Care Home: Roborough House

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What the care home does well People are consulted on how their care will be provided and external specialist advice is sought as required and in a timely manner. Where necessary advocacy is arranged to help people make decisions and the home seeks to protect people through the legal arrangements to do so. The standard of care planning ensures people`s full needs and wishes are known to staff and these documents are being more personalised. People are financially protected through the arrangements at the home should this be necessary. There is a broad programme of activities available to people and they are supported to live fulfilled lives. This programme is under constant review. People`s health care needs are well understood and met by a competent nursing team and the support staff. People who use the service generally like the staff and have trust in their ability to care for them. The way staff are recruited protects people from those who may be unsuitable or unsafe to care for them. What has improved since the last inspection? People now have a full assessment of their needs before being admitted to the home. People tell us that the standard of food provided has improved. The hours of duty of the acting manager are now clear on the duty rota so the running of the home will be more efficient and effective. Continual investment in the building is ensuring a safer and more pleasant environment. There is now a structured training programme and staff have more training opportunities available to them. The standard of record keeping continues to improve which aids the smooth running of the home and protects people. There is now a manager in place. She made application with the Commission to register within one month of being in post. What the care home could do better: There must be accurate written information available to help people decide if the home is the right place for them. People should be more fully consulted about changes within the home which affect their day to day lives, such as changes in how staff will work and whether uniform should be worn. Catheter bags should be positioned more discreetly so as to preserve people`s dignity. All medicines must be stored securely so that people who not have the right to access them are unable to do so. All medicines must be recorded into the home, so that a full audit is possible; this promotes safe practice and is a repeat requirement. All `as necessary` medicines must be part of planned care so their use is consistent. Meal time arrangements should be reviewed. People should not be taking second place to staff and staff should be assisting only one person to eat at a time. So that vulnerable people are protected from abuse: Information, which suggests abuse may have occurred, must be responded to promptly and the safeguarding authorities informed; There should be a very clear distinction as to what will be handled under the home`s complaints procedure and what might be abuse and therefore passed to the Local Authority Safeguarding team and all staff should receive training in how to safeguard people from abuse. All radiators in the home must be covered or have guaranteed low temperature surfaces, to remove the risk of contact burns. This was a previous good practice recommendation. Where the home is registered to provide a specialist service, such as dementia care, there should be environmental adaptation to help promote the independence of people with that condition who may be admitted. Bar soap should not be available for use in shared areas as its use may lead to cross contamination. The patio should be kept cleaner and fresher so it is a pleasant outdoor space for all people who use the service, not only those who smoke. The smoking shed should be cleaner and fresher also. There must be enough competent staff, at all times, to meet the needs of people who use the service in a timely and dignified manner. In the interest of all who live or work at Roborough House staff/management disharmony needs to be resolved. Key inspection report Care homes for adults (18-65 years) Name: Address: Roborough House Roborough House Tamerton Road Woolwell Plymouth Devon PL6 7BQ     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: Anita Sutcliffe     Date: 0 5 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 39 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 39 Information about the care home Name of care home: Address: Roborough House Roborough House Tamerton Road Woolwell Plymouth Devon PL6 7BQ 01752700788 01752721088 nicola@roboroughhouseltd.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Roborough House Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 51 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia physical disability Additional conditions: Maximum of 3 service users with mild learning disability needing to convalesce following surgery or other general health care needs - for a maximum of 6 weeks One service user named elsewhere under the age of 60 with mild learning difficulties may reside at the home This home is registered as a Care Home with Nursing for a maximum of 51 Service Users in the category of PD 51, PD(E) 51, DE 12 To include a maximum of 12 service users in the DE category Date of last inspection Brief description of the care home Roborough House is a care home with nursing. Twenty four hour nurse cover is provided. The 51 bedded home is registered for people with physical disability who Care Homes for Adults (18-65 years) Page 4 of 39 Over 65 0 51 12 51 0 1 1 2 2 0 0 9 Brief description of the care home may be under or over 65 years of age. It may also admit up to 12 people below the age of 65 who have dementia. The home is owned by Roborough House Ltd. which is a subsidiary of CareTech Community Services Limited, which employs staff to work at Roborough House. CareTech has over 40 subsidiaries. The home is situated on the outskirts of Plymouth. People need transport in order to get to local services. The home is a large older building which has a modern extension. There are extensive grounds suitable for use by wheelchair users, with ample parking for staff, visitors and people living in the home. Accommodation is arranged on two floors with access to most areas via passenger lifts and a step lift. There are two lounges, a dining room, activities room, hairdressing salon, independant kitchen and fitness suite available to people. Information about the home, called the Statement of Purpose and Service User Guide, and a copy of the inspection report, are available in the reception area of the home. We were told in April 2010 that the weekly fees range between £490 and £3,297 and in June that people who use the service do not currently contribute toward the costs of the transport provided at the home. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at /www.oft.gov.uk . Care Homes for Adults (18-65 years) Page 5 of 39 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: The Commission has collected information about Roborough House since the previous key inspection 16th June 2009. We did a random inspection 1st. December, to check compliance with requirements made in June. Toward this inspection we sent surveys to people who use the service (five were returned), and staff (three were returned). The home provided us with information about the service. This includes data, such as how many staff work there and when policies were last reviewed. It also gives the home the opportunity to tell us what they do well, any barriers to improvement and what improvements are planned. We did two unannounced visits to the home spending sixteen hours there in total. We looked closely at the care of several people who use the service. This included, where Care Homes for Adults (18-65 years) Page 6 of 39 possible, meeting them, speaking with staff about their needs and examining records pertaining to their care. We also spent time observing staff and their interaction with the people in their care. We have received information from several health and social care professionals with knowledge of the home. We saw most of the building at both visits and several bedrooms. We asked a series of questions of fourteen staff with differing roles at the home and six people who use the service who were able to tell us what it is like to live there. The acting manager was present at the inspection and helpful throughout. People who use the service may be described within this report as residents, clients, service users or patients. Care Homes for Adults (18-65 years) Page 7 of 39 What the care home does well: What has improved since the last inspection? What they could do better: There must be accurate written information available to help people decide if the home is the right place for them. People should be more fully consulted about changes within the home which affect their day to day lives, such as changes in how staff will work and whether uniform should be worn. Care Homes for Adults (18-65 years) Page 8 of 39 Catheter bags should be positioned more discreetly so as to preserve peoples dignity. All medicines must be stored securely so that people who not have the right to access them are unable to do so. All medicines must be recorded into the home, so that a full audit is possible; this promotes safe practice and is a repeat requirement. All as necessary medicines must be part of planned care so their use is consistent. Meal time arrangements should be reviewed. People should not be taking second place to staff and staff should be assisting only one person to eat at a time. So that vulnerable people are protected from abuse: Information, which suggests abuse may have occurred, must be responded to promptly and the safeguarding authorities informed; There should be a very clear distinction as to what will be handled under the homes complaints procedure and what might be abuse and therefore passed to the Local Authority Safeguarding team and all staff should receive training in how to safeguard people from abuse. All radiators in the home must be covered or have guaranteed low temperature surfaces, to remove the risk of contact burns. This was a previous good practice recommendation. Where the home is registered to provide a specialist service, such as dementia care, there should be environmental adaptation to help promote the independence of people with that condition who may be admitted. Bar soap should not be available for use in shared areas as its use may lead to cross contamination. The patio should be kept cleaner and fresher so it is a pleasant outdoor space for all people who use the service, not only those who smoke. The smoking shed should be cleaner and fresher also. There must be enough competent staff, at all times, to meet the needs of people who use the service in a timely and dignified manner. In the interest of all who live or work at Roborough House staff/management disharmony needs to be resolved. 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 39 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 39 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. People do not have accurate information from which to decide if the home is the right place for them. Peoples needs are fully assessed prior to admission. Evidence: We looked to see whether admission arrangements at the home were in peoples best interest. Three people who use the service told us through survey that they did receive enough information about the home before they moved in so they could decide if the home was the right place for them. Two said they did not receive enough information. We were provided with current copies of the information which informs people what the home has to offer, called the Statement of Purpose and Service User Guide. The Statement did contain some good information but we found it was misleading on several counts. For example, it states that the manager is registered, which she currently is not. The document strongly indicates that people can be admitted if their main care need is learning disability or mental health illness, but, with the exception Care Homes for Adults (18-65 years) Page 11 of 39 Evidence: of a maximum of 3 people with mild learning disability needing to convalesce, this is not the case. We are aware that the home is considering varying the categories of service user it may admit. Neither does the Statement state that the registered provider is Roborough House Ltd. The Service User Guide provides some clear information for people as to what can be expected at the home. The home reports that information is available in different forms, including a small leaflet, full guide or website, but information must be current and factual. We looked at documentation pertaining to a person recently admitted to the home. He was already known to Roborough House through respite arrangements. His file contained an informative personal profile of recent history. Also, his ability to communicate, mobility and dietary requirements, were well documented. We saw that professional health care advise had been sought on