Care Home: Royal Hill

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What the care home does well Warm and, relaxed and comfortable environment with some staff who have known them a long time and understand their needs. Staff are generally trained and competent and understand their needs. Procedures in place Staff are provided with training to ensure they have the skills required to provide the care and support individuals need. Service users` monies What has improved since the last inspection? Since the last inspection the requirements made have generally been complied with. This includes the development of risk assessments for moving and handling and first aid training. A more detailed fire risk assessment is also in place and with these improvements the safety of people living and working there is improved. People are now being weighed more regularly ensuring this aspect of their healthcare is monitored. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 The environment has also improved with a new extractor fan in place in the laundry, trailing wires made safer and the corridors made more homely as well as some redecoration. The Providers have also been more committed to ensuring monitoring visits take place and producing a report on their findings. What the care home could do better: There continues to be changes to the management of Royal Hill and this does not provide people living there or staff with stability or security. This aspect must be addressed by the Providers to ensure there is consistency in the management of the service. Risk assessments need to be developed for some health related areas and where assessments are in place they need to be reviewed and updated with regularity. Medication practices must be improved to ensure peoples` health care needs are fully met and they do not present unnecessary risks to individuals. The way in which information is presented needs to be reviewed to ensure it is in a format that gives people more opportunity to understand it and it must be made more accessible. There are also issues with ensuring information is kept secure and confidential, where necessary. The open access for individuals to view confidential information must be addressed so that people can be assured that it is not open to others. This is also true of ensuring that staff ensure their personal belongings are kept secure throughout the day to minimise risks of allegations being made. Whilst care plans generally provide information about the individual`s needs the lack of information on how best to communicate means staff may not be able to determine how the person`s needs are best met. Procedures are in place to ensure people are able to complain or raise concerns. However, these need to be improved to ensure procedures are accessible, followed fully and staff are clear about their role in protecting people. Recruitment procedures must be further improved to ensure the risks of employing unsuitable staff to work in the home are reduced. There is also a need to ensure that the home has the right mix of staff to ensure people`s identified needs are being met and that access to community activities are not affected by the staffing in the home.Royal HillDS0000043007.V376918.R01.S.docVersion 5.2The system for reviewing the quality of care must include a report on the outcome of the review and supplying of a copy of this report to the Commission. We also made some recommendations, one of which has been repeated from the last inspection. Contracts and tenancy agreements should be reviewed to ensure they reflect current procedures and that they do not give conflicting information. Menus should give details of the choices for the day and alternatives on offer so that people can be assured that their dietary needs and likes and dislikes are addressed. Key inspection report CARE HOME ADULTS 18-65 Royal Hill 101 Royal Hill Greenwich London SE10 8SS Lead Inspector Wendy Owen Key Unannounced Inspection 29th July 2009 10:00 Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 1 This report is a review of the 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. 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 home adults 18-65 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. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 2 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 Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Royal Hill Address 101 Royal Hill Greenwich London SE10 8SS 020 8694 3652 020 8692 8211 key.gordon@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Greenwich Council Manager post vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 7 31st July 2008 Date of last inspection Brief Description of the Service: Royal Hill is a Home for seven adults with a severe learning disability and complex needs, who are also residents of the London Borough of Greenwich. The Home is owned by Hyde Housing Association and managed by the London Borough of Greenwich. The Home is purpose built and is situated on a corner site in a residential area of West Greenwich. There is limited parking in the drive to the front of the building. The Home is within walking distance of the heart of Greenwich with its shops, markets, park, river walks and Maritime Museum. Greenwich station is close by and buses routes run to Lewisham, Blackheath and Woolwich. Tenants have spacious single-occupancy rooms with en-suite toilet and shower facilities. A kitchen and laundry are on the ground floor. Two communal lounge-diners open out onto the enclosed garden, which is mainly laid to lawn. All people are funded by the Local Authority and the charges are fixed for each person. We have been made aware that the charging system is likely to change in the near future but have not been given the information on the changes. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 1 star. This means the people who use this service experience adequate outcomes. This inspection included a visit to the home over the course of a day and a half, completed by one inspector. During the visit we toured the home, looked at records, spoke to the manager, staff and a relative and observed practices. We received four completed surveys: one from a member of staff, relatives, a health professional and one completed by a resident, with help from a member of staff. We also received the Annual Quality Assurance assessment (AQAA) which told us about any changes, improvements and how the home is ensuring they provide a quality of care that meets the National Minimum Standards. What the service does well: What has improved since the last inspection? Since the last inspection the requirements made have generally been complied with. This includes the development of risk assessments for moving and handling and first aid training. A more detailed fire risk assessment is also in place and with these improvements the safety of people living and working there is improved. People are now being weighed more regularly ensuring this aspect of their healthcare is monitored. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 6 The environment has also improved with a new extractor fan in place in the laundry, trailing wires made safer and the corridors made more homely as well as some redecoration. The Providers have also been more committed to ensuring monitoring visits take place and producing a report on their findings. What they could do better: There continues to be changes to the management of Royal Hill and this does not provide people living there or staff with stability or security. This aspect must be addressed by the Providers to ensure there is consistency in the management of the service. Risk assessments need to be developed for some health related areas and where assessments are in place they need to be reviewed and updated with regularity. Medication practices must be improved to ensure peoples’ health care needs are fully met and they do not present unnecessary risks to individuals. The way in which information is presented needs to be reviewed to ensure it is in a format that gives people more opportunity to understand it and it must be made more accessible. There are also issues with ensuring information is kept secure and confidential, where necessary. The open access for individuals to view confidential information must be addressed so that people can be assured that it is not open to others. This is also true of ensuring that staff ensure their personal belongings are kept secure throughout the day to minimise risks of allegations being made. Whilst care plans generally provide information about the individual’s needs the lack of information on how best to communicate means staff may not be able to determine how the person’s needs are best met. Procedures are in place to ensure people are able to complain or raise concerns. However, these need to be improved to ensure procedures are accessible, followed fully and staff are clear about their role in protecting people. Recruitment procedures must be further improved to ensure the risks of employing unsuitable staff to work in the home are reduced. There is also a need to ensure that the home has the right mix of staff to ensure people’s identified needs are being met and that access to community activities are not affected by the staffing in the home. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 7 The system for reviewing the quality of care must include a report on the outcome of the review and supplying of a copy of this report to the Commission. We also made some recommendations, one of which has been repeated from the last inspection. Contracts and tenancy agreements should be reviewed to ensure they reflect current procedures and that they do not give conflicting information. Menus should give details of the choices for the day and alternatives on offer so that people can be assured that their dietary needs and likes and dislikes are addressed. 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. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5 People using the 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 pre-admission processes enable people to make decisions on whether the home is suitable for them. However the lack of appropriate information in suitable formats restricts the decision- making process. EVIDENCE: Information is available in the form of a Statement of Purpose and Service Users Guide produced in the written format. Copies of these documents are kept on individual files. This format is not suitable for those living in the home as they have little understanding of the written word. Therefore the information must be provided in way that they would be able to understand, whether this be a DVD, pictorial format or audio. This area of improvement is acknowledged in the AQAA. With one exception, the residents have been in the home for a number of years and therefore have settled well with staff who know them well. All are Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 10 funded through Greenwich Local Authority. We are still waiting for the current guidelines or information on the fees. The pre-admission process includes obtaining the social worker’ assessment and the assessment completed by a senior member of staff. They follow procedures to ensure that any prospective tenant would have an opportunity to visit the home and have trial periods to enable them to make an informed choice (starting with tea visits to meet other tenants and staff, overnight stays and weekend visits.) This process helps the person decide if they like the home and if they “fit in” with other people living there. The last inspection commented on contracts and tenants guides in place for each person, although the conflicting information has not been changed and still gives rise to misunderstanding and possible complaints. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 People using the 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 receive care individual to their identified needs with independence promoted and involvement in day to day decisions. EVIDENCE: All of the people living in the home have care plans and supporting documentation developed according to their assessed needs. We viewed two of these, one of which was of a person with quite complex needs, whilst the other, a little more independent and requires less support. We found them to be recent and easy to read to enable staff to care and support for the individual. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 12 The care plan covers a variety of health, social and personal care, as well as night-time routines. The information about their identified needs is kept in a file with much more information which is not related to the care and support plan. It makes it a rather cumbersome file and difficult to locate the information needed. We would recommend this is kept in a more user friendly way. On looking at the information we found a lot of good information about the needs of the individual and the two care plans seen during this inspection had been reviewed recently and changes made. However, most of the people living there are not able to fully communicate verbally and therefore further guidance would give staff information about the best way to communicate with the individual. Risk assessments had been developed to ensure independence is promoted, whilst balancing risks. These include going out into the community, using the stairs, accessing the kitchen and the community. These were dated early 2008 or prior to that and therefore need to be updated. In the case of one person a “best interest” meeting had taken place regarding some health issues. This is good practice with the manager expressing a desire to ensure such processes are more rigorously followed in light of recent legislation and codes of practice . Residents meetings also take place with some evidence of records of these. They have also taken “on board” the need to record who is responsible for taking action on the issues discussed. Basic discussions take place including meal choices, holidays, activities etc. We also noted from our observations that residents are able to wander freely around the home and make basic decisions about how they wish to spend their day. One member of staff spoke about the information contained in care plans and felt it gave the guidance needed to care for the individual. They stressed that the handover held before each shift and the message book are integral to good communication. We do have one concern relating to the security and handling of the information held by the home. The office is located in the main corridor close to bedrooms and communal areas. The office door is often left open and staff and residents come and go at their leisure. Some residents take away information from the office (we observed this on the day). Whilst most information is securely stored in cabinets when people are working confidential information is left out and also working on information held on the computer is able to be viewed clearly by staff coming in to the office or looking from the corridor. This is also true verbal communications. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 13 Whilst this is the person’s home the manager is also responsible for managing and organising in line with good practice including security and confidentiality of information held. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the 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 living in the home have access to a range of activities although this is not as consistent as it should be so people may enjoy the stimulation that would benefit them. Food provided is adequate and appears to be healthy and nutritious. EVIDENCE: People are offered a variety of activities so that they are engaged and stimulated. This does not include educational activities due to individuals’ abilities and dependency. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 15 The AQAA states “Tenants are actively involved in the local community. People are well known in their local community by their regular use of local shops, pubs, the local community centre and other local mainstream facilities.” Some individuals attend a day centre ranging from one or two visits to virtually daily visits and others are funded for 1:1 staffing to enable them to enjoy leisure activities. We observed people going and coming back from their day centres and there is some evidence of people going out and visiting the local area, enjoying everyday social activities. Some people enjoy physical activities such as swimming, going for walks in the park which is in very close proximity to the home or going to guides. They are also encouraged to visit the local shops, use the local hairdressers and also to buy their own clothes. A number of people have sustained relationships with family members and the home encourages them to do this with individuals visiting their family home for weekend visits or family members actively involved in supporting the individual whilst in the home. It is sometimes difficult for staff to engage individuals in activities as they present with behaviours that challenge often refusing to participate and being determined in their refusals. There is also an issue with the staffing in the home at times the number of permanent staff are much less than agency staff, thereby impacting on the daily activities undertaken. One resident has a befriender to support them and help make decisions. This is another aspect of care that the manager wishes to expand to others who have limited family involvement. We noted people were free to wander around the home at their leisure, free to choose where they sit and relax. However, once gain during this visit there was little activity and stimulation provided by staff and that there were once again, missed opportunities for interaction and engagement during the time they spent together often seated watching TV. Holidays are arranged for each person every year with staff escorting individuals. Staff costs are split between the individual and organisation. The Tenants’ Guide for Royal Hill states that ‘You will be offered your own key to the house and your bedroom’. In fact none of the service users holds a key, but rooms can be locked at the individuals’ request, if they go away for the weekend for example. A record of this is now maintained on the individual’s file. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 16 One resident has had their room recently redecorated with the colour chosen by their family member. The AQAA does not give any information about the quality of foods provided so it is difficult to judge this against their assessment. Meals are provided and from the feedback people enjoy an adequate standard of food provided at various times to suit their lifestyle. When we looked at the kitchen we found adequate dry and fresh food supplied with meals cooked, mainly from fresh. The menus viewed however, did not show any choice, although we were told that people tell staff what they want on the menu. From the care plans it is not clear about peoples likes or dislikes in these areas or the special diets. This would be beneficial to ensure staff have the information to ensure these needs are met. However, the care plans do detail where there are issues with individual weights and dietary issues. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People using the 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 using the service generally have their health needs met, although potentially their needs may not be fully met which present risks to their health. EVIDENCE: Each person has information on how people wish to have their personal care provided and mobility issues. This is quite detailed as it needs to be where people are not able communicate their specific needs. The manager should look at how they could make the care plans more userfriendly and accessible to individuals. Care plans, risk assessments and other documentation provide details of physical health needs and any particular behavioural problems. There are also a number of risk assessments completed including risk of choking, epilepsy seizures and verbal or physical aggression. However, we Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 18 noted that moving and handling or nutritional risk assessments had not been developed. Most of the risk assessments were dated May 2008 and earlier and therefore must be reviewed and, where necessary, updated. This is the same for some of the guidelines, such as PRN medication health profile. One survey from a community disability nurse states “ I find the support that the care home staff give is extremely invaluable to X. On request they have provided information that I have needed, they have seeked my advice, kept me informed of health related issues.” Another wrote “X is well looked after by the staff very well at Royal Hill.” In the case of one person a “best interest” meeting had taken place regarding some health issues to ensure they received the support and care they required to remain fit and well. On viewing the two records including message books, diary and individuals’ records we found evidence of various health care support from GPs, hospital appointment, dentist, optician, podiatry and specialist support from psychology. The home has also now complied with a previous requirement to ensure people are weighed regularly and weights recorded. We also audited the medication systems and practices. People who have prescribed medication have their medication stored safely and records of medication prescribed are in place. We were told that no individual is able to take responsibility for their medication at present. All the medication is dispensed by Boots pharmacy and arrives at the home in blister packs, where appropriate and all records are generally pre-printed by the pharmacist, except where medications need to be added later, for whatever reason. We noted that the records were still not completed in the allergy section. Where the records required prescribed medication to be handwritten onto the medication records there were still a number of occasions where there was only one signature in place and at times no signature. This raises an element of risk where medication could be wrongly transcribed. For one person the records had gaps for all their medication in the morning and at lunch-time, although the medication had gone from the blister pack. We noted that they had now commenced recording where medication had been carried forward form one month to the next. This is good practice. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 19 The records viewed showed generally that medication was being recorded when administered, although there were gaps, particularly for one day where no signatures were in place, medication not in the pack and no reasons recorded. We noticed that whilst medication had been signed in there were no dates recorded when they were received. We were also told that care staff administer prescribed creams although the records are signed the person responsible for administering medications that day. We explained that those that administer the prescribed medication, including creams must also sign the records and suggested a user friendly system for this. When touring the home we also noticed that prescribed creams are left in individual’s rooms and not locked away at all. This gives rise to potential risks. We asked about homely remedies and found there was no guidance or records in place although ibuprofen and paracetemol were available. The training records show how many staff had received medication training. We also spoke to the staff member about the administration practice and found this to be adequate although the issues above need to be addressed. We had been advised of an error in medication. They took appropriate action and through discussions with the Commission and referring them to our guidance the risks of errors occurring have been reduced. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to ensure people can raise concerns to improve their care and are protected from harm. These systems are not always followed as closely as they should be which means there are potential risks to people. EVIDENCE: There is a complaints procedure in place copies of which are held on individuals’ files. They are produced in symbols, pictorial and word format. There is also the Social Services complaints procedure that is available for people to view. This information should be made more accessible to people living there and their relatives to ensure they have the information they need with some ease. There is a hard-backed book for the purpose of recording complaints or concerns. We found three complaints recorded since March 2008 and although there is evidence that they have been investigated they have not been finalised ie detail of outcome and responses and there was difficulty in locating the actual investigation paperwork. We commented at the last inspection that it was difficult to determine if some individuals are unhappy because they cannot communicate verbally. Therefore staff need to look for other signs of where things are not right and staff who Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 21 have been working with people there for a long time they are able to do this. However, it would be beneficial, especially where new staff work in the home or new individuals admitted with communication issues, to have some guidance for staff in this area. There have been two adult protection concerns since the last inspection both referred to safeguarding teams for co-ordinating investigation, although we appeared to have only received on notification. This may be due to internal issues rather than the notification not sent. One of the allegations was raised formally much later than the alleged incident took place and meant there was some difficulty in the investigation. Staff must ensure that they raise concerns without delay to ensure safeguarding procedures can be followed fully. We spoke to one person about how the home protects people from abuse. The feedback from their perspective was that processes could be improved, although felt people were safe. We spoke to two staff who were aware of their role in ensuring people are protected from abuse and ensuring appropriate action taken. However, we are aware of an investigation regarding one allegation that shows staff may not always act in the best way to protect people. This is currently being managed by the organisation. The evidence we could obtain showed that many staff have been provided with adult protection training although their understanding of their role in this area should be further addressed in light of the comments made above. The home has a “no restraint” policy and staff are provided with training in how to manage those with more “difficult” behaviours. The council are appointee to all people living there with a member of the council staff, the bursar, visiting the home regularly, ensuring monies are provided and monitoring that individuals’ monies are safeguarded. These are audited regularly, including during Provider monitoring visits. As part of the safeguarding adults we also looked at how people are protected from the employment of unsuitable staff by viewing of their recruitment practices. The findings are commented on in the staffing outcome group. However, we are concerned about the lack of evidence of the checks completed on agency staff, in particular. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 & 30 People using the 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 live in a homely and comfortable environment which is safe and reasonably maintained. EVIDENCE: We toured the home and found that some improvements have been made since the last inspection. The Regulation 26 visit reports show there to be areas that need to be improved and our tour showed a number of these have been met. The requirement regarding the trailing wires in one room has been partly complied with. There are still issues with many appliances used so they do need to ensure any wires are secure and do not present a trip hazard. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 23 Individual rooms were generally personalised and one person has recently had their bedroom decorated with a colour scheme chosen by family member who has significant contact with the resident. We noticed that the curtains need to be replaced which the manager assured me would be completed soon. The AQAA shows that they redecorated the lounge and living room “with the tenants actively involved in choosing the colour scheme”. The lounge and dining areas remain comfortable and homely with comfy furniture and furnishings. Improvements have been made to the garden with new garden furniture purchased, the garden swing painted, flower pots purchased and planted and a barbeque been bought that will hopefully “lead to a greater use of the garden.” At the last inspection we required that the laundry room extractor fan be fixed or replaced and on this visit we found that they had replaced it but this one was not working either. The manager has also purchased a new washing machine with the required sluice facility, although this has not been plumbed in yet. We noted that hand-wash facilities were in place with protective equipment for staff to use when required. Other areas of the home were adequately decorated and furnished. We noted from the Regulation 26 report that the home is due for redecoration this year. We have commented earlier about the security and confidentiality of the main office. This is also true of the staff room/sleep-in room. This remains unlocked at all times. However, the room also stores the medication trolley and storage cupboards and residents meet staff here for medication to be administered. We noticed that staff hand bags were on the floor that were accessible to others and give potential security issues. A cupboard with lockers in was available for staff belongings and so there is no need for this room to be used. On viewing the records relating to the servicing of equipment we found that the equipment used has been serviced and safe to use. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36 People using the 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 are supported by a staff team who are trained and know them well. However, this is affected by a high use of agency staff and recruitment practices that do not adequately protect them or ensure they are cared for by people who are experienced and competent. EVIDENCE: Royal Hill is staffed by a core number of staff who have worked with the residents for a number of years. We looked at the staff rosters and had discussions with the manager about staffing levels and agencies used to support the home. The roster showed two staff working in the morning and three in the evening plus 1:1 for some individuals. During the night one waking staff and one sleepin staff supports the people living there. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 25 The staffing roster showed care and domestic staff in place but omitted to record the management arrangements in place. The manager is reminded to record management responsibilities on the staff roster. We were made aware that there are issues with the employment of domestic staff and therefore agency staff are used and we are also aware that there are care staff vacancies, along with long term staff sickness. This affects the number of agency staff used. We were told that the same agency staff are used for continuity with a preferred list of names in place. However, on looking at the rosters viewed for w/c 3/08/09 it showed some gaps and names on the roster that appeared not to be permanent or on the “used agency staff” list. This should be investigated. We also noted from the Regulation 26 reports that there have been issues with the staff mix at times, particularly the ratio between permanent and agency staff. This means residents will not have the continuity they need and also affects the activities undertaken. One member of staff who completed a survey felt more staff were needed to provide the required level of care and support. It is clear that there is a high percentage of agency staff being used which must impact on the care provided, particularly in light of the comments made below. On auditing the recruitment practices and looking at the records relating to permanent staff we found profiles completed with information about the person, including Criminal Records Bureau number. However, the information held was variable and inconsistent. Some did not show the references obtained, or if they are from previous employer, verifications of why people left previous care employment or proof of identity were also at times absent. Our main concern relates to the use of agency staff, particularly as a number of agency staff are used as 1:1 for some residents, as well as covering for permanent staff when required. We found that Greenwich use a main agency, Manpower, who co-ordinates the needs of the services and allocates agency staff to be placed in the homes. On viewing the evidence maintained by the home, relating to the checks completed, we found limited information held by them. Of the three agency staff used often, one of those used that day had an identity badge but no other information regarding checks completed; a second showed a Criminal Records Bureau check only and the third had no records of the checks completed. We are also concerned that there is limited evidence of the skills, qualifications and experience of those agency staff being supplied. The people using the service are very dependent and exhibit a number of different behaviours and so need to be supported by staff who have the rights skills and experience and are able to work with permanent staff to enable the service to continue effectively. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 26 We spoke to two members of care staff about their role in caring for those living in the home. One individual told us about the training they had received including food hygiene; first aid; moving and handling and various service specific training. They also told us they had achieved NVQ 3. The second member of staff had also received appropriate training. At the last inspection we commented on the lack of training matrix to provide clarity over the training provided. This has yet to be developed which meant that we had to search through the training file where certificates and records are held about training provided. Training is arranged through the Greenwich learning and development team and covers core and specific training for learning disability staff. The manager told us that they have produced a training and development for staff to record this information on, although the information has yet to be added. However, this would be very beneficial in determining what the individual training needs are as would a training matrix detailing the whole of the service training needs. On viewing records and sampling those for four staff these showed various training provided over the last few years including food hygiene, learning disability, adult protection, epilepsy and challenging behaviour. Staff supervision has not been as robust and up to date as the manager would have liked due to changes in management and trying to get to know the new service. However, the manager and deputy manager have restarted a programme of staff supervision and the list was available on display. One member of staff spoken to had been working in the home for three months but only recalls one formal supervision. Records viewed on staff files confirmed this and that supervision of staff is an area to be improved. The manager assured us that this is being addressed and staff will be supervised with more regularity. Of the eleven permanent staff nine have achieved NVQ 2 or above. However, given the high use of agency staff these need to be included in the ratio of 50 or more staff achieving this qualification. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 People using the 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 constant management changes means that people using the service cannot be assured that they will receive a consistent quality of care and support. EVIDENCE: A new manager is once again in place. She transferred from another home in the area due to the previous manager being off work. The current manager has experience of managing a home, albeit slightly smaller. The manager has achieved NVQ level 4 and according to the AQAA attends regular training. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 28 There continues to be issues with the management of the service as there has not been a stable management for a number of years. The area manager, manager and staff are currently “working together” to address issues arising in the home. This does continue to impact on the home with staff having to continually adapt to different management styles. We would expect to see some continuity in the management of this service to assure ourselves that people receive a consistent service and one that continually improves. The current manager has worked hard to address the requirements made at the last inspection and is looking forward to improving the service. It is too early to make a judgement on the impact the new management team have on improving the service. We have received a number of Regulation 37 notifications, although we are concerned that a Regulation 37 regarding a safeguarding allegation may not have been sent which may affect how these issues are investigated. A number of requirements from the last inspection have been complied with. This includes the development of a fire risk assessment and a moving and handling risk assessment along with a basic first aid risk assessment (although this needs to be worked upon). Another requirement was that Regulation 26 visits must take place and there is evidence that these are occurring with reports completed. It is positive that the reports pick up issues areas of good practice and areas requiring improvement. For example: one report detailed the need for a blind to be put up in the upstairs bathroom, make upstairs hallway more homely. We looked at the records relating to the servicing of the equipment and services used and these were generally in order with fire equipment, fire drills, fire risk assessment and system serviced along with the fixed wiring and gas services. We also viewed the training records related to core training, taking into consideration the risk assessments for moving and handling and first aid, training is appropriate. We noted from the information provided that a survey had been undertaken in September 2008. However, the Commission has not received a report on the outcome of this. Regulations require the organisation to supply us with a copy of any report completed on the review undertaken. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 2 LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 2 x 2 3 x 3 x Version 5.2 Page 30 Royal Hill DS0000043007.V376918.R01.S.doc yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement Timescale for action 01/12/09 2 YA10 17 3 YA7 15 4. YA20 13 Information must be provided in a format suitable to the individuals who are using the service to give them an opportunity to understand what the service provides. Information held about 01/10/09 individuals must be kept secure and remain private so that people can be assured it remains confidential. The care plans must include 01/11/09 information about the individual’s method of communication so that staff are aware how best to make themselves understood as well as understanding the individual. This would assist in ensuring that peoples’ needs are met. Medication practices in relation 01/10/09 to the safe administration, storage and record keeping must be improved to ensure the health needs of individuals are not placed at risk. Risk assessments must be developed in respect of nutritional needs and moving DS0000043007.V376918.R01.S.doc 5 YA9 13 01/10/09 Royal Hill Version 5.2 Page 31 6 YA33 18 7 YA22 22 8 YA23 13 8 YA34 17 and handling requirements. All risk assessments must be reviewed regularly and updated, where necessary to ensure people receiving care remain safe and well. Staffing levels and staff mix must be reviewed to ensure people are given opportunities to continue access community activities. Specifically the level of agency staff used on each shift must be reviewed so that there are trained, skilled and experienced staff available to support individuals. The complaints procedure must be made accessible to the individuals and their representatives and where complaints are made there must be full records in place detailing the complaint, investigation, outcome and action taken to resolve the complaint. Adult protection procedures must be followed by all staff ensuring people are safeguarded through appropriate referral in the home and to external agencies. Recruitment practices must be more robust so that the manager can assure himself that people working in the home, including agency staff, have had the required checks and therefore individuals are safe. A report on the outcome of any review undertaken about the quality of care provided by the service must be made available to the Commission and to those using the service. 01/11/09 01/10/09 01/10/09 01/10/09 9 YA39 24 01/12/09 Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA5 YA17 Good Practice Recommendations Contracts and tenancy agreements should be reviewed to ensure they do not provide contradictory information. There should be a record of the choices offered at each meal time to ensure people are being offered food of their choice which is healthy, varied and nutritious. Royal Hill DS0000043007.V376918.R01.S.doc Version 5.2 Page 33 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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