Care Home: St Andrews, Paignton

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What the care home does well The admission procedure is managed well at the home. The information that staff obtain on each person is in depth and used to base the plan of care on. People receive a good standard of personal health and mental health care. Communication with healthcare professionals in the community is good. The care provided by staff is done so in a respectful way. Staff at the home ensure people see the GP or other health care professionals when they need to. People tell us the food is very good at the home and any issues regarding dietary requirements, preferences or weight issues are sensitively managed. St Andrews is generally a safe and pleasant place to live and work. What has improved since the last inspection? Despite regular intentional damage caused by people living in the home environmental improvements have continued to take place. Three bedrooms had been decorated and two rooms have been provided with new carpets. A new glass door at the entrance of the home has been installed. New furniture including two armchairs and coffee table have been introduced, whilst the kitchen is benefiting from a new gas cooker. Medication policies have been reviewed and improved to ensure that staff have information on how to manage medication safely. Fire risk assessments have been improved and have involved the introduction of new smoke strips on some fire doors. Some new activities have been introduced including baking in the kitchen and accessing bus passes for some people living in the home. The providers have attempted to introduce a games room in the garage but this has not taken place because of refused planning permission. The home have provided a new rabbit run for the home is kept rabbit. What the care home could do better: Staff training must be a priority for the Providers of this home. As a basic requirement all staff must be up to date with mandatory training which would ensure that staff have the skills and knowledge to care for people in a safe way whilst promoting the health, safety and welfare. Systems should be introduced to ensure that this training programme is rolling to ensure that all staff have access to refresher sessions at regular intervals. In addition to mandatory training staff should be provided with opportunities to update their knowledge regarding the specialist and individualised needs of people in the home. It would benefit people if the staff are aware of the types of medicines used and their effect on people living at the home. Staff should also be aware of the common conditions suffered by people living in the home.With safety and protection in mind staff should also be provided with suitable safeguarding adults training to ensure they know the correct procedures to follow and correct healthcare professionals to contact should any allegations of abuse be made. The protection of the staff and people in the home should also be promoted by ensuring staff have suitable training to deal with violent and aggressive behaviours. The providers should also look at ways of improving the quality of life for people in the home which could also benefit their mental health policies and state of well-being. Routines could be reviewed to ensure they promote engagement of people at all times. Ways of making lunchtimes more sociable should be investigated and increasing the range and type of activities and encouraging the involvement of people would also provide more stimulation and engagement of people in the home. The issue and difficulty the providers face regarding smoking could also be used as an opportunity to improve safety and increase engagement people in the home. Consideration should be given to provide communal area for people to smoke and meet together which could reduce the amount of times people smoke in their rooms. Record keeping should also be improved in the home. The provider must ensure that all care needs, including short term needs and goals, are documented within each service user plan. This would reduce the need to rely solely on verbal communication between staff and would minimise errors being made especially when staff do not have enough time to handover between each shift. Risk assessments and healthcare assessments must be kept under review to monitor any changes in condition. Medication administration record could also be improved by ensuring there is a photograph of all people living in the home which would help minimise drug errors. Policies and procedures in the home should also be reviewed to ensure they are still relevant and safe to follow. The statement of purpose and service user guide must also be updated to ensure they contain accurate information. These documents should also be available to people visiting the home. Recruitment records could be improved by ensuring all staff have a recent photograph on their staff file which provides evidence of their identity. Staff should be reminded about how records should be performed and should be reminded that the use of Tippex (correctional fluid) is not suitable on professional records. The providers should also look at the way complaints are managed to ensure they do not keep recurring. The providers should look at solutions to ongoing issues to ensure they do not affect the well-being and safety of other people in the home. The environment could also improve by looking at creative ways to stop people smoking within their bedrooms. Access to the garden could be made easier so people could enjoy this space. The providers should also look at the home to ensure that it does not present as an institutionalised environment. The risk of spread of infection could be reduced by introducing paper hand towels within staff bathrooms and communal areas. The spread of infection could also be reduced by ensuring systems are in place to keep bathrooms and toilets hygienically clean at all times. Another major focus for the providers is to look at staffing levels and numbers. The providers must ensure that sufficient staff are employed to ensure that the needs of people are met. The providers must ensure that staff are able to interact and engage with people which will promote well being and improve mental health. Key inspection report Care homes for adults (18-65 years) Name: Address: St Andrews, Paignton 24 St. Andrews Road Paignton Devon TQ4 6HA     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: Clare Medlock     Date: 1 9 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 41 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 41 Information about the care home Name of care home: Address: St Andrews, Paignton 24 St. Andrews Road Paignton Devon TQ4 6HA 01803559545 01803391582 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Paulette Davies and Mr John Davies care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 21. