident their needs will be met 02/02/2010 2 19 13 People using the service 02/03/2010 must be supported to attend routine health checks and appointments such as the dentist as assessed. This will help people to maintain their general health and well being. 3 22 22 A record must be kept of all issues raised or complaints made by people using the service and other interested parties, with details of any investigation, action taken and outcome. 02/01/2010 Care Homes for Adults (18-65 years) Page 29 of 32 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 This will ensure the concerns of people living at the home are taken seriously and addressed. 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 The statement of purpose and guide to the service should be reviewed so they are accurate and reflect the aims of the home. This is so new people can be confident the home is the right place for them. A personalised approach to care planning should be considered so that individuals are involved in their care in a way they can understand and that is accessible for staff and the individuals concerned. Staff should make sure they consistently record occupation and activities. This will help to monitor whether people are maintaining and developing their social, emotional, communication and independent living skills. The service should consider the use of appliances and computer technology to support people to maintain and develop independent living skills appropriate to their age and needs. Consideration should be given to recording communications and decisions with health professionals and family in a clear and more accessible way. Staff should ensure that planning for health needs are consistently recorded so that all staff coming to the home are aware of the current needs and plans for all individuals. As new people move into the home, consideration should be given to the use and layout of these large rooms with consideration for noise and different activities that might take place within them, and creating a more homely atmosphere. Page 30 of 32 2 6 3 12 4 16 5 19 6 19 7 24 Care Homes for Adults (18-65 years) 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 8 33 As new people move to the home it will be necessary for the manager to regularly review the staffing levels according to peoples needs and abilities. As a specialist service specialist training should be made available to all staff and a means to monitor this should be developed to monitor future training needs. 9 34 Care Homes for Adults (18-65 years) Page 31 of 32 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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