his behalf and followed up appropriately. Risks had been assessed, such as moving and handling and prevention of pressure sores. There was also information available from the hospital discharge team. We contacted the health care professional involved in his discharge who told us they believe the home can meet his needs quite well, adding that he needs a lot of encouragement and they think the home achieves this. We were told that Roborough House did not get the chance to personally assess the last admission prior to discharge from hospital, which would be good practice so as to ensure current needs can be met. The acting manager told us that she will always endeavour to visit and assess a potential resident and take a registered general or mental health nurse with her depending on the need. She added that any referring worker (such as GP or hospital) will have a form to complete from the home and that this information, plus family and service user views, will influence the admission decision. The home reports that information about the home does need updating, only staff who have the skills to carry out pre-admission assessment should carry out the task and service user contracts are now being formulated. There are plans to have specified induction programmes for new admissions, to meet and greet and organize their settling in. Care Homes for Adults (18-65 years) Page 12 of 39 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are generally consulted, their individual needs known and they are involved in planning their care. People are financially protected through the arrangements at the home. Evidence: We looked to see how individual needs and choices are met at the home. Each person living in the home must have a plan of care that accurately reflects his or her care needs and identifies the action required by staff to meet those needs. The plan must be updated as necessary so that a persons changing needs are assessed and met. Roborough House management are very enthusiastic about a new method for planning care which puts the person who uses the service at the heart of the planning. We saw two examples of the fourteen we are told exist; they were very individual to the needs of the person. Care Homes for Adults (18-65 years) Page 13 of 39 Evidence: Currently most people who use the service have the old style care plans in place. They provide a detailed account of the persons needs, including any restrictions on choice and freedom agreed with them. Care planning does (and we believe will more so) put the person in charge of their future. One staff told us through survey that they are always given up to date information about the needs of the people they support or care for, for example through care planning, and one said they sometimes are. We were told that new arrangements at the home will better ensure that all care and nursing staff are more fully involved in care planning. The Commission is aware of the home protecting a persons right to make a decisions, which others may feel is not in their best interest. The persons right has been safeguarded through the legal channels for doing this. We asked people if staff listen to what they tell them and if they are involved in planning their care. One said: Oh yes, staff listen, and I get what I want anyway. Most said that staff do listen and thought they were involved in planning their care, within reason. Most felt they could do what they want most of the time. Information is readily sought from external health and social care professionals on how a persons plan will best benefit them. Examples include where a persons behaviour is a challenge to others and where eating certain foods may pose a risk. People who use the service are able to make some decisions about how the home is run. We observed a residents meeting where people were consulted about menu choices and activities. One person is involved in interviewing potential new staff. We asked him if people had been consulted in any way on proposed changes within the home. This includes the new Cluster groups where people with differing needs are cared for by a specified staff group. He was aware care staff will now be giving medication (not only nursing staff) but said he had not been consulted about the wider changes. Several people told us they had a problems with staff now not wearing uniform and visitors reiterated this. We asked what opportunity people had to engage with the election process, the election being imminent to the inspection. We were told that some leaflets had been available and some people had a postal vote. The manager felt that not enough had been done nationally to enable and encourage people to vote. There is regular one to one time available with the activities team and people and Care Homes for Adults (18-65 years) Page 14 of 39 Evidence: their family have recently received surveys so they can give their opinion of the home, and therefore have more participation. We looked at how people are supported to manage their finances safely. We looked closely at the arrangements in place for one person. We were told that they are in control of their own money. They have a cash card which they have agreed that home can look after. This is kept securely in an office. It is very clear that they are entitled to have this whenever they want. They are encouraged to take cash rather than the card if they go out without staff but this is their choice. They have the right not to accept staff presence. We spoke to a second person about their financial arrangements and confirmed that he has complete control over financial management, which is done independently. We saw a spreadsheet with details of peoples individual finances. Individual monies and disability living allowance are paid into peoples aggregate account. This is transferred each month into account under individual names. Money is then transferred to individual accounts. Arrangements for this differ according to individual need / preference and individual financial management arrangements. Cash transactions were recorded and receipts held. We concluded that people are financially protected by arrangements at the home. Care Homes for Adults (18-65 years) Page 15 of 39 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Roborough House are well supported to live fulfilled lives within their capabilities. Meal times should be reviewed so that people have a more satisfactory experience when dining. Evidence: We looked to see if people are enabled and supported to lead fulfilled lives within their capabilities. Many people