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Mental disorder, excluding learning disability and dementia- Code MD Date of last inspection Brief description of the care home St Andrews is a care home for up to 21 younger or older adults with mental health needs. The building is situated in a residential area of Paignton, within walking distance of the sea front, shops and amenities. There is level access through a small front garden, with one step inside the lobby area to access the house. There is also a concreted area and lawn to the back of the home. The home has a lower ground, ground, first and second floor with stairs throughout. This may cause difficulties for residents with mobility problems, as there are no bathing/shower facilities on the ground floor. An external fire escape connects all floors. On the lower ground floor Care Homes for Adults (18-65 years) Page 4 of 41 Over 65 0 21 2 9 0 6 2 0 0 9 Brief description of the care home there is a laundry, storeroom, bedroom, shower, bathroom, and lounge , taff sleep-in room. On the ground floor there are bedrooms, a kitchen, toilet, office, dining room and lounge. The first floor has a shower room, bathroom, and bedrooms, and on the second floor there are bedrooms and a toilet. Two of the bedrooms are doubles. The costs per week for residential care at St Andrews vary between roughly three hundred and fifty pounds and five hundred pounds. Care Homes for Adults (18-65 years) Page 5 of 41 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 CQC received a complaint in June 2009. This complaint included information that the home was caring for more people than it was registered for. A random inspection was performed following receipt of this information where evidence found supported the complaint. As a result the home was found to be guilty of an offence under the Care Standards Act 2000 section 24 from the 23rd June to the 29th June 2009, namely that the home was accommodating more residents than allowed by the homes condition of registration. Paulette Davies, Registered Provider, accepted a Simple Caution in light of this offence. This inspection: The quality rating for this service is one star. This means the people who use this Care Homes for Adults (18-65 years) Page 6 of 41 service experience adequate quality outcomes. Prior to this inspection we received a completed Annual Quality Assurance Assessment (AQAA) from the registered provider. The AQAA is a self-assessment record that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. This key inspection also consisted of an unannounced visit to the home between 07:00am and 15:00pm on Tuesday, 19 January 2010. We inspected this service with an expert by experience. The Care Quality Commission consider an expert by experience as a person who either has a shared experience of using services or understands how people in this service communicate. They visited the service and spoke with the majority of people living at the home. This helps us get a picture of what it is like to live in or use the service. During the inspection we spoke with the Registered Providers of the home, people who live in the home, and three staff who work at the home. We case tracked three people who live at the home. Case tracking means we looked in detail at the care these people received. We spoke to staff about their care, looked at records that related to them and made observations if they were unable to speak to us or able to provide feedback. We looked at staff recruitment records, training records and policies and procedures. We did this because we wanted to understand how well the safeguarding systems work and what this means the people who use the service. All this information helps us to develop a picture of how the home is managed and what it is like to live at St Andrews. We asked about fees charged at St Andrews and were told that currently the lowest fee is £320 rising to £520 per week. This does not include personal items, toiletries or chiropody. This fee does include entertainment and some activities. Care Homes for Adults (18-65 years) Page 7 of 41 What the care home does well: What has improved since the last inspection? What they could do better: Staff training must be a priority for the Providers of this home. As a basic requirement all staff must be up to date with mandatory training which would ensure that staff have the skills and knowledge to care for people in a safe way whilst promoting the health, safety and welfare. Systems should be introduced to ensure that this training programme is rolling to ensure that all staff have access to refresher sessions at regular intervals. In addition to mandatory training staff should be provided with opportunities to update their knowledge regarding the specialist and individualised needs of people in the home. It would benefit people if the staff are aware of the types of medicines used and their effect on people living at the home. Staff should also be aware of the common conditions suffered by people living in the home. Care Homes for Adults (18-65 years) Page 8 of 41 With safety and protection in mind staff should also be provided with suitable safeguarding adults training to ensure they know the correct procedures to follow and correct healthcare professionals to contact should any allegations of abuse be made. The protection of the staff and people in the home should also be promoted by ensuring staff have suitable training to deal with violent and aggressive behaviours. The providers should also look at ways of improving the quality of life for people in the home which could also benefit their mental health policies and state of well-being. Routines could be reviewed to ensure they promote engagement of people at all times. Ways of making lunchtimes more sociable should be investigated and increasing the range and type of activities and encouraging the involvement of people would also provide more stimulation and engagement of people in the home. The issue and difficulty the providers face regarding smoking could also be used as an opportunity to improve safety and increase engagement people in the home. Consideration should be given to provide communal area for people to smoke and meet together which could reduce the amount of times people smoke in their rooms. Record keeping should also be improved in the home. The provider must ensure that all care needs, including short term needs and goals, are documented within each service user plan. This would reduce the need to rely solely on verbal communication between staff and would minimise errors being made especially when staff do not have enough