Care Home: Swiss House

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What the care home does well People live in a positive environment where staff has the skills to communicate effectively with them. The staff team has worked in the home for many years. Staff knows each individual and has a very good understanding of their character personality and specialist needs. This enables them to support people who have complex needs and they do this with genuine care and understanding. There is good communication between staff which means people have consistency and continuity. Staff continues to work in an encouraging manner supporting people to maintain their skills. Staff continues to receive specialist training in specific areas related to health care. This has helped them to develop the skills and knowledge to meet individuals changing needs. People continue to benefit from the improvements to their living environment. The adapted bathing facility means they have the specialist equipment needed to support them with personal care. There is improved stimulation from the large plasma screen TV and sensory area in the conservatory. Bedrooms reflect individual tastes and provide a space where people can be private and comfortable. What has improved since the last inspection? Information in care plans and risk assessments has been improved. These are now up to date and accurately reflect the needs and desires of people and show how they will be supported in a safe manner. People have more regular opportunities to engage in activities in the community. This is happening on a more regular basis because there is now additional staff available who can drive the vehicle. This means people can plan their activities knowing that both staff and transport is available to support this. The management of medication has improved. Medication is appropriately labeled and controlled drugs records are up to date. This ensures people have their medications in a safe manner and in the way they are prescribed. Appropriate equipment has been purchased to ensure individuals who require support with their movement are moved safely. Risk assessments reflect the support people need and how to use equipment safely. Essential safety works in respect of the building has been completed for electrical work and servicing of lifting equipment. This ensures people live in a safe environment. On going re decoration ensures that people continue to live in a well maintained and pleasant environment. What the care home could do better: The management of risk is generally satisfactory but some improvements are needed. Risks must be clearly identified and say exactly what staff needs to do to keep the person safe. Monitoring records should provide specific details of what staff is to do. For instance if this is a visual check it should state this. Risk assessments for the use of the hoist should state the sling size to be used. This is to ensure people are moved safely with the appropriate equipment. Individual contracts should include the current rate of fees charged. Staff should explore opportunities for people to participate more fully in the daily running of the home. People have expressed a wish to pursue sensory placements and swimming facilities. This should be pursued. All equipment used in the bathroom should be regularly checked and cleaned. This is to ensure people are not at risk of infection or injury. Ensure provision is made for people to have privacy locks on bedroom and bathroom doors. Staff ratios should be kept under review to ensure they are appropriate to the increased dependency needs of individuals. The monthly provider report should monitor and comment on staff numbers to ensure that the service is actively monitoring this area. The monitoring of hot water outlets must clearly show what action has been taken if the water is too hot. The manager took immediate action to regulate outlets and prevent the risk of scolding. The manager must ensure that this monitoring is robust. Key inspection report Care homes for adults (18-65 years) Name: Address: Swiss House 41-43 Brierley Hill Road Wordsley Stourbridge West Midlands DY8 5SJ     The quality rating for this care home is:   two star good 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: Monica Heaselgrave     Date: 2 0 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 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 34 Information about the care home Name of care home: Address: Swiss House 41-43 Brierley Hill Road Wordsley Stourbridge West Midlands DY8 5SJ 01384573110 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Select Health Care (2006) Limited Name of registered manager (if applicable) Mrs Linda Power Type of registration: Number of places registered: care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 7. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Learning Disability (LD 7) Date of last inspection Brief description of the care home Swiss House is situated in a cul-de-sac off Brierley Hill Road in Wordsley. The home opened in 1993 following the conversion of an existing residential property. Swiss House is close to local facilities and bus routes, allowing easy access to shops and surrounding areas. There are gardens to the front and rear of the property, although the rear patio is mainly used due to the busy road at the front of the house. There is a communal lounge and dining room with a conservatory, which overlooks the rear patio and another house owned by the same owners. There is a lift, which enables access to Care Homes for Adults (18-65 years) Page 4 of 34 Over 65 0 7 2 5 0 3 2 0 0 9 Brief description of the care home the first floor. Accommodation consists of seven bedrooms. There are no ensuite facilities. The Home provides care for persons with a range of disabilities including profound and multiple learning disabilities, severe learning disabilities with complex communication and health care needs, although the building does not always prove suitable in respect of provision of a service to people who require the use of a wheelchair. A statement of purpose and service user guide are available to inform people of their entitlements. The charges for accommodation are not currently stated within these documents. Care Homes for Adults (18-65 years) Page 5 of 34 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: two star good 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: We carried out an unannounced visit to the home which means that the provider did not know that we were coming. The visit was undertaken to establish if the service is run to the best interest of those who live there and offers a good quality and safe service. Prior to the visit we looked at a variety of information. This included things the Service must tell us about such as any accidents or concerns that have taken place. We also looked at the Annual Quality Assurance Assessment that was completed by the manager. This provides up to date information as to how the Service is run and the improvements the service wishes to make. During our visit we tracked the care for two individuals looking at all the documentation in respect of their care. We observed practice and talked to the people who live there as well as the staff and manager. We reviewed a range of other documentation as well as looking around the building. Care Homes for Adults (18-65 years) Page 6 of 34 What the care home does well: What has improved since the last inspection? What they could do better: The management of risk is generally satisfactory but some improvements are needed. Care Homes for Adults (18-65 years) Page 7 of 34 Risks must be clearly identified and say exactly what staff needs to do to keep the person safe. Monitoring records should provide specific details of what staff is to do. For instance if this is a visual check it should state this. Risk assessments for the use of the hoist should state the sling size to be used. This is to ensure people are moved safely with the appropriate equipment. Individual contracts should include the current rate of fees charged. Staff should explore opportunities for people to participate more fully in the daily running of the home. People have expressed a wish to pursue sensory placements and swimming facilities. This should be pursued. All equipment used in the bathroom should be regularly checked and cleaned. This is to ensure people are not at risk of infection or injury. Ensure provision is made for people to have privacy locks on bedroom and bathroom doors. Staff ratios should be kept under review to ensure they are appropriate to the increased dependency needs of individuals. The monthly provider report should monitor and comment on staff numbers to ensure that the service is actively monitoring this area. The monitoring of hot water outlets must clearly show what action has been taken if the water is too hot. The manager took immediate action to regulate outlets and prevent the risk of scolding. The manager must ensure that this monitoring is robust. 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 8 of 34 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 9 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is presented in an easy read style to help people decide if Swiss House is the home for them. People can be confident that a full assessment of their needs will be carried out to ensure the staff and the service can meet their needs in a positive way. Evidence: The home has a Service User Guide that is in pictorial format that would help to inform people who are considering living there. It was positive to see that each person living at Swiss House had a copy of this. It is evident that some people living at Swiss House would have difficulty understanding the contents of such documents but staff showed that they try to support understanding by explaining information to individuals. There has been a positive attempt to inform people who are considering moving into the home of some of the shortfalls of the environment. It was observed that the width of corridors and doorways present difficulties for people who require a wheel chair. People also need to be able to negotiate differing floor levels when moving from one area to another. It is good to see that the service has made efforts to inform people of these considerations Care Homes for Adults (18-65 years) Page 10 of 34 Evidence: in the documents it provides. In the reception and dining area there is lots of information displayed. This is in pictorial format and informs every one of events and other interesting information. There have been no admissions to the home for a number of years. Currently there is one vacancy. The admission process was discussed with the manager and staff and current care reviews were looked at. The needs of the people living at Swiss House have increased and this has an impact on staff availability. In considering these factors it was evident that the service is aware of both the limitations of the environment and the need for a robust assessment of any new referral. This is to ensure each person prior to admission has a