Care Home: Roundtrees

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What the care home does well People are able to visit the home before they choose to move in. People who live in the home are able to take part in some activities of their choosing and lead an independent lifestyle, maintaining family/friend relationships. On the whole daily routines and house rules promote independence and enable people living in the home to make decisions about everyday life. It was observed that staff have developed good relationships with people and were respectful, polite and supportive. The home continues to offer a varied menu and from speaking to people living in the home, it was clear that choice is offered and the quality of the food is good. People live in a warm and comfortable environment. People live in a home where staff are supportive and caring. Three staff files were looked at confirming that the majority of essential training had taken place. People live in a home that is run to an adequate standard, it seeks peoples views about the service they receive. What has improved since the last inspection? Plans that detail how to manage risk or difficult behaviour have been updated since the last inspection and these covered a variety of areas including; road safety, financial abuse, scalds and burns. However, not all gave sufficient information to the reader in order for them to understand the risk and how this could be managed or reduced. In this home people on occasions people display behaviour that might impact on the welfare of others or themselves`. The manager told us, "all staff staff have been trained in the use of restrictive physical intervention (RPI)". Peoples basic health needs are met, the home has developed health action plans. The home has a complaints system, whistle blowing policy and procedures to ensure the protection of people from the risk of harm and the development of detailed plans for the management of difficult behaviour means that staff have the required guidance and people are better protected from the risk of harm. Since the last inspection the home has introduced a sixteen week skills for care training package and staff have this work assessed at the end of that time. What the care home could do better: The home has taken unsuitable referrals for admission that does not fit in with its Learning Disability registration category. Staff do not always have the skills or knowledge to deal with the more diverse needs of people, such as mental health needs or acquired brain injuries. They do not currently receive training in Learning Disabilities. Some plans that describe how to manage behaviour do not specify the level of risk and whether this has been agreed with other professionals. These must include specific direction to the reader about what the risk is and how this is to be managed. The medication procedure is not always adhered to and not all staff who administer medication have undertaken training or had their competency assessed. Some parts of the environment were not clean and hygienic. The attic room had a portable electric heater in place and although this had been portable appliance tested, there was no risk assessment for the use of this heater nor had the manager checked with the Fire Department that this would be safe to use in that particular room. It was observed that people living in the home have to go outside to smoke a cigarette and there was no shelter for them to use. There are not always staff on duty through the night who can administer medication when people require it. Staff are employed using a Protection of Vulnerable Adult (POVA) 1st check as routine practice and this is prior to the full Criminal Records Bureau (CRB) check being received back. This must only be undertaken in exceptional circumstances and not for every new staff member. The manager has been in post since 2008 and is currently not registered with CQC. Not all incidents are recorded thoroughly and we found several examples of this when looking at the care files. Recording must be of a good standard and protect people living in the home. Key inspection report Care homes for adults (18-65 years) Name: Address: Roundtrees 340 Beverley Road Kingston upon Hull East Yorkshire HU5 1LH     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: Angela Tew     Date: 1 8 1 1 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 37 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 37 Information about the care home Name of care home: Address: Roundtrees 340 Beverley Road Kingston upon Hull East Yorkshire HU5 1LH 01482342404 01482342404 vivian.bone@milewood.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Milewood Healthcare Limited care home 9 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 9 The registered person may provide the following category of service only: Care Home only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Learning Disability, Code LD - maximum number of places 9 Date of last inspection Brief description of the care home Milewood Healthcare own Roundtrees, one of a number of homes the company owns in the area. It is registered to provide personal care and accommodation for up to 9 adults aged 18 to 65, of either gender with a learning disability. The home is on Beverley Road, a main bus route into the city centre. There is a range of local shops and amenities close by. There is an enclosed rear garden and parking is limited to nearby street parking. On the ground floor is a large through lounge and dining room, a kitchen, laundry and one rear bedroom. There is no passenger or chair lift and no wheel chair access. Private accommodation is provided in 9 single bedrooms 8 of which are upstairs on the first and second floors all of the bedrooms have en suite facilities. There is also a bathroom with WC, shower room without WC and 2 more Care Homes for Adults (18-65 years) Page 4 of 37 Over 65 0 9 2 9 1 0 2 0 0 8 Brief description of the care home WCs all located upstairs. Care Homes for Adults (18-65 years) Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This site visit took place over one day and took a total of 10 hours. Two regulation inspectors visited the home as part of the process. Prior to the visit surveys were posted out to people living in the home, staff members and health and social care professionals, information was gained from these and this has formed part of the evidence. The Annual Quality Assurance Assessment was returned to the CQC prior to the visit taking place. It had been completed to an adequate standard. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at significant risk of Care Homes for Adults (18-65 years) Page 6 of 37 harm. In future if a requirement is repeated it is likely that enforcement action will be taken. A discussion was held with the manager about the homes registration under the Care Standards Act 2000. The home is registered to take people with a learning disability and this must be their primary need. During the visit three care files were looked at and although these did contain an assessment of need undertaken by the placing local authority. It was clear that two people did not have a primary need of a learning disability. CQC has formally warned the home that they are committing an offence and that if they dont make the required changes within a defined period, prosecution might ensue. Several of the people living in the home were spoken to throughout the day about the care they receive and what it is like to live in the home, some of their comments have been included in this report. Four files of people living in the home and three staff personnel files were looked at during the site visit. Two staff members were spoken to this was to find out what it was like working in the home and what training support and supervision was offered to them. A tour of the premises was undertaken and a number of records were looked at to ensure that the correct maintenance has been undertaken. The medication procedure was looked at and the manager was given feedback at the end of the visit. The manager told us that the current fees charged range between £1389 and £1800, additional 1-1 funding is provided for some people. Additional charges are made for the following, newspapers, magazines and sweets, hairdressing. We also checked to see how residents were included in how the home was run and how privacy and dignity was maintained. We also wanted to be sure that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We observed the way staff spoke to people and supported them. We would like to thank the people that live in Roundtrees, the staff team and management for their hospitality during the visit, and also thank the people who had discussions with us. Care Homes for Adults (18-65 years) Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: The home has taken unsuitable referrals for admission that does not fit in with its Learning Disability registration category. Staff do not always have the skills or knowledge to deal with the more diverse needs of Care Homes for Adults (18-65 years) Page 8 of 37 people, such as mental health needs or acquired brain injuries. They do not currently receive training in Learning Disabilities. Some plans that describe how to manage behaviour do not specify the level of risk and whether this has been agreed with other professionals. These must include specific direction to the reader about what the risk is and how this is to be managed. The medication procedure is not always adhered to and not all staff who administer medication have undertaken training or had their competency assessed. Some parts of the environment were not clean and hygienic. The attic room had a portable electric heater in place and although this had been portable appliance tested, there was no risk assessment for the use of this heater nor had the manager checked with the Fire Department that this would be safe to use in that particular room. It was observed that people living in the home have to go outside to smoke a cigarette and there was no shelter for them to use. There are not always staff on duty through the night who can administer medication when people require it. Staff are employed using a Protection of Vulnerable Adult (POVA) 1st check as routine practice and this is prior to the full Criminal Records Bureau (CRB) check being received back. This must only be undertaken in exceptional circumstances and not for every new staff member. The manager has been in post since 2008 and is currently not registered with CQC. Not all incidents are recorded thoroughly and we found several examples of this when looking at the care files. Recording must be of a good standard and protect people living in the home. 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 37 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples individual needs are assessed prior to admission. However, the home has taken unsuitable referrals for admission that does not fit in with its Learning Disability registration category. Staff do not always have the skills or knowledge to deal with the more diverse needs of people, such as mental health needs or acquired brain injuries. Evidence: A discussion was held with the manager about the homes registration under the Care Standards Act 2000. The home is registered to take people with a learning disability and this must be their primary need. The manager said, apart from one person all of the current service users have a primary need of learning disability. During the last inspection it was made clear that this person would need to move as their primary need was clearly mental health. The home had documentation to confirm that they had telephoned the social worker, however no meetings had taken place and the person was still living at Roundtrees. The person told us, I want to move out because people are always shouting or hitting each other and this