who use the service have illness and disability which precludes them from further education, training or employment. There is a team of activities workers at the home who work from a well equipped activities room, containing, for example, pets, a computer and arts and crafts materials. We received information from fourteen staff. Several mentioned activities provision as Care Homes for Adults (18-65 years) Page 16 of 39 Evidence: one of the things the home does best. One person who uses the service told us that the activities team are Absolutely lovely. They take a lot of notice of me. Its a very hard task to please everybody but they do more than they can. They go overboard to help you. People go shopping, visit cafes, restaurants, cinema, theatre, concerts and pubs. One person told us they went to Torquay the week before and several people went on a farm visit during the inspection. In-house entertainment includes the Wii and Karaoke machines and large flat screened television. An aromatherapist visits and there are professionally led fitness/exercise sessions. People are able to make use of the two vehicles available to the home, which is some distance from community facilities. The home employs three full time and two part time activities workers. They are very pro-active in findings new and more interesting activities for people. However, some felt they needed more time, one saying: It would be good if we had more staff so there is more time with people. People feel lonely. Some have no family. We saw that peoples files contain personal profiles, so personal history of relevance is available, from which the meeting of their needs can be planned. Three people told us through survey that they can do what they want during the day, evening and weekends; one said they can during the day not not the evening or weekends; one said they can in the evening and at week ends but not during the day. There are regular resident meetings where food and activities are discussed and the home reports that, for those who do not attend meetings, their views can be sought on a regular basis via face to face initially. A small domestic style kitchen is provided for people who are able to use it. This gives people and their families access to drinks during the day. Visiting family told us they often eat at the home and sandwiches are always made available for people on request. The home reports that people are able to follow their faith and there is a quiet and very comfortable lounge where people can meet family and friends. However, this is also used by staff for their break. The home reports that there are no visiting restrictions and visitors confirmed this. We saw that some bedrooms are very personalised; people have items of importance and interest with them. Care Homes for Adults (18-65 years) Page 17 of 39 Evidence: There are gardens available for peoples use. These include a patio area and smoking shed. These were unclean, with cigarette ends over the floor, and smelt unpleasant. There is a no-smoking policy within the home which is made clear in the Service User Guide. There have been issues around peoples choice and safety regarding physical contact, not wanted and found offensive. Whilst relationships should not be thwarted people must also be protected. (See Outcome on Complaints and Protection). At the previous key inspection we found that food was not always to the taste and preference of people using the service. Now people tell us it is: Alright and Good. Staff and visiting family felt it was improved and many eat at the home. There is a new chef. He told us there is always two choice of meals, usually both home cooked. He said peoples preferences are met; we saw a fresh fruit milk shake being made for one person, as this is what they like. There is the option of a cooked breakfast twice a week. People are asked daily and at residents meetings what they want to see on the menu. We were shown a copy of the results, which included: prawn salad, BBQ, kippers, smoked haddock and a themes night. The chef is currently producing a photographic portfolio of meals, which he intends to use instead of the four week menu, which he says can be repetitive. We observed a lunch time at the home and this raised some issues. People arrived and were placed at tables, which had clean cloths and fresh flowers. They were then left waiting while a number of staff gathered around the serving hatch talking and being served their own lunches. One resident pointed at the lunch and when told by staff that his would be coming in a minute he looked disappointed. He was then passed by a trolley containing lunches. He also pointed at this and tried to gain staff attention. One staff leaned across the table by one non-vocal person to use the condiments on their table. They looked at the staff meal, which was being held at head height, and they become more alert. As that staff moved away, apparently with his own lunch, the persons head dropped. After the initial organisation lunches were served. People who needed assistance to eat had one staff to help two of them, so staff have to move between them. However, staff told people what the meal was. Care Homes for Adults (18-65 years) Page 18 of 39 Evidence: One person tried unsuccessfully to eat a meal with a knife and fork. Staff then noticed him and provided a spoon. One person then arrived and asked for his lunch. It appeared he had been forgotten. We saw that he had been sitting in the lounge unattended but staff thought he had had his lunch and was asking for a second lunch, which he was not. We saw, and visiting family confirmed, that staff have more than one person at a time to assist to eat. This is undignified and not good practice. It was clear from what we observed that people look forward to their lunch but that the lunch-time experience is not always a satisfying one. The acting manager told us that staff were aware they should not take their food whilst people are waiting to be served. Care Homes for Adults (18-65 years) Page 19 of 39 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. Personal and health care are generally well met but the handling of medicines and the upholding of dignity needs attention. Evidence: We looked at whether people receive flexible personal support and nursing care, which promotes their privacy, dignity and independence and to a standard that supports their health and well being. There are those at the home who require every aspect of their care to be provided whilst others need only prompting, supervision and support. The home reports