full assessment to determine what assistance and care they may need. It is important also to ensure that the needs of the people already living at Swiss House are not compromised. Care Homes for Adults (18-65 years) Page 11 of 34 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. Care plans reflect that people are supported in ways that suit them. Risks are properly assessed although minor improvements would ensure they are fully managed. Further opportunities to experience different things and to take a full part in the daily life of the home are developing and should be expanded so that people can make their own decisions. Evidence: Two people were case tracked. This involves reading their care plan which should cover all aspects of personal and social support. The plan is important in setting out how the current and anticipated needs of people will be met by the Service. The majority of people living at Swiss House have profound communication difficulties. It was very pleasing to see that the care plan clearly identifies their preferred communication methods enabling staff to interpret responses and understand the choices people wish to make. Care Homes for Adults (18-65 years) Page 12 of 34 Evidence: The two plans looked at showed that staff do involve individuals in the planning of their care. For example one person had been supported to explore activities he would like to engage in to include train rides and access to brass band music. Another plan identified food choices for an individual who has specific needs in relation to food. It was positive to see that staff understands the things that are important to individuals and try to promote individual lifestyle choices which affect their quality of life in a positive manner. During the course of the visit it was observed that staff uses communication aids such as photographs and symbols to enable people to exercise their choices. For instance choices for meals and activities were evident in photograph form. The care plans are written in an easy read pictorial format which makes them easier to understand. Where able to the individual and or their family has contributed to this. The service has taken appropriate steps in referring to the occupational therapy team and obtained a suitable chair to allow quick and safe movement of the individual. There are a variety of risk assessments to guide staff in supporting people in a safe manner. This includes what equipment they may need and how it is to be used for instance when some one requires the hoist. However there are some improvements needed to the risk assessment to ensure they are specific and say exactly how the risk is to be minimized. The risk assessment for ingesting materials at night is not specific. It does not say exactly what the night staff is to look for or look at. The monitoring sheet that staff completes following their check on the individual was not completed from the 10th to the 17th January. During this period the individual is either not monitored or staff are not recording this. This could potentially compromise the safety of the individual. Where risks are identified staff must follow the guidelines to ensure the person is safe. It was positive to see that the plan included a profile of the skills and abilities of the person. Tasks people did for themselves included meal choices and undertaking aspects of their personal care. This is important in ensuring people are supported to maintain the skills they have. We saw that care plans included individual goals one person wished to access hydrotherapy swimming in the community. The care plan included information about their health. Some people have complex health needs and it is evident that they receive specialist input and support in managing these. The care plans we saw had been reviewed regularly. Evaluation sheets had been used to identify what aspects of the plan had been achieved or enjoyed. From this new Care Homes for Adults (18-65 years) Page 13 of 34 Evidence: goals had been identified. One of the care plans reflected where decisions about health had been made on behalf of the person and the reasons for this. This ensures that the right for people to make their own decisions is only limited where their capacity prevents them from doing this for themselves. These decisions are made in the best interests of the person so that the risk is positively addressed. Discussion with staff showed that they recently had training in this area so that they understand issues around deprivation of liberty and are aware of the need to follow this guidance. Information taken from the AQAA and resident meeting minutes reflect that people are being encouraged to participate more in the day to day running of the home. They have expressed satisfaction in planning trips and holidays. The Service is intending to hold service user meetings more frequently so that people are able to express their views and influence change. Since our last visit there has been improvement in maintaining up to date care plans. Activities have improved and the system of monitoring these and setting new goals is much clearer. Care Homes for Adults (18-65 years) Page 14 of 34 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have benefited from improved access to social and leisure activities. The availability of both a driver and transport means people get out and about more frequently in line with their preferences. Good arrangements are in place to support people with their nutritional needs. Evidence: The majority of people living at Swiss House have