time to handover between each shift. Risk assessments and healthcare assessments must be kept under review to monitor any changes in condition. Medication administration record could also be improved by ensuring there is a photograph of all people living in the home which would help minimise drug errors. Policies and procedures in the home should also be reviewed to ensure they are still relevant and safe to follow. The statement of purpose and service user guide must also be updated to ensure they contain accurate information. These documents should also be available to people visiting the home. Recruitment records could be improved by ensuring all staff have a recent photograph on their staff file which provides evidence of their identity. Staff should be reminded about how records should be performed and should be reminded that the use of Tippex (correctional fluid) is not suitable on professional records. The providers should also look at the way complaints are managed to ensure they do not keep recurring. The providers should look at solutions to ongoing issues to ensure they do not affect the well-being and safety of other people in the home. The environment could also improve by looking at creative ways to stop people smoking within their bedrooms. Access to the garden could be made easier so people could enjoy this space. The providers should also look at the home to ensure that it does not present as an institutionalised environment. The risk of spread of infection could be reduced by introducing paper hand towels within staff bathrooms and communal areas. The spread of infection could also be reduced by ensuring systems are in place to keep bathrooms and toilets hygienically clean at all times. Care Homes for Adults (18-65 years) Page 9 of 41 Another major focus for the providers is to look at staffing levels and numbers. The providers must ensure that sufficient staff are employed to ensure that the needs of people are met. The providers must ensure that staff are able to interact and engage with people which will promote well being and improve mental health. 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 10 of 41 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 11 of 41 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The out of date information is not available to people and when it is available is misleading and does not provide an accurate picture of the home. Evidence: Although the home provide a statement of purpose and service user guide this was not available for people visiting the home. The Providers informed us that there used to be a copy of these documents within the entrance hall that this had been damaged by a person living at the home and was therefore removed. Copies of the statement of purpose and service user guide was located within an office at the home. Both of these documents contained out of date information including details of their manager who has not managed to the home for a number of years. Contact details for the regulatory body were incorrect and also out of date. We did not case tracked anyone who had been newly admitted to the home because the majority of people have been at the home for a number of years. However, evidence was seen at a needs assessment had been performed on existing people Care Homes for Adults (18-65 years) Page 12 of 41 Evidence: which was used to form the base line of care needs of people in the home. Staff informed us that in the past people moving into the home have had opportunity to have an introductory visit, but that some people were admitted as part of an emergency process. Once the settling in period has been completed people are issued with a contract. Care Homes for Adults (18-65 years) Page 13 of 41 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The amount of flexibility and choice people have at the home is good but the amount of choice could impact negatively opportunities for engagement and recovery. Improvements to service user plans would mean that short-term goals and needs are highlighted and communicated more effectively. Evidence: Each person living at the home have their needs assessed and documented within a service user plan. We looked at service user plans for four people living at the home. Generally the plans were well constructed and contained information which included: personal details, religion, next of kin and healthcare professional contacts, past medical history, allergies, the reason for admission, social history, diet preferences, and information about health care needs. None of the service user plans inspected were up to date. All service user plans Care Homes for Adults (18-65 years) Page 14 of 41 Evidence: contained at least three documents that had not been reviewed in recent months. The majority of assessments and risk assessments had been reviewed in October 2009. Although service user plans highlighted the general needs of each person, and these were specific to each person living in the home, some service user plans lack to specific details of current problems and short-term goals. This meant that communication relied on staff handing over relevant information verbally. Should staff needs to refer to service user plans, they would have to read several pages of daily notes to find the current problems. One example was of a person who had had a recent hospital stay. The service user plan did not contain a short term care plan highlighting what needs this person had. It was observed that staff have a brief handover where they communicate verbally the summary of the previous shift. Service user plans did not contain information to suggest how each person was being supported to improve or maintain their mental and physical health. People living at the home had a lot of individual control over their lives, it seemed that they could do anything they wanted- Stay in bed, eat in their rooms, go out whenever they wanted. We raised concerns with the Providers that with all this flexibility, there was almost too much opportunity for people who live at the home to do their own thing, and miss any opportunity for engagement between other people living in the home, which may not be affected in any recovery of mental health illness. Surveys received from health care professionals supported this view with one comment that read I think they try hard to let clients do what they choose, but this is often a difficult balance between individual freedom and communal living. People living at the home had support to make decisions about their lives. We also saw examples where staff would prompt people to make decisions with the support or guidance where any risk to personal safety is highlighted. People were supported to make decisions regarding their finances with examples of individual