upsets me. During the visit three care files were looked at and although these did contain an Care Homes for Adults (18-65 years) Page 11 of 37 Evidence: assessment of need undertaken by the placing local authority. It was clear that two people did not have a primary need of a learning disability. One person had a mental health diagnosis as detailed above and the second person had an acquired brain injury, which caused some learning difficulty. However it was not clear that learning disability was the primary need or prevalent before the brain injury had been acquired. The social worker told us that previous placements had been in homes with a physical disability registration and she felt that this placement is suitable. However, she did confirm that due to the nature of the illness and when it progresses then this person would need to move. The home must ensure that they do not offer a place to someone whose needs are outside of their registration category. They must assess the needs of the individual and ensure that their needs can be met before they offer them a place in the home. Other care files looked at confirmed that a pre-assessment is undertaken before people are offered a place. The manager said, I usually visit a person and gain information before a place is offered. The pre-assessment includes next of kin, social worker, previous issues, interests, likes and dislikes, general health and any risk. People told us that had visited the home before coming to live there. One person said, yes I came to have a look around and met the others living here. From speaking to staff it was clear that although they receive induction and foundation training, a lot of this is undertaken in-house and one staff member commented, its a hands-on way of learning and we observe other staff. We could not find evidence that would confirm that training would be offered to meet more diverse needs such as learning disability awareness, mental health and acquired brain injury. Staff do not always have the skills or knowledge to deal with the more diverse needs of people. Care Homes for Adults (18-65 years) Page 12 of 37 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have care plans that cover a range of identified needs and there are plans in place that describe restriction on freedom and choice. However, some plans do not specify the level of risk and whether this has been agreed with other professionals. These must include specific direction to the reader about what the risk is and how this is to be managed. Evidence: We looked at sample of files which belonged to people living in the home. We saw that a lot of work had been done by the manager in updating the plans of care and identified risks and some new forms had been introduced. We saw that each person had a care plan that covered communication, social skills, personal relationships, leisure, daily living skills, domestic skills, personal care, spiritual and cultural, choice and self-image, health, mobility, finance and challenging behaviour. The plans were detailed and give direction to staff in how to meet the persons needs. Care files contained a key information sheet, summary of the persons history, self-medication assessments. Some of the documents had not been signed or dated by the person Care Homes for Adults (18-65 years) Page 13 of 37 Evidence: living in the home. The manager showed us three person centred plans that she has been developing, these were in picture format and included the views of the person. She said, all service users will have a person centred plan eventually. People living in the home confirmed that they had been involved in the development of their plan and they could describe the content in their own words. Plans that describe risk and difficult to manage behaviour had been updated since the last inspection and these covered a variety of areas including; road safety, behaviours ie sexually inappropriate towards others, financial abuse, scalds and burns. However, not all gave sufficient information to the reader in order for them to understand the risk and how this could be managed or reduced. For example, one plan stated inappropriate sexual behaviours, but it did not detail what this could be or how the person may present or how staff would intervene. One person spoke about wanting to return to their home city and the manager confirmed that this had been discussed with the placing authority, but the social worker feels that this is an appropriate placement for personal safety reasons. The person did state that they were able to make choices about other everyday events such as what time they would get up, when they would go out and whether they would take part in activities. Overall the home promotes choice and self-determination allowing people to make decisions and take risks within their everyday life. However, with regard to the person making major decisions within their life, such as where they would like to live, the home needs to demonstrate that there has been an assessment of that persons capacity. A survey received from a relative stated, the service provides unique care tailored to the individual. My brother does not fit into any obvious categories and the staff have gone out of their way to understand his needs and as a result he has settled in a way that could not have been guessed. In this home, people on occasions display behaviours that might impact on the welfare of others or themselves. Detailed behaviour management plans have been prepared that are individual to the person and give staff clear guidance on what they can do to protect the person and those around them from the risk of harm. These now include any use of restrictive physical interventions to be used and when. The manager told us, all staff staff have been trained in the use of RPI. The placing Local Authorities have agreed to the Behaviour Management Plans and the use of specific restrictive techniques and the number of incidents