profound communication difficulties. It was very pleasing to see that records clearly identified preferred communication methods used by individuals. Care staff also used their extensive knowledge off individuals to interpret responses which enables them to understand the choices people wish to make. We saw that staff has identified the preferred activities and preferences of people and has recorded these in care plans and activity plans. On the day of our visit the activity Care Homes for Adults (18-65 years) Page 15 of 34 Evidence: plans for people were displayed and were seen to be followed. There are flexible routines to match preferences and provide some structure. People go to bed when they want to and have a staggered start to their day depending on their commitments for that day. On the day we visited one person was having breakfast whilst four people were already up and engaged in their leisure. One person had already gone to day centre. People have access to day care placements and the Service has access to an exercise therapy worker who has commenced one to one sessions. This was observed on the day for two of the individuals who interacted well and clearly enjoyed the activity. At the previous visit it was noted that staffing levels and the lack of drivers affected how frequently people had opportunities to make use off community based activities. Since then the Service has employed additional activity workers who can drive. This has meant that the Service can now engage in both spontaneous and planned community activities. The day prior to our visit people went out shopping where they enjoyed lunch and visited the hairdresser. Discussion with staff and observation of individuals showed that at times the dependency levels of individuals make it difficult to offer outdoor activities every day as everyone requires an escort and a wheelchair. Records show there has been an improvement in outdoor opportunities which benefits the people living at Swiss House. Some days there are less people at home and so staff tries to plan outdoor activities around this. When everyone is at home this is not always possible. The Service should continue to evaluate this area to ensure that people can make choices and that this is not limited to group outings on the days the driver is available. We saw that the provision of a sensory area in the conservatory provided positive stimulation for individuals who on the day also enjoyed a video. The sensory room is curtained off from the dining room which ensures other distractions are limited although noise levels remained the same. Two people actively enjoyed the large plasma T.V. and one showed us the illuminated aquarium in the lounge which he clearly enjoyed. We were told by staff that they explore what people like to do. The house has regular service user meetings and the minutes of these showed people express choices about holidays and trips. One person told us he likes the trips out and enjoys the parties they have. A trip to Skegness is currently being arranged which when asked people said they were looking forward to. The service continues to ensure individuals are able to maintain contact with relatives. Daily records showed when people had visits and Care Homes for Adults (18-65 years) Page 16 of 34 Evidence: telephone calls. During the course of our visit two mealtimes were observed. We saw that pictorial menus were used for people to make their choices. Care plans looked at provided good detail as to how people require assistance when eating their meals. Observations showed staff followed this practice. One individual has specialist nutritional needs and records show that specialist support is in place in setting this guidance. Staff has had specific training to meet these needs. We saw that staff has completed nutritional assessments for each person who may be at risk. Records reflected good monitoring of weight and nutritional intake ensuring the nutritional needs of people are known and understood. It was positive to see that staff supports one person to have tasters of food and from this identify preferences to build upon. Care Homes for Adults (18-65 years) Page 17 of 34 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. Personal support is provided in a way that meets the needs of individuals and is safe. The health needs of people whilst complex are generally well managed. Some improvement is needed in relation to identifying and monitoring risks. People have access to the treatment and health support they need without delays. The management of medication has improved ensuring people receive their medications in a safe way. Evidence: We observed positive communication and interaction with individuals. It was particularly pleasing to see that the chosen communication techniques were recorded in peoples care plans so that staff can understand what the individual is expressing. For instance licking means hungry. Sitting on people means person want contact and clapping hands over hands is contact. In the same way negative expressions are also recorded and understood by staff so that they can identify when someone is in pain or uncomfortable or not happy. This coupled with the very good understanding and knowledge staff have about individuals enables them to support them in a personalized way. Care Homes for Adults (18-65 years) Page 18 of 34 Evidence: Individual plans showed the personal preferences and routines of people which is important when people cannot easily communicate these. It was positive to see the consistency that staff members