plans of care and arrangements. The Providers of the home ensure that people living there are offered opportunities to participate in the day to day running of the home. Regular resident meetings are held where people can express their views and dissatisfaction with the service and the Providers daily presence also enables people to do this on an informal basis. Care Homes for Adults (18-65 years) Page 15 of 41 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of activities, and insufficient encouragement to join in, mean that people are not engaged as much as they could be and could have a negative impact on their mental health recovery. Evidence: There were posters displayed on a communal notice board promoting painting classes, cookery sessions and cinema trips. Records kept showed that regularly it was only two or three people only that took up these activities. These activities had included trips to local attractions, visits to the cinema and trips to the local pub. Only six of the 21 people at the home has joined in with these activities. We noted that the home really suffered from the lack of activities that could promote more engagement with people who live at the home which would improve their lifestyles and possibly improve their mental health. Our expert noted people tucked Care Homes for Adults (18-65 years) Page 16 of 41 Evidence: away in isolation. The AQAA stated that some new activities have been introduced including baking in the kitchen and accessing bus passes for some service users. The providers also told us by the AQAA that they have attempted to introduce a games room in the garage but this has not taken place because of refused planning permission. At mealtimes people were not encouraged to group together for meal times which would give an opportunity for interaction and communication between people and staff. The tables in the dining room faced the walls leaving diners to sit back to back. Only three people ate their meal in the dining room who sat with their backs to each other providing no engagement with each other . There were no carers in the room while they ate. People living in the home told us that there was nothing to do in the home. We asked about the activities displayed on the notice board but were told that they didnt happen. people told us that no one went to church or to the leisure centre but they could go to the shops for their cigarettes if they asked. We spoke to one person about joining in with the painting classes. We were told there wasnt any. There was little choice available for the people living at St Andrews. They could stay in their rooms or sit in the lounge and watch TV. carers did not spend time in any of the communal rooms, as they were too busy running up and down the stairs, performing household chores or cooking in the kitchen. We saw one member of staff chatting with people whilst she was performing a task, but staff appeared not to have sufficient time to engage with people at the home or encourage them to become involved in anything. We observed that the community rooms appeared fairly bland without much evidence of photographs or pictures. There were no souvenirs of trips or holidays. One or two pictures of artwork were displayed within the home, but not enough to show that activities had taken place. The TV was playing in the lounge and the seating was arranged into a circle around it. All the dining room tables were pushed up against the walls so that people would have to sit with their backs to each other, which would not promote conversation or communication. We were told that there were board games, books and puzzles at did not see that these were easily accessible. There were a pile of VHS videos were under the TV. Care Homes for Adults (18-65 years) Page 17 of 41 Evidence: There were no examples were entertainment had been bought into the home and no examples of annual holidays provided at the home. We talked to the manager, Paulette, about the lack of activities and she told us that she tried but the people living at the home were so unmotivated, she couldnt get anyone to join in. The activity records show that the cinema trips get an average turn out of just two people every week. One person said that the Provider was going to take her swimming but this hadnt happened yet. Although we had been told of birthday buffets and summer barbeques discussions were held regarding the importance of engagement and encouragement to prevent isolation. We communicated that the lack of events, exercise, expressive activities or any community group events is a concern in mental health care. One person told us he spent his time looking after the rabbits and informed us that it was beautiful out in the back garden. We asked people why no one used the back garden for smoking and he said it was too much trouble to get all the way round to the back so most people just stood out the front or had a smoke in their room, although they knew this was not allowed. Lunch was served around 12.00, it was home made chicken pie with fresh vegetables and obviously very popular. People all appeared to collect their meals but most of them took them away to their rooms. There wasnt a choice of menu but we were told by people living at home that if they didnt want the meal they could have something else, or that if they had missed the meal because they slept through it, they could get a sandwich in the afternoon. Personal diet requirements were being met, dietary preferences were recorded within service user plans and the deputy manager who performs most of the catering is aware of what people like and dislike. Weight charts are maintained within the service user plan with the steps taken to address changes. Alcohol is permitted at the home, subject to service user plan. We saw one person enjoying a beer with his cigarette outside. Despite the lack of engagement and activities, we saw examples were the providers had put effort into considering the individual needs of people in the home. This included providing rabbits and chickens and be individualised bedrooms, which included equipment and pets and plants. Care Homes for Adults (18-65 years) Page 18 of 41 Evidence: We saw no examples were people were encouraged to take part in further education, distance learning or other training. However one person living at the home was assisting the Providers with household decoration. Other people are assisted within the kitchen areas and help with household chores. The daily routines within the home do promote privacy and dignity. People are offered a key to their bedroom and receive their post unopened. Staff use the persons preferred term of address which is also recorded in the service user plan. Care Homes for Adults (18-65 years) Page 19 of 41 