that it delivers a high standard of personal support to people. Many of the people we saw looked clean and well presented but not all. In one case we found that the issue of their cleanliness was being addressed through their care planning. We asked a visiting health care professional what she thought about the standard of personal and health care provided at the home. She told us: On the whole it is OK although XXXs nails get quite dirty and she had food all over her nails. Its variable. The attention to detail is not always there. We saw from peoples care Care Homes for Adults (18-65 years) Page 20 of 39 Evidence: plans that personal care is planned and their preferences are recorded. We found that peoples health care needs are well monitored and potential problems are identified and dealt with. Where necessary specialist health care professionals are sought for advice and guidance. People have transport available to take them to health care appointments. We are aware of people at the home that have been supported to make legally binding arrangements which ensure their wishes will be followed should they be unable to direct their care themselves. Nursing staff appeared knowledgeable and well informed about peoples medical needs. There are plans to extend their knowledge with additional training. We found staff to be generally respectful and they appeared caring. We are told staff always knock before entering peoples rooms and all personal care is delivered in private. However, we saw people with full urinary catheter bags dangling from their wheelchair in full view of other people in the dining/lounge are. This is undignified. We looked at how the home handles medicines which enter the home. There are few people at Roborough House able to manage their own. There are two rooms in use for medicine storage. One we found secure but the other we found unlocked at our first visit. On entering it was clear that medicines could be taken from a loosely locked wall cupboard. We took some out and then replaced them, later showing the manager how this was done. We also found a persons medicines sitting in the care supervisors office. Although the person to whom they belong had recently returned from an appointment with the medication, it had not been stored securely immediately they returned. Otherwise medicines appeared to be kept securely. We are told that there are plans to provide individual medication cabinets from June. Medicine records were examined and were found to be clear. We found that most hand written entries had been checked by two staff but the quantity of medicine had not been checked/recorded as it must to ensure a full audit of medicines can be undertaken. This is to reduce to possibility of mistakes or mishandling and is a repeated requirement. We also found that it is not part of planned care when as necessary medicines may be administered to people. This had been discussed at the previous inspection visit. Staff do have guidance, but this is not sufficient to ensure their use is consistent. We found that controlled drugs are kept in accordance with the legislation and staff are to be commended for checking the balance twice daily. Care Homes for Adults (18-65 years) Page 21 of 39 Evidence: As part of the homes plan to divide peoples care into Clusters care staff are being trained to administer medicines. This is a new role for them. They have received a one day Caretech course as their training. The acting manager told us she is assessing their competence but we did not see information that suggested she was sufficiently trained to do this. We were also told that care staff are asking nurses for help to complete questions about medicines handling. Care staff did their first medicines round just prior to our second visit. Due to problems because of the time it was taking them to complete the task and several other concerns, the situation was under review. Care Homes for Adults (18-65 years) Page 22 of 39 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. People have not been protected in a consistent way at Roborough House. Evidence: We looked to see if people are protected through the complaints and safeguarding arrangements at the home. Three people who use the service told us through survey that they know who to talk to if they are not happy but two said they did not. Each of the five people who completed surveys told us they did now how to make a complaint. There are various copies of the homes complaints policy clearly displayed around the home, some in pictorial format to help people with limited skills. One of the copies does not make an adequate distinction between what should be handled under the homes complaints procedure and what will constitute a safeguarding/protection concern and should be passed to the Local Authority Safeguarding team. The home reports that they have received nine complaints in the past twelve months but that none were upheld. We asked about this. The acting manager felt that the information had been recorded wrongly and found records which described complaint investigation and actions taken where the complaint had been upheld. Over the previous two years we have received many concerns, some anonymous Care Homes for Adults (18-65 years) Page 23 of 39 Evidence: about Roborough House; it is not unusual. Some have been upheld and some not substantiated. In the past year the management of Roborough House have raised concerns with the local authority safeguarding team themselves so as to protect people who use the service. In the last five months there have been two anonymous disclosures to the Local Authority Safeguarding team. The first described low staffing levels (see the Outcome on Staffing) and, following an immediate visit to the home by a member of the safeguarding team, they concluded this had been the case. The second concerned a person at the home who was distressed by inappropriate and unwanted behaviour from another resident. She reported this to staff. We know that those staff reported this to the management but the management did not follow the expected protocol and take the concern to the Safeguarding team themselves. Another person did so. The acting manager says training records show that all staff have received training in how to safeguard people from abuse. However, one laundry staff told us they had not. Staff should know how to recognise abuse, how to disclose concerns and how they are protected in law should they feel they need to whistle blow. Care Homes for Adults (18-65 years) Page 24 of 39 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 