provide. There are no rigid rules or routines. Observations showed a flexible day and records showed spontaneous activity and meals out when routines are more relaxed. On our visit people had good personal hygiene. Their appearance and clothing was appropriate for their age and gender. Staff accurately told us about the health and personal care needs of individuals and how risks are managed. At the previous visit we had some concerns related to the moving of an individual. At that time it was evident that there was a need to move the person quickly which was in a confined space not suited to the use of a hoist. The transfer of people in this manner can compromise their and staff members safety. The service has taken appropriate steps in referring to the occupational therapy team and obtained a suitable chair to allow quick and safe movement of the individual. There are a variety of risk assessments to guide staff in supporting people in a safe manner. This includes what equipment they may need and how it is to be used for instance when some one requires the hoist. However there are some improvements needed to the risk assessment to ensure they are specific and say exactly how the risk is to be minimized. For instance a risk assessment for ingesting materials at night asks for night staff to monitor. The guidance on the risk assessment is not specific. It does not say exactly what the night staff are to look for or look at. The monitoring sheet that staff completes following their check on the individual was not completed from the 10th to the 17th January. During this period the individual is either not monitored or staff are not recording this. This could potentially compromise the safety of the individual. Where risks are identified staff must follow the guidelines to ensure the person is safe. Risk assessments for the safe use of the hoist should also state the sling size to be used. This is to ensure people are lifted using correctly fitting safety devices. One person recently had a medical concern resulting in treatment from the G.P. Following this staff introduced a monitoring sheet in case of re-occurrence of the problem. The monitoring sheet does not specify what staff is to do. In discussion with staff they informed us this is a visual check. In this case the monitoring sheet should specify this so that there is no confusion or invasive practice. Care Homes for Adults (18-65 years) Page 19 of 34 Evidence: Nutritional needs are assessed and people are regularly weighed. One person has had a weight loss and records showed that the G.P has prescribed supplements and a weight record is maintained. We saw from records that specialists such as the dietician and speech and language therapist have been involved in developing appropriate guidelines to manage nutritional needs of individuals. Training records also showed staff are fully trained in the management of tube feeding and have the support from specialists to ensure best practice is used. Staff has additional training to understand conditions such as epilepsy. Appropriate monitoring is in place and observation on the day showed staff is confident in responding to seizures. Records are kept of visits by health and social care specialists and their advice is incorporated into care plans. Records showed people are supported to attend health care appointments including annual health checks. Dental and sensory checks are up to date. Where there has been a concern about individual capacity to exercise decisions consenting to health treatment a multidisciplinary meeting has taken place. It is at this meeting decisions regarding the best interests of the individual are made. This is to ensure people do not miss out on important treatments because they are unable to understand the implications of doing so. Discussion with staff showed that they have had some training in this area to help them understand Deprivation of Liberty Safeguarding or DOLS as it is commonly known as. Records show that health care plans are regularly revised. Staff said and records showed they had appropriate training in respect of specialist health needs to reflect the changing needs of one individual. A second person is currently being assessed for changing health care needs. Staff has had training in dementia care and was able to describe how they currently manage these needs. They expressed some concern about the staffing levels compromising their ability to offer more one to one support. Indeed on the day of our visit observation showed this individual to require a great deal of support to manage meal times mobilize around the house and engage in activities without distress. The home has had a good record of compliance with medication management and we saw that further improvements had been made that we asked for at our last visit. We checked the small amount of controlled drugs the home handled this was stored appropriately and the drugs tallied with the entries in the CD record. In addition we found original containers with the printed label intact. Previously the label had been removed and placed on the MAR chart. There was no evidence of creams or ear drops without date of opening or frequency of use. We were Care Homes for Adults (18-65 years) Page 20 of 34 Evidence: informed that staff now ensures directions and dates are evident. This ensures safer practice. Staff training records showed all had completed the appropriate training also evidenced by certificates. Additional training was evident for administering medication via a tube feed and this practice was supported with