between people that live in this home have reduced. Care Homes for Adults (18-65 years) Page 14 of 37 Evidence: We found that written documentation was sometimes judgemental about the person, for example a staff member had recorded generally in a nasty mood with everybody. Other records were not accurate in that incidents that had taken place were not recorded in full and lacked detail about what had happened. For example, one behaviour chart stated the person had become aggressive. Records must be detailed and give a clear account about what exactly had happened, as this would ensure that risk management plans are developed and accurate for areas that could place people at risk. Care Homes for Adults (18-65 years) Page 15 of 37 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are able to take part in some activities of their choosing and lead an independent lifestyle, maintaining family/friend relationships. Evidence: People told us that they are encouraged to attend day centres or community groups and written evidence in case files confirmed this. The manager told us, we encourage people to attend college and take part in activities. Two of the care files looked at detailed when the people attend college or community groups. During the visit some of the people living in the home were spoken to and some comments included, the staff are great, I can go out when I want to, but I let the staff know when I will be back, I go out to my friends and they can visit me. People told us that activities occur on a daily basis and one person commented, the Care Homes for Adults (18-65 years) Page 16 of 37 Evidence: staff ask us what we want to do the night before, sometimes I change my mind and do not want to do it. The manager told us that staff will sit with individuals and discuss what activity they might like to do and she also confirmed that regular day trips out occur. Activities are recorded once they have been undertaken. A survey received from a health care professional commented, there is a lack of activity for people and a lack of occupation, although this has improved since the new manager has been in post. One person living in the home confirmed that they took part in activities, but that sometimes this depended upon the availability of staff, I do get to go to the pictures or swimming, but it depends if staff are available. On the whole daily routines and house rules promote independence and enable people living in the home to make decisions about everyday life. It was observed that staff have developed good relationships with people and were respectful, polite and supportive throughout the day. People told us, the staff are great, I like all of them. The home continues to offer a varied menu and from speaking to people living in the home, it was clear that choice is offered and the quality of the food is good. Some comments included, the food is good, we always get enough. The home received a score of A with the Environmental Health Department, this means the hygiene in the kitchen was of an excellent standard. However, from checking some of the food stock it was noted that not all of the food packaging is labelled when opened. Care Homes for Adults (18-65 years) Page 17 of 37 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples basic health needs are met, the home has developed health action plans. However, the medication procedure is not always adhered to and not all staff who administer medication have undertaken training or had their competency assessed. Evidence: Four care files were examined and health care plans were in place for each person. The manager told us that the Community Team Learning Disability now assist in the process of health screening and the development of health action plans. From speaking to people using the service it was clear that they are supported to attend hospital appointments and for routines check ups such as hearing, optical and dental. People told us that the staff usually go with them if they need support. Written records were seen confirming that some people had seen the GP, the consultant Psychiatrist and community nurse and social workers. The health action plan detailed the promotion of healthy lifestyles and there was evidence where people are refusing to access health provisions that relevant people have been consulted and are aware and that the individual themselves is made aware of the risks of not having regular Care Homes for Adults (18-65 years) Page 18 of 37 Evidence: medical care. During the visit the medication procedure was looked at and the recording was found to be of a low standard. Although staff have undertaken in-house training in relation to medication, there were no written records confirming that they had been assessed as competent. Since the previous inspection visit the home has ceased to use the training package and is currently seeking a new provider. The training must cover the basic knowledge of how medicines are used and how to recognise and deal with problems. At the end of the training staff must be assessed as competent to ensure they are safe to give medication to people. Several of the Medication Administration Records (MAR) were looked at and it was observed that the use of codes is inconsistent, when staff are transcribing onto MAR charts they do not put on the full details or prescription and they are not signing the chart. Some people did not have a photograph on their medication records. The home books the medication in onto a stock control sheet, but then does not carry forward the amount onto MAR, making it difficult to check what stock is currently being held in the building. When people require medication on an as and when basis, there is a protocol in place covering this. However, one chart looked at was for Haloperidol and it stated that the person should receive upto a maximum of three within 24 hours. None of the night staff are trained to administer medication and therefore if a