environment meets the needs of most people who use the service but could be improved regarding adaptation and safety. Evidence: We looked to see if the environment meets the needs of people currently using the service by visiting all shared areas of the home and several bedrooms. The home provides an activities suite and an exercise and physiotherapy room and a hair salon. In addition to a large lounge/dining room there is a quiet lounge with very comfortable seating. Each person has their own room, which they are able to lock as they wish. Some rooms are very individual and personalised. There is a fob system in place to ensure that areas of the home are accessible to people unless this is deemed inappropriate, such as medicines and record storage. Staff told us that they have the equipment they need to ensure safety and promote independence and we saw equipment in use. The home is registered to provide care for people with physical disability and is adapted for such. It is also registered to provide care for people with dementia but Care Homes for Adults (18-65 years) Page 25 of 39 Evidence: there are no environmental adaptations for people with this condition, such as pictorial information or colour signposting. There is a planned maintenance and renewal programme and some major upgrading of the fire call system and boiler, currently being planned. We have previously raised the issue that radiators in the home do not have covers to prevent people receiving contact burns from the hot surface. Following a random inspection 1st December 2009 we recommended that there should be a planned approach to the covering of all radiators within a reasonable period. We find now that some have been covered and are told that others are risk assessed. However, during this inspection we found a radiator too hot to touch in the quiet lounge and saw some uncovered radiators in bedrooms. We know there are people in the home with increased risk of burns due to a medical condition. We will therefore set a timescale for compliance so that all people are protected. One person told us through survey that the home is always fresh and clean and four said it usually is. We found most areas of the home to be fresh and clean. However, the patio (and smoking area) were littered with cigarette butts and smelt unpleasant. The home now employs three domestic staff although only two have recently been available. The home employs laundry staff and the laundry is fully equipped to meet the needs of the home. Staff have the personal protective clothing they require (such as gloves and aprons) and there are protocols within the home to reduce the possibility of cross contamination. However, we saw bar soap in bathrooms, the use of which increases the risk of cross contamination as many different people may use it. Care Homes for Adults (18-65 years) Page 26 of 39 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. People receive a service from staff they like and trust, who are recruited using safe procedures and where training is improving. Staffing numbers are not always sufficient for what the service offers and to meet peoples needs. Evidence: People who use the service speak highly of the staff who provide their care. We met and spoke with nursing, care/support, activity, domestic, administrative, catering and maintenance staff. Each was clear about their role within the home. Staff roles have been reviewed by the new management. The plan to divide the care team into three clusters appeared to be well accepted as a positive move by staff. Where previous responsibilities lay within the home itself some are now moved to Caretech head office. These include staff employment and maintenance. The staff rota has also been reviewed. Staff are now guaranteed alternate week ends off duty and a more structured and consistent working pattern. People who use the service told us they were aware of the rota changes but they did not have a view as to whether it would affect them. There are core staff at the home which provides a constancy for people who use the service. There have also been some key staff leave and some recruitment of new Care Homes for Adults (18-65 years) Page 27 of 39 Evidence: staff. The home is currently using agency staff to meet staffing short falls. They aim to ensure the same staff are used who have experience of the home and those staff receive supervision of their work there. The acting manager told us that of the thirty two support/care staff ten have achieved National Vocational Qualifications (NVQ) in care to level 2, one to level 3 and four to level 4. There are also several about the begin the qualification. NVQ is an indicator of staff competence. Opinion on the sufficiency of staff numbers varies. One staff told us through survey that there are usually enough staff to meet the individual needs of all the people who use the service, one said there only sometimes are and one said there never are. In January of this year staffing sufficiency was the subject of a safeguarding alert. A concern was reported to the Local Authority which led to a member of the safeguarding team going to the home. They found that there were not sufficient staff, for a period of a couple of hours, to adequately care for people. A health care professional, who visited the home in January, also reported: When I visited it was pretty chaotic. There was nobody on reception. I just walked in and it was hard finding people who new the service users. During our visit we asked staff who provide care: Are there usually enough staff to meet the individual needs of people who use the service. All told us it had improved, with comments including: At the moment there are enough yes. We have started using agency staff again, There are now usually enough staff, It plummeted when Caretech took over. At times it was very hard but it seems to be getting better now and I think there are. There was a patch when we were short but now its quite good. We asked people who use the service if staff are available when they need them and were told:No, Im kept waiting,Most times,Yes, most times and always in an emergency and The level of nursing/staffing is not enough. We spoke with two frequent visitors to the home. They were very negative about staffing levels at the home, giving examples of what they see happen in the lounge. The staffing rota indicates sufficient staff numbers but there are two people who require one to one staff supervision and people who require supervision for their safety when they use the smoking area. The home