correspondence from the G.P. Staff was observed to administer medication safely. Audits in the home confirmed that checks are carried out to ensure staff follows procedures. A recent external audit by a pharmacist confirmed good practice. Medication reviews had taken place for some people ensuring they have the most appropriate medication their doctor intends. Care Homes for Adults (18-65 years) Page 21 of 34 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person can be confident that any concerns or complaints will be taken seriously and acted upon. They can be confident that there are systems in place and staff have training to ensure they know how to protect people from harm. Evidence: Staff has access to appropriate policies and procedures to guide them in respect of safeguarding adults. A pictorial version of these was also seen in each bedroom so that people living there and their families could access them easily and know what to do if they had any concerns. Staff told us they knew what to do if people had concerns. The care files seen were particularly impressive in identifying how individuals communicate their feelings through non verbal techniques. This is particularly important so that staff can identify when someone is distressed or unhappy and act on it quickly. At the previous visit to the home we had been concerned about how staff moved an individual. This was reported as a safeguarding concern and was looked at by social services. Since that time we have had confirmation that the home worked well with social services to resolve the issue. This led to lifting alternatives being explored which included the purchase of a chair that could be moved quickly should the individual need to be moved safely. From observing the practice and talking to staff at this visit it was positive to see that Care Homes for Adults (18-65 years) Page 22 of 34 Evidence: appropriate lifting techniques are being used and that appropriate lifting equipment is available for this purpose. Two staff files looked at showed that staff had attended training in moving and handling techniques which ensures they know how to move people safely. The manager has identified in the AQAA that all staff will attend training in both complaints and safeguarding. This will ensure they are able to recognize an issue that may have safeguarding elements. Comments from staff spoken with confirmed that all elements of their practice are looked at in their supervision. They are confident that they have the support they need to act in the persons best interests. Care Homes for Adults (18-65 years) Page 23 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the building is homely there are limitations with space. People who have a physical disability do not have independent clear access to all the facilities. Evidence: The layout of the home presents some challenges in respect of meeting the needs of the current people living there. The front of the house is on a slope and we were informed by staff that they use the rear door as it is easier to negotiate wheelchairs. The rear door also has a raised door frame so chairs still have to be tilted to enter or exit. The width of the doorway is sufficient to wheel the chair through without causing damage to peoples arms but there is not much room to turn into the ramp on exit. The lounge area is cosy and well furnished. It has been thoughtfully furnished to ensure the best use of space. This included a large flat screen TV and illuminated fish tank for people to enjoy. The seating was observed to be comfortably used by the people living there. Five of the people were present and from observations it was evident that some people have restricted mobility. People cannot freely access all areas of the house without the risk of injuring themselves. This is due mainly to the narrowness of corridors and the differing floor levels they need to negotiate. Staff members ensure Care Homes for Adults (18-65 years) Page 24 of 34 Evidence: people move around safely with support and supervision. All of the people who have a first floor bedroom rely on staff to access their bedrooms because they have to use the passenger lift. This potentially limits their independence. The bedrooms were viewed and although some are small it was evident staff had tried to utilize the larger ones for those people who require aids and wheelchairs. All of the bedrooms had an individual style and it was evident staff have supported people to have their own possessions around them. One person told us he liked his bedroom. There were no locks on bedroom or bathroom doors. Staff said no one would use these. This needs to be addressed as an issue of choice and privacy and recorded in peoples care plans. The upstairs toilets are not large enough for use by a person with a physical disability and the upstairs bathroom has a domestic bath so no hoist equipment can be used to assist people. This does limit the choice people have. However we were told two people can use these facilities with support. The ground floor bathroom is spacious and equipped with a mechanical bath. The hoist equipment is used in this area to assist people. There are sufficient aids in this area for people to have their personal care met safely. There is a conservatory which has been fitted with sensory equipment. Five of the people were observed to be enjoying this with a curtain used to screen it off from the dining room. This lessons the distraction although the noise level is not diminished. We saw that the building was reasonably decorated and homely. Outside