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to service user plans and assessments reviews would mean that people have their health care needs are monitored more closely. Improvements to medication training is needed to ensure staff are more informed regarding the medications they routinely provide at the home. Evidence: People living at the home appeared well cared for and were able to choose their own clothes, hair style to reflect their personality. We saw examples where staff needed to prompt people with personal care and hygiene. Service user plan showed that people have their health care needs met, and are able to attend local doctors practices and hospitals. Records showed that people have access to NHS services and input from healthcare professionals. These have included optician visits, neuropsychological assessments, speech and language therapists, doctors, nurses and psychiatrists. One person told us about their own physical health Care Homes for Adults (18-65 years) Page 20 of 41 Evidence: and told us that she was regularly taken to the doctors by the carers. Another person confirmed this saying that they were all taken to see their psychiatrists and that their Key Workers came in to see them. Whilst we were talking to this person he asked a staff member to get his Key Worker in and the staff member went off to arrange this. Despite each person having a service user plan, some health-care assessments, medication reviews and risk assessments had not been reviewed as regularly as they should be. At the last inspection and assessments called the health of the nation assessment was recommended to be reviewed more regularly. Despite this recommendation four of the four service user plans contained assessments that had not been reviewed since October and November 2009. Surveys received from healthcare professionals highlighted concerns regarding staff training and knowledge. One comment read this home has some of the most challenging and emotionally disturbed people. I feel that they struggle to meet the level and sophistication of the care required. We spoke to a person who had returned from a recent stay away from the home. He only good things to say about St Andrews and said he was so glad to be back home and it felt like home to him. He told us that the people who looked after him were wonderful and he had a lovely basement room with a door opening onto the back garden where he could smoke and watch the chickens. Medication is managed by staff in the home using a blister pack system, which had been prepared by a local pharmacist. Certificates displayed on the wall show that staff who administer and manage medication had received specific training in medication, although the training was due to be repeated and had been organised. Discussion with staff showed that the knowledge of medications is basic and relates to safe administration rather than the specific side-effects for medication often used in the home. A survey received from my health care professional also raised concerns regarding the level of knowledge of medications used in the home. Medicines are stored appropriately in lockable cupboards and designated fridges. There were policies on the disposal, administration and out of hours facilities. There are examples assessment signatures and guidance on self medication and consent. Staff were able to explain how medication was ordered and returned to the local pharmacist. Controlled drugs was stored appropriately and records of these were checked and appeared correct. Medication administration records were well completed and contained the reasons for omissions. All but one person had a photograph displayed on their medication administration record. Care Homes for Adults (18-65 years) Page 21 of 41 Evidence: The AQAA informed us that medication policies have been reviewed and improved to ensure that staff have information on how to manage medication safely. Care Homes for Adults (18-65 years) Page 22 of 41 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are not always managed effectively to reduce their occurrence. The lack of training regarding safeguarding awareness and procedures could place people at risk and the lack of training in how to deal with physical and verbal aggression could play staff at risk. Evidence: Whilst talking to people in the home one specific issue was raised repeatedly by many people at the home. This specific issue seemed to cause problems, distress and feelings of fear for people at the home. The issue could also be another reason why people preferred to keep in their rooms. Discussion with the Providers confirmed that they were aware of this issue and that people had raised this issue with them personally. The Providers gave assurances that they would, once again, review the situation as a matter of priority. Despite this situation causing great distress and feelings of fear, people did not feel as though the issue had been dealt with appropriately by the Providers. There is a complaints procedure displayed within the home, although this could contained out of date information about the Care Quality Commission (CQC) The contact details for CQC was listed as the National Care Standards Commission which Care Homes for Adults (18-65 years) Page 23 of 41 Evidence: has not been in operation since 2004. This would mean that people who tried to contact a regulatory body to complain would be unable to do so. The complaints procedure within the statement of purpose and service user guide also contained out of date information. The complaints folder was located within the office at the home. This confirms that the last recorded complaint had been sent by the Commission for Social Care Inspection in May 2009. Part of this complaint had been dealt with appropriately within timescales, but part of the complaint related to the issue raised above which indicates that the complainant continues to consider this an issue. In addition to the complaint in May 2009, the CQC also received a complaint in June 2009. This complaint included information that the home was caring for more people than it was registered for, and associated issues. A random inspection was performed following receipt of this information where evidence found supported the complaint. Since this time we also recieved annonymous information regarding issues including staff training, recruitment and the environment which are highlighted in other areas of this report. At the last inspection it was recommended that the home obtained the local alerters guide for staff to follow should there be an allegation of abuse. The AQAA informed us that all staff have received POVA training, Although the guide has been obtained, staff knowledge was still poor regarding who should be contacted in the absence