is large and peoples needs are very diverse; some are bed bound and require full nursing care, whilst some are mobile with behaviour that is a challenge. We know there are sometimes altercations Care Homes for Adults (18-65 years) Page 28 of 39 Evidence: between people. We saw staff assisting two people at a time with their lunch, which indicates a lack of sufficient staff for that task. One staff had reported to her supervisor: We do not get enough time for baths and showers. We were told of recent difficulties in providing medicines on time because of deployment changes, later reviewed and made safe again. We saw records pertaining to staff employment, spoke with the administrator and acting manager and have information from the service, which indicates that all the required checks, to ensure staff are suitable and safe to work with vulnerable adults, are completed before they start work at the home. Nursing staff appeared professional, with sound judgment and an awareness of where they have shortcoming in their knowledge. The acting manager told us that lots of training is outstanding and this is actively being addressed. She gave us information on how new staff induction now ensures they are able to work safely and in line with management expectations. We looked at whether staff are trained in the conditions specific to peoples health care needs. This included looking at the homes training matrix, talking to the acting manager and trying to match training certificates to the computer records. The information indicates that there is some specialist training. However, few have had training in behaviours that challenge, mental health, dementia or impaired vision. The home reported in March that ten people at the home have mental health needs, thirteen have impaired vision and six have dementia and we have received notifications describing peoples challenging behaviour, leading to altercations at the home. We are aware that external professional guidance is sought where necessary but also that staff have had people at the home whos needs they felt they could not meet. Two staff told us through survey that they are being given training that is relevant to their role and one said they are not.Two told us that their training helps them understand and meet the individual needs of people and one said it does not. One staff told us that they get enough knowledge about health care and two said they do not. The home reports that much training has been delivered in the past few months, including: Mental Capacity Act, end of life care, medication and training for the new Care Homes for Adults (18-65 years) Page 29 of 39 Evidence: shift leaders. We asked staff about the training arrangements. They told us that there is in-house and external training and recently started on-line training. Comments included: Not bad, We get offered all the training and Quite a lot going on. Theres a big bought of training. The shared opinion was that the new management was improving the standard of training at the home. Information indicates that the standard of nursing care, such as prevention of pressure sores, nutrition and hydration, are of a high standard. The home reports that all staff now have regular supervision of their work. Staff opinion and records support this. Opinion as to the usefulness of the supervision varied. Some did not feel very supported and some felt it was very good. (See Outcome on Management and Administration). Care Homes for Adults (18-65 years) Page 30 of 39 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 failure by the new management to assimilate the culture of the home has led to disharmony and mistrust. Health and safety appear to be properly managed. Evidence: The person in day to day management of the home must register with the Commission as this is a legal obligation. It came to our attention in February of 2009 that the person registered to manage the home was no longer in post. There have been four managers since the last registered manager. The most recent started at the home late 2009 and made prompt application to register with the Commission. The process to assess her fitness to manage the home is not yet completed by the Commission. She has successfully managed services in past employment. The home reports:The current manager has twelve years experience as a registered manager,has a degree and the Registered Managers Award and is currently undertaking a community psychiatry and mental health level 4 qualification. Care Homes for Adults (18-65 years) Page 31 of 39 Evidence: The hours of duty of the acting manager are now clear on the duty rota so the running of the home will be more efficient and effective. The service provider is Roborough House Ltd which is a now a subsidiary of CareTech Community Services Limited. They run the home on a day to day basis. They tell us that they provide a vast array of experienced professionals to support the running of the service. Caretech Area Manager is new to the home and works in the building. Concerns about the home have been received by the Commission and Local Authority Safeguarding team since the previous key inspection. In the last five months they have included information about the new management arrangements. We received one complaint of this nature from a visitor to the home and one from a now ex member of staff. Toward this inspection we received three completed surveys from staff and spoke to fourteen staff during our two day visit. Six people who use the service were asked if they knew who the manager is. There are common themes from staff of a management which is distant, does not value or respect them or their knowledge about people who use the service and who are said by some to be intimidating. Some told us the manager gets angry and shouts. Some told us that they have been made to feel stressed and incompetent; that they do not know how to prioritise the varied tasks they have been given. One told us the new management has bulldozed their way through. Staff we spoke with were very clear that their anonymity should be respected. Two staff were very positive and praiseworthy of the management and some staff felt the situation was improving. Staff said that a lot of the proposed changes now seem quite positive and there are some good new ideas and plans for the future. We also know that the manager has put some recent changes on hold when staff told her of problems implementing them, thus responding to requests. Asked how management could do better the home report: Ensure a cohesive staff team.... We asked people