person required medication during the night, the person would have to wait until the morning staff arrived on duty before they received it. The home has a returns policy and currently returns all of the medication at the end of the month, regardless of whether the medication has been opened or not. This is a waste of resources and providing the medication is in date there is no need to return every month. It was found that Lorazepam had been booked in, but not put onto the MAR. This medication was as required and during the inspection two staff members transcribed the prescription onto the MAR, then completed the previous ten days retrospectively. Records must be accurate and up to date and give a clear view of medication administered, to ensure that people receive the correct amount and this is recorded accurately. It is good practice for the home to see the prescription before the medication is dispensed from the pharmacist, as this would make sure that only medication that has been ordered and is required will be dispensed. Care Homes for Adults (18-65 years) Page 19 of 37 Evidence: During this visit the medication was stored securely and none was left out. Care Homes for Adults (18-65 years) Page 20 of 37 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints system, whistle blowing policy and procedures. To ensure the protection of people from the risk of harm and the development of detailed plans for the management of difficult behaviour, means that staff have the required guidance and people are better protected from the risk of harm. Evidence: The home has a complaints procedure and it was confirmed from speaking to people living in the home and staff that complaints are listened to and acted upon. There had been one complaint since the previous inspection visit. The manager told us that the outstanding complaint had been dealt with and that she had met with the person and given feedback with regard to the outcome. A letter to the person was seen confirming how the complaint had been dealt with. People are informed about how to complain in the service user guide and the surveys we received stated this too. People told us, I would speak to one of the staff or the manager, Leah is very good, yes I can complain to the staff. The home has a multi agency policy and procedure for the prevention of abuse. The manager told us that all staff undertake mandatory training in this area and due to the level of incidents regarding physical assault it is a vital part of the essential training staff require. Since the last inspection the home has made 31 safeguarding referrals to the Local Authority Safeguarding team. There are two outstanding referrals that relate to people living in the home assaulting each other. These are currently being looked Care Homes for Adults (18-65 years) Page 21 of 37 Evidence: into by the local authority, these will be commented upon in the next inspection report. People living in the home told us that usually they feel safe in the home and some comments included, yes I feel safe here, other people shout and hit each other sometimes and this upsets me. The manager told us that all staff had undertaken in house safeguarding training and the majority of the staff have attended the Mental Capacity Act briefing offered by Hull Social Services. The manager is going to attend the Deprivation of Liberty level 2 training in December 2009. From speaking to the staff it was evident that their understanding of safeguarding people from harm was basic, however they could describe the various forms of abuse and stated that they would pass any concerns onto the manager or senior. Records were looked at to make sure that peoples finances were dealt with appropriately and people had access to their money. The home has a policy and procedure for dealing with peoples monies and financial affairs. Records for maintaining the personal finances were lclear the procedure was being followed. All of the records examined were accurate and up to date. Records were examined about difficult to manage behaviour or incidents that had occurred including verbal or physical violence displayed by the people living in the home. Some records were brief and one commented a person had, become aggressive, there was no explanation about what exactly that meant, how long it had lasted and what intervention was required to diffuse the situation. Behaviour charts, risk management and daily records must be clear and specific about incidents to ensure that people are protected from abuse. We examined some care files and found that one person who had a history of starting fires, putting themself and others at risk was living in an isolated room. There were two doors and a set of stairs to access before reaching the persons bedroom. This would appear an unlikely room to offer this person and could be placing them and others in the home at serious risk. There was also a portable fire in the room and there wasnt a risk assessment for the use of this. The home needs to reconsider which room this person would live in and there needs to be a clear risk management plan with regard to behaviour and the environment. Care Homes for Adults (18-65 years) Page 22 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a warm and comfortable environment. However, some parts of the building was unhygienic. People need supporting to keep their room clean, free from odour and the risk of infection. Evidence: During the visit a tour of the building was undertaken and overall the standard of accommodation is good. The manager told us that the outside of the building had been repainted and some bedrooms had been redecorated and that the people living in the home had been consulted about decor and colour. People living in the home showed us their rooms and were very proud that they had been decorated and some had new carpets and furnishings. One person told us, I like my room it is nice, I picked the colours. The main lounge has