of the managers should an allegation be made, although all staff said they would would make sure that poor practice is reported. Only half of the staff files inspected contained evidence that staff have been provided with recent training in the protection of vulnerable adults and safeguarding. Other staff spoken to said they were due for a refresher or had not received this training. There are panic alarms present for staff to carry, although observation confirmed that these were not being carried. Training records did not contain evidence that staff had been provided with training regarding how to deal appropriately with physical and verbal aggression. We saw no examples were deprivation of liberties are suspected. There were restrictions in place regarding some issues such as access to money and cigarettes, but the staff were able to explain the reasons for these restrictions and the links to Care Homes for Adults (18-65 years) Page 24 of 41 Evidence: safety for people. Care Homes for Adults (18-65 years) Page 25 of 41 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the home is generally well maintained improvements would enhance the environment in which people live and reduce the spread of infection throughout the home. Evidence: St Andrews is a large house in a quiet residential area of Paignton close to the sea front and a short walk away from the town centre. Some areas of the home appeared well maintained, whilst other areas appeared run down. Bedrooms are arranged over four floors via many corridors. The home is registered to care for 21 people and on the day of inspection there were 19 people living at the home. On the ground floor there is a large kitchen, a communal lounge and dining room overlooking a back garden which appeared to be neglected in places. There are chickens in the garden who are cared for by one of the Providers. Rabbits are also kept at the home and cared for by a person living there. In front of the home there is a small garden which is used by people who live at the home and staff to smoke in. There is no covered areas for smokers outside, which could lead to an increase in people smoking in their rooms. The property did have a feel of an institution with its various unmatched furniture and Care Homes for Adults (18-65 years) Page 26 of 41 Evidence: chipped paintwork, but it smelt fresh and was tidy, especially the kitchen area which was immaculate. It was noted that there was a buildup of cobwebs in some areas of the home. The AQAA informed us that despite regular intentional damage caused by people living in the home environmental improvements have continued to take place. Three bedrooms had been decorated and two rooms have been provided with new carpets. A new glass door at the entrance of the home has been installed. New furniture including two armchairs and coffee table have been introduced, whilst the kitchen is benefiting from a new gas cooker. Many people were in their rooms when we conducted a tour of the building. It was noted that many of the rooms had tea and coffee making facilities. Three people were grouped in one of the rooms having a cuppa, two people were in still in bed and one had gone out and had barricaded her door up so we couldnt enter. One room had a broken light and shelves and the provider told me that the person staying there had smashed up the room and was not living at the home at present. Another room had just been re-decorated and the person had chosen the new blue paint for the walls, herself. The communal rooms were not used very often, although a couple of people were in the kitchen cleaning the worktops and making themselves drinks. Rooms were individually styled and decorated. One room had been kitted out like a bedsit and another person had lots of plants in their room. People living at the home are permitted to keep pets. Examples included a hamster and a cat. The upstairs office contained a put you up bed for staff who sleep at night. The bathrooms and toilets were adequate and functional but not very clean, some in need of refurbishment. There were enough facilities for everyone and people were able to lock themselves into the bathrooms for privacy. Windows to all the rooms were safety locked and there was a fire escape on the outside of the building from the top floor. Other fire escapes were available. One person has an individual escape. We were informed that smoke seals had been replaced on the fire doors since the last inspection. Smoking was still an issue at the home, with some people ignoring the well advertised Care Homes for Adults (18-65 years) Page 27 of 41 Evidence: ban on smoking within the home. We asked people why no one used the back garden for smoking and were told it was too much trouble to get all the way round to the back and that most people just stood out the front or had a smoke in their room, although it wasnt really allowed. There were no communal smoking areas provided or covered areas outside the building. Whilst generally the home appeared tidy, some areas of the home needed further cleaning. It was noted that of the three staff on duty in the morning one was providing care for people and was responsible for cleaning, one was within the kitchen to the majority of the morning and the other appeared to be very busy performing tasks. The Providers were present throughout the inspection and were performing managerial and administration tasks. Infection control was not seen as a priority within the home. Bathroom and toilet areas contained faecal debris and splashes of urine. Although soap dispensers were available there were no hands towels for staff and residents use. Communal towels were provided which does not prevent the spread of infection. Laundry facilities were present within the home, washing machines were domestic in style although staff informed us that no foul linen was handled at the home. Tumble dryers were present for use by people at the home. floors within the laundry room were easily cleanable and equipment suitable for their purpose. Care Homes for Adults (18-65 years) Page 28 of 41 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. Major improvements in staffing numbers, staff training and induction are needed to ensure staff have the time, skills and knowledge to perform their roles in a safe and effective way. Minor improvements in the recruitment process would mean that full information is obtained on all staff before they work. Evidence: Interactions between staff and people living at the home were appropriate supportive and affectionate. Staff were seen to work extremely hard performing the tasks allocated to them for their shift. All staff were professional, cooperative, helpful and friendly. There were three carers on duty on the day of inspection who were