who use the service if they know the manager. Two knew correctly, two gave the names of both new management unsure which was the manager and two said they had seen them but did not know their names or which was manager. We asked two visitors who the manager was; their response was incorrect. Another persons family was upset that, after visiting frequently and regularly since the new management, the manager had never introduced herself. Care Homes for Adults (18-65 years) Page 32 of 39 Evidence: The home reports that the Quality Assurance Systems currently being implemented are robust and thorough. The required monthly provider visits are being undertaken by the Caretech Area Manager, whose office is within the care home. Those visits must be unannounced and take into account what people and staff have to say about the service. Clearly this is not happening and we raised the point that those the Area Manager speaks to within the home may not feel free to speak freely as she is not seen to be at arms length from the day to day management. As part of quality monitoring there has been an unannounced night visit to the home and the manager stays at the home for the night on a regular basis so that night staff do not feel excluded. We saw that there are regular resident meetings and were present for one where peoples opinion was being sought about a new pictorial menu and choice of activities. Staff told us about their meetings. Quality Assurance surveys were recently sent to people who use the service, health and social care professionals, peoples family and visitors to the home and staff. The results had not been received. There have been many changes within the home which, we are told, are improvements, and people who use the service, staff and visitors, were keen to list them. They include every staff member having alternate weekends off, improved training, the food and the new approach to individualised care planning. We were given a copy of the Roborough House Business Plan, which outline the proposed future for the home and includes information about specialising and staff abilities and deployment in the future. We saw that staff have up to date copies of policies and procedures to inform them how the service is to be delivered. We did not check whether people who use the service have access to relevant policies, procedures and codes of practice. We saw that, since the previous key inspection 11 months ago, the standard of record keeping has improved considerably. We looked at whether health and safety are properly met at the home. Improvements since the previous key inspection have ensured that the electrical system is now safe, all hot water outlets have safety control valves, all radiators have any risk to people assessed and many have as a consequence been covered to prevent contact burns. However, it is disappointing that this risk has not been fully removed, especially as we Care Homes for Adults (18-65 years) Page 33 of 39 Evidence: found radiators in communal areas which were extremely hot and would burn if touched. We are told that there are imminent plans to improve the fire alarm system and boiler system. We saw that general maintenance is carried out to ensure a safe environment and staff receive training in health and safety through the improving training programme. Care Homes for Adults (18-65 years) Page 34 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 All medicines must be checked into the home. So that a full audit is always possible as this measure helps to protect people. 31/12/2009 Care Homes for Adults (18-65 years) Page 35 of 39 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 1 4 Information provided in the Statement of Purpose must be factual, current and not lead to misinterpretation. So that people can make a fully informed decision as to whether the home is what they want and can meet their needs. 05/06/2010 2 8 12 People must be consulted 31/05/2010 about proposed major changes to the way the home will be run on a day to day basis. So that they have a voice on issues that directly affect them. 3 20 13 The use of medcines 31/05/2010 described as as necessary or as required must be part of planned care. This is so that their use is consistent, the effectiveness of the medicine can be Care Homes for Adults (18-65 years) Page 36 of 39 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 monitored and there is less opportunity for misuse. 4 20 13 All medicines must be checked into the home. So that a full audit is always possible as part of peoples protection. 5 20 13 All medicines must be stored 31/05/2010 securely. To that end the door to the medicine storage room must be kept locked, cupboards containing medicines must be fitted with effective locks and medicines should not be left sitting in an office. So that only those who have a right to access them are able to do so. 6 23 13 Allegations of potential 31/05/2010 abuse must be responded to promptly and the safeguarding authorities informed. To protect vulnerable adults from abuse. 7 33 18 There must be sufficient competent staff deployed at all times to meet the individual needs of people who use the service. So that peoples individual needs will be met. 31/05/2010 31/05/2010 Care Homes for Adults (18-65 years) Page 37 of 39 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 2 3 17 19 22 Arrangements for mealtimes should be reviewed so that the needs of people who use the service are the priority. Urinary bags should be positioned discreetly to maintain dignity. There should be a very clear distinction as to what will be handled under the homes complaints procedure and what might be abuse and should be passed to the Safeguarding team, so that people are confident the matter will be handled properly. All staff should receive training in the types of abuse, how to disclose concerns and how they are protected in law should they feel they need to whistle blow. They should be aware of the training they have received. If the home admits people with dementia the environment should be adapted to meet their needs, based on current good practice guidelines. All areas of the home should be kept clean, fresh and pleasant to use, including the patio and smoking areas. Bar soap should not be used in shared areas of the home as this increases the possibility of cross contamination. 4 23 5 24 6 7 30 30 Care Homes for Adults (18-65 years) Page 38 of 39 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 39 of 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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