a new carpet in place and overall the communal areas are warm, homely and comfortable. People living in the home had personalised their room with belongings, TV, music systems, pictures and posters. Two rooms were found to be unhygienic and did not smell fresh, they both contained dirty clothes both on the floor and overflowing from a linen basket. The manager said that they do offer 1-1 support and encourage people to undertake cleaning tasks, but that sometimes this is difficult to implement. People should live in a home that is clean, hygienic and free from offensive odour and Care Homes for Adults (18-65 years) Page 23 of 37 Evidence: therefore the support offered to people needs reviewing and must be managed more effectively. The home does not employ cooking or cleaning staff and care staff have to undertake these duties. The attic room had a portable electric heater in place and although this had been portable appliance tested, there was no risk assessment for the use of this heater nor had the manager checked with the Fire Department that this would be safe to use in that particular room. It was observed that people living in the home have to go outside to smoke a cigarette and there was no shelter for them to use. The home should look into purchasing a form of shelter for people to use, as in the colder months they should be expected to stand out in bad weather. The home has a laundry room and there is a domestic washer and dryer. The manager said that the dryer has broken and currently staff are having to take washing to the launderette to dry. The home should have the dryer repaired or renewed, to ensure that people have their clothes cleaned and dried at all times. Care Homes for Adults (18-65 years) Page 24 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home where staff are supportive and caring. However, staffing levels are not always sufficient to meet peoples needs. The home employs staff before the full disclosure is received and this may put people at risk of receiving support from unsuitable staff. Evidence: The manager told us the home employs 8 care staff. However, only 2 have obtained NVQ level 2 in care. She said, the remaining six are currently working towards the award. Two staff members were spoken to and although they could describe the basic needs of people living in the home, they were not so clear about specific need such as mental health, acquired brain injuries or learning disabilities. The home currently does not offer basic training in any of the afore mentioned. During the visit staff were observed to be patient, calm and supportive when dealing with people. It would appear that they have developed very good relationships and the atmosphere was relaxed. It was noted that staff respect the person and their privacy at all times and also supported people with everyday chores. Staff spoke to people living in the home in a way that was encouraging and enabling to the person. People living in the home told us, staff are great, I like them all, they are ok, I get on with all of them. Care Homes for Adults (18-65 years) Page 25 of 37 Evidence: People living in the home told us that there are not always enough staff on duty to support them in going out or undertaking activities. Some comments included, yes I can go out with staff, but sometimes I have to wait until another day. A social care professional told us, overall the service try to some degree to meet the needs of service users, however staffing levels are not sufficient and their is a lack of activity for people. The two staff and manager told us that they felt the staffing levels were sufficient. However, although the home has three carers on duty throughout the day as least one of those carers are funded to provide 1-1 support for one to two individuals. Therefore the home has two staff on duty who undertake all of the caring tasks, cooking and domestic chores as no auxiliary staff are employed. The staffing levels require looking at to ensure that there are sufficient staff on duty to undertake the various tasks required of them including administering of medication through the night and staff must be competent and be able to decide when as required medication is given. It is recommended that the home employs specific staff for cleaning and cooking, as this would then enable the care staff more time to undertake activities and spend time on an individual basis with people. The manager told us that there is a training plan in place and this meets the Skills for Care requirement. The manager said, we offer an in-house induction programme and the first week covers basic health and safety and getting to know the service users. Since the last inspection we have introduced the sixteen week skills for care training package and staff have this work assessed at the end of that time. Each new staff member has a mentor and they meet on a regular basis to discuss progress and any issues. The manager told us, most of our training is done internally, but I am trying to access other training via Hull City Council. Three staff files were looked at confirming that the majority of essential training had taken place. There were appropriate checks in place that would deem the person appropriate to work in the home. However, the manager told us that staff are always employed using a Protection of Vulnerable Adult (POVA) 1st check, prior to the full Criminal Records Bureau (CRB) check being received back. Current guidance states that this must only be undertaken in exceptional circumstances and not for every new staff member. The manager told us that staff meetings and supervision are occurring on a regular basis and written evidence was seen that supported this. Staff members told us that they received both informal and formal support from both the manager and the owner of the home. Staff said, we get regular support, I can go to the manager at any time. Care Homes for Adults (18-65 years) Page 26 of 37 