busy, one never left the kitchen and two were dashing up and down the stairs with plates and mugs and were responsible for cleaning. We noted that most of the people took their meals to their rooms so this explained the waitress activity. Information recieved since the last inspection was a concern that staff are expected to clean peoples rooms as well as take them out, cook for them and look after their day Care Homes for Adults (18-65 years) Page 29 of 41 Evidence: to day needs and considered that the staff numbers were insufficient to do this. Our observation supported this statement. Off duty records showed that at night to members of staff on duty. The majority of residents are in bed one member of staff is able to sleep was the other stays awake and accesses the sleeper were necessary. Off duty records also showed that at weekends only two staff are present in the morning and two in the afternoon. During the week this rises to 4 staff on duty in the morning and two in the afternoon. We noted that whilst people had the freedom to eat in their rooms, and had the luxury of flexibility of choice this appeared to result in extra work for the carers, so they have less time to spend talking to people and attending their needs. The Deputy Manager was working within the kitchen all morning. He had no administration all care role during the inspection and the only interaction he had with people living in the home was when they entered the kitchen. However these interactions were professional and very caring. The most concerning comment on health care professional surveys included I have the impression that some staff know too little about medications or their implications and that their behaviour management is unsophisticated. I am very concerned that St Andrews has been and still seems to be a place to go if no one else will take you. Whilst at the same time the Providers do not always provided up-to-date care. We spoke with staff about their training. None of the staff spoken to were up to date with all aspects of mandatory or general training. Some staff spoken to were unable to explain what basic mental health conditions were. Since the last inspection we also received information that staff did not have adequate training regarding some of the specific health care needs of people at the home. The home care for people who can sometimes become violent and aggressive. None of the staff files contained evidence that staff had received training in dealing with violence and aggression. The home also care for people with addiction issues. Staff spoken to had not received training in how to care for people with drug or alcohol addiction. Posters were displayed which were advertising some training regarding the specific mental health issues. Staff informed us that they were encouraged to do NVQ training. Care Homes for Adults (18-65 years) Page 30 of 41 Evidence: Induction records for new staff were inspected and showed that staff are not completed mandatory induction expected within the care home, although staff were able to tell us that existing staff were able to show them the ropes. Recruitment records were well maintained. Each new member of staff is allocated a folder which contained evidence that staff had completed an application form and included information regarding next of kin and employment history. Staff complete and health declaration and equal should use form and when interviewed an interview record is kept of this process. Each member of staff is issued on employment contract and is only employed following receipt of two references. All staff files contained evidence that the Providers had performed the criminal records bureau check and protection of vulnerable adults check (now independent safeguarding authority). Staff told us they had regular supervision and support from the Provider. Staff files contained evidence of supervision records. Care Homes for Adults (18-65 years) Page 31 of 41 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. Improvements are needed to ensure that systems are in place to improve the quality assurance processes at the home. Improvements to the mandatory training programme would ensure staff have the skills and knowledge necessary to promote the health, safety and welfare of people in the home. Evidence: The Providers are present most days to oversee the day-to-day running of the home. One of the Providers is responsible for the general maintenance management in the home and personal money for people living at the home. Records were seen to show this process is robust, although storage of receipts could be more effective. Maintenance records for the home were well maintained and show that regular servicing was in place for Legionella, electrical testing, gas and oil safety, electrical safety and fire risk assessments. Care Homes for Adults (18-65 years) Page 32 of 41 Evidence: Valid insurance certificates and regulation certificates were on display and reflected the service being provided. General risk assessments were present in the home and included general building safety, individual rooms safety, hygiene safety and fire safety. Fire doors had been fitted with new smoke seals since the last inspection. The final book showed that there were regular emergency light tests and these were serviced in the last couple of weeks. Records also showed that fire extinguishers and fire alarm systems had also been checked on a regular basis. However records showed that there had been a lapse in five instructions and drills and this check had last been performed in October 2009. Records could also not confirm that all staff had received fire training. Staff were clear about who is responsible for all is within the home and were clear regarding lines of accountability. Regular resident meetings are held to inform people living at the home of changes and are allowed and opportunities to voice their opinions or dissatisfaction with the service. The home have also produced a monthly newsletter which includes information such as recipe of the month, information regarding birthdays and forthcoming trips and information regarding new members of staff. People who live at the home spoke highly of the Providers. One person said Paulette and John, were wonderful. We witnessed interactions that were positive and encouraging between one of the Providers and people in the home. We noticed people who live at the home coming to talk to her. One person threw their arms around Paulette and went off to get some shopping to show her. Another person brought his new trainers for Paulette to see. There was obviously a lot of love for the manager and a lot of care from her. There were no recent examples seen for quality assurance. Feedback forms were present that related to 2008. The