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is run to an adequate standard, it seeks peoples views about the service they receive. Peoples individual needs are assessed prior to admission. However, the home has taken unsuitable referrals that does not fit in with its Learning Disability registration category. Staff are trained and receive support, however, if training in diverse needs and medication were offered, this would ensure staff have the skills and knowledge required to maintain the health and safety of those living in the home. People live in an environment that is relatively safe environment. Evidence: As mentioned earlier in the report a discussion was held with the manager about the homes registration under the Care Standards Act 2000. The home is registered to take people with a learning disability and this must be their primary need. The manager said, apart from one person all of the current service users have a primary need of learning disability. During the last inspection it was made clear that this person would need to move as their primary need was clearly mental health. During the visit three care files were looked at and although these did contain an Care Homes for Adults (18-65 years) Page 27 of 37 Evidence: assessment of need undertaken by the placing local authority. It was clear that two people did not have a primary need of a learning disability. One person had a mental health diagnosis as detailed above and the second person had an acquired brain injury, which caused some learning difficulty. The home must ensure that they do not offer a place to someone whose needs are outside of their registration category. CQC has formally warned the home that they are committing an offence and that if they do not make the required changes within a defined period, prosecution might ensue. The manager told us that she had been employed as the acting manager since October 2008 and then the manager in April 2009. However, she is not registered with CQC. The manager told us that a CRB check has been undertaken at the CQC Leeds office and the application for registered manager would be submitted as soon as her CRB check is received. She also told us that she is currently working towards achieving NVQ level 4 in Care and is about half way through the course. Other training undertaken since the last inspection includes health and safety, infection control and Mental Capacity Act briefing. The manager said, I receive supervision on a monthly basis, but can get hold of senior management at any time. Staff and people living in the home told us that the manager was supportive to them and always available. People living in the home spoke highly of the manager stating, Leah is lovely, she always listens to me, the manager is nice. We looked at the way the home quality assures its service and overall this was done in consultation with people, their views are sought and acted upon. Care plans are regularly reviewed and there are staff meetings held regularly. Surveys are given to people living in the home, relatives and other professionals and the results are gathered and a report is prepared giving the outcome. The home is subject to audits by higher management and the findings are shared with the manager. Visits required by CQC under regulation 26 are undertaken by the company and reports are held in the home. Upon looking at recent reports it was identified that further medication training maybe required and generic risk assessments need updating in particular for smoking in bedrooms and previous convictions, these had not been actioned at the time of the visit and have been commented upon earlier in the report. It was also observed that not all incidents are recorded thoroughly and we found several examples of this when looking at the care files. Again this was mentioned Care Homes for Adults (18-65 years) Page 28 of 37 Evidence: earlier in the report. Recording must be of a good standard and protect people living in the home. During the visit the medication procedure was looked at and the recording was found to be of a low standard. Although staff have undertaken in-house training in relation to medication, there were no written records confirming that they had been assessed as competent. We could not find evidence that would confirm that training would be offered to meet more diverse needs such as learning disability awareness, mental health and acquired brain injury. Staff do not always have the skills or knowledge to deal with the more diverse needs and people may be put at risk. Care Homes for Adults (18-65 years) Page 29 of 37 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 20 13 Staff administering medication need to be assessed and deemed as competent. to ensure that people are kept safe from the risk of harm 31/01/2009 Care Homes for Adults (18-65 years) Page 30 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation 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 14 People must have their needs assessed and the home be sure that all of the identified needs can be met, before being offered a place and that the person has a primary need of learning disability. This would ensure that the home can meet all of the assessed needs of the people living there and it fits within their registered category and you are complying with the conditions of your registration. The home is subject to a formal warning. 28/02/2010 2 3 18 Staff must undertake specialist training including learning disability, mental health and acquired brain injury. 28/02/2010 Care Homes for Adults (18-65 years) Page 31 of 37 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 would ensure that they have the knowledge and skills to deal with peoples needs. 3 7 12 People must be supported to 28/02/2010 make decisions within their everyday life and if they are restricted in anyway, this must be subject to a mental capacity assessment and detailed risk management plan and agreed in a multiagency setting. This would ensure that people are involved in any decisions about their life and their rights are respected. 4 9 15 Plans that describe risk and behaviours must give clear information and direction to the reader about what the risk is and how this is to be managed. This would ensure that staff would be clear about what risks where present and how they are managed. 5 9 13 Any behaviours that place 28/02/2010 people at risk must be recorded accurately and that this information is used to form a risk management plan. 28/02/2010 Care Homes for Adults (18-65 years) Page 32 of 37 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 would ensure that all incidents are recorded in detail and people are protected. 6 20 13 Staff administering medication must undertake appropriate training and be assessed as competent. This would ensure that staff who administer medication are trained and assessed to do so and people will receive their medication in a safe way. 7 23 13 Incidents involving people living in the home must be recorded in detail, giving information about what had happened, for how long and how this was managed. This would ensure that incidents of verbal and physical aggression are recorded appropriately and people are protected from abuse. 8 23 13 People living in the home must be protected at all times and risk management plans in place that would cover potential risk, including the risk of fire and the environment. 28/02/2010 28/02/2010 28/02/2010 Care Homes for Adults (18-65 years) Page 33 of 37 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 would ensure that all people living in the home are protected from harm and risk is reduced to a minimum. 9 24 23 The use of portable heaters must be risk assessed and agreed with local Fire Department as safe to use. To make sure that people live in a safe environment. 10 33 18 The home must have 28/02/2010 sufficient staff on duty at all times including staff who are trained to administer medication and be competent to decide when as required medicines are to be given. To ensure that there are staff who are trained and sufficient in numbers to undertake the administration of medication, activities, daily programmes with people both inside and outside of the home. 11 34 19 Staff must only be employed 28/02/2010 using the POVA 1st check in exceptional circumstances and must be supervised at all times. 28/02/2010 Care Homes for Adults (18-65 years) Page 34 of 37 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 would ensure that people receive support from staff who have been properly checked and who are supervised at all times. 12 41 17 Recording must be of a good 28/02/2010 standard, be factual and detail events that may put people at risk. To ensure that records are up to date, accurate and factual. 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 6 All documentation relating to the identification and meeting of peoples needs should be signed and dated, to ensure that it is clear when documents are reviewed and updated and by whom. When food is opened and not used in full, it should have a date recorded on it. To ensure that food stock is eaten within the recommended use by date. The home should see the prescription and check the details are correct before the pharmacist dispenses it. This would reduce the possibility of receiving medication that has not been ordered or is required. Stock control for medication should be carried out on a regular basis and systems put in place to detect errors. This would ensure that the records are accurate and match what stock is in the home. Medication stock should be recorded as coming into the home, but also then put onto the MAR if not already printed on. This would ensure that stock coming in matches what is Page 35 of 37 2 17 3 20 4 20 5 20 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 being given and people do not receive medication that has not been prescribed. 6 20 Protocols for medication that is prescribed as required should be clear about when they can be given and timescales. To ensure that people receive their medication in a safe way and are not given too much. Medication stock should be accurate and any carried forward amounts should be detailed on the MAR chart, as this would give an up to date stock level. People living in the home should have a photograph with their medication records. To ensure that medication is given to the person it was prescribed for. When staff transcribe onto MAR charts, the prescription should be written in full, with the persons name and date of issue. There should be two signatures in place. To ensure that medication changes are done in accordance with good practice guidelines. The use of codes should be consistent and there should be clear guidance for staff. To ensure that it is clear when people have received their medication or not. The home should provide a smoking shelter, to ensure that people are not subject to adverse weather conditions. The taps in the kitchen should be replaced as they were loose and may pose a risk to the person using them. People should be supported to keep their bedrooms clean and hygienic and if this is part of their rehabilitation programme then this be clearly documented and agreed with the person. Staff should continue to progress with national vocational qualifications in care at level 2 or 3 to ensure a target of at least 50 percent of care staff are trained to this level. The registered provider should consider employing staff to undertake domestic and catering duties. This would enable care staff to offer more time to people living in the home. The manager should be registered with CQC and hold the relevant NVQ qualifications, to ensure that a qualified and approved person is running the home. 7 20 8 20 9 20 10 20 11 12 13 24 24 30 14 32 15 33 16 37 Care Homes for Adults (18-65 years) Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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