Provider explained that they were due to send out feedback forms. There were no clear systems in place to ensure that policies and procedures and documents in the home were continually kept under review. The statement of purpose and service user guide had not been updated for two years and policies and procedures within the office had not been reviewed since 2008. Some policies and Care Homes for Adults (18-65 years) Page 33 of 41 Evidence: procedures were located in the home which were dated 2006. Examples reported on earlier this report indicated that there were no clear systems in place to ensure care plans and risk assessments were kept under regular review. Some recommendations set up the last inspection have also not been met. These have included updating contact details for CQC on key documents, reviewing assessment forms and ensuring staff are provided with moving and handling training. First aid boxes were present and accident records were kept up to date and managed effectively. Records showed that not all staff were up to date with their mandatory training. Evidence of lack of training were seen for first aid, fire safety, moving and handling, food hygiene, protection of vulnerable adults/safeguarding, infection control and dealing with violence and aggressive behaviour. Care Homes for Adults (18-65 years) Page 34 of 41 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 35 of 41 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 5 The registered person must ensure and up to date Service User Guide is available. This would mean that people considering moving into the home are provided with up to date and accurate information regarding the care home. 07/05/2010 2 1 4 The registered person must ensure and up to date Statement of Purpose is available. This would mean that people considering moving into the home are provided with up to date and accurate information regarding the care home. 07/05/2010 3 6 15 The registered person must ensure that the service user plan contains up-to-date information and is kept under review. 07/05/2010 Care Homes for Adults (18-65 years) Page 36 of 41 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will help promote communication and ensure people have their health care needs met effectively. 4 14 16 The registered person must ensure that people are consulted about a programme of activities and provide facilities for recreation and enjoyment. This will ensure that people living in the home have access and are encouraged to engage in appropriate leisure activities. 5 22 22 The registered person must ensure that complaints procedure available to people contains the right contact information for the Care Quality Commission. So people know where to complain to if they are unhappy with the way the home has dealt with complaints 6 23 13 The registered provider 07/05/2010 should ensure systems are in place to enable staff to be aware of the correct action to be taken should an allegation of abuse been made. 07/05/2010 05/08/2010 Care Homes for Adults (18-65 years) Page 37 of 41 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 mean that staff are aware of who to contact and watch the local reporting procedures are. 7 32 18 Staff must have the skills 04/06/2010 and experience necessary to the tasks they are expected to do. This must include mandatory training, a knowledge of the disabilities and conditions of people living in the home, specialist knowledge of common conditions at the home and understanding of physical and verbal aggression and self harm and ways to manage this. This will ensure that staff have the skills and experience necessary to care for people in a safe and appropriate way 8 33 18 Staff must be supplied in sufficient numbers to meet the needs of people living at the home. This will ensure that staff levels do not restrict activities being provided or interaction between staff and people living at the home 06/08/2010 Care Homes for Adults (18-65 years) Page 38 of 41 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 9 35 18 Staff must be provided with suitable induction. This will ensure they have the skills and knowledge to care for people in a safe and appropriate way and understand the needs of people living at the home. 06/08/2010 10 39 24 The registered person 06/08/2010 should ensure that there is a system for reviewing and improving at regular intervals the quality of care provided at the home. This will ensure that people who use the service continued to be happy with the service they receive and any systems used are still effective. 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 7 The registered person should ensure that allowing people choice and flexibility in their life does not impact negatively on their well-being and mental health. The registered person should ensure that people living in the home are encouraged to participate in daily routines to improve engagement. The registered person should look at ways of encouraging people to spend more time with each other during mealtimes. 2 16 3 17 Care Homes for Adults (18-65 years) Page 39 of 41 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 4 20 The registered person should ensure that staff have an understanding and basic knowledge of the medications they administer within the home. The registered person should ensure that staff are up to date with medication training. The registered person should ensure that each medication administration record contained a recent photograph of the person, which will help reduce any medication error. The registered person should ensure that complaints are fully investigated to reduce re-occurrence. The registered person should ensure that the issue raised at inspection is reviewed and dealt with appropriately. The registered person should consider introducing communal areas in the garden to encourage interaction between people living at the home. The registered person should introduce paper hands towels to reduce the spread of infection The registered person should ensure systems are in place to ensure toilets are kept clean at all times. There must be a recent photograph kept of each member of staff working in the home. This will ensure that all recruitment checks have been performed and can provide proof of identity. The registered person should ensure that policies and procedures are reviewed on a regular basis. The registered person should ensure that Tippex is not to use on official documents The registered person should review the way receipts are stored in relation to service users money. 5 6 20 20 7 8 9 22 22 24 10 11 12 30 30 35 13 14 15 40 41 41 Care Homes for Adults (18-65 years) Page 40 of 41 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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