facilities could be better. The garden to the rear is small but has a barbeque area. The garden to the front is large but not private. The driveway to the rear is shared by another home. People cannot access these areas independently which restricts their independence. We checked the servicing records for equipment used in the home. At our previous visit there was no current and up to date evidence of the servicing of hoists. At this visit it was seen that these had been serviced as required. We saw that there continues to be a good effort to maintain and improve the physical environment for the people who live at Swiss House. Some areas have been redecorated. People have benefited from the adapted bathing facility. We saw that the home was clean and has appropriate infection control procedures in place. We saw that the home has a washing machine with sluice cycle. Staff was observed using protective wear for tasks and we saw equipment was appropriately stored. There was no unpleasant odour and the house was warm. Care Homes for Adults (18-65 years) Page 25 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by a staff team who are consistent in their approach and well informed of individuals needs. Sufficient staff numbers are not always evident to allow the service to meet the increased needs of individuals and ensure the diverse needs of all the people are met. Evidence: People living in Swiss House benefit from being supported by an established group of staff some of whom they have known for many years. Continuity of care is of particular significance to the people who live at Swiss House. Previous reports have shown that staff shows a good understanding of the people in their care and that they are sensitive to the importance of individual routines and understand individual styles of communication. Direct observations of staff interacting with individuals confirm this. Staff talked with confidence about the support people need which was consistent with information in individual care plans. Since the last visit the service has recruited a driver for twenty hours a week. Staff said this has greatly increased opportunities for people to access the community. Staff expressed concern about the increased level of dependency of one individual. This was evident in the persons care file and from observations made on the day. It was stated that although three staff are generally on a shift and that this met the immediate safety and physical needs of people it did not Care Homes for Adults (18-65 years) Page 26 of 34 Evidence: allow for appropriate one to one time or stimulation people needed. This was demonstrated on the day when staff was involved in both preparing lunch and in the morning domestic duties leaving one staff to five people one of whom required constant prompts to eat. The staff rotas for the previous month showed that although shifts are covered by three staff these often finish or start at staggered times so that there is not a full shift of three for the duration. Two mealtimes were observed on the day. Care staff undertakes the preparation and cooking of these which further impacts on staff availability. The weekly activity planner was looked at this showed that on occasions there can be five people at home during the day. It can be difficult to offer the one to one support individuals need to engage in activities. It was positive to see that an external fitness worker is utilized for some people who enjoyed the keep fit session in the house. Staff also utilized the conservatory so that some of the people could watch a video. It was evident that staff work hard to motivate people with interesting activities but one person could have benefited from one to one away from the main group. Sampling of staff files confirmed that appropriate recruitment and selection procedures are carried out prior to people working within the service this ensures people are protected from unsuitable staff being recruited. To ensure that people are supported by a qualified staff team at least 50 per cent of staff should achieve an NVQ in care. Information received in the Annual Quality Assurance Assessment confirmed that the staff team members have achieved this qualification. The home has a rolling program of training so that staff has access to regular sessions and updates to assist them to care for the people who live there. Specialist training has been undertaken to meet with the changing needs of individuals this has included dementia care being sourced and PEJ training to support the nutritional needs of an individual. Staff have also utilized computer based refresher training to keep them up to date with new developments. Whilst the service has made improvements to benefit the people who live at Swiss house the number of staff on duty is not always sufficient to ensure that the individual needs of people are consistently met. Care Homes for Adults (18-65 years) Page 27 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been continued improvements that benefit people at Swiss House. The manager is improving and developing systems that monitor practice but the outcome of these needs to be more robust to ensure safe working practices. Evidence: The manager of the home has in excess of twenty years experience in social care. She holds an NVQ level 4 in care and has attained an Assessors Award. Discussion with her shows she continues to update her professional qualifications including management so that she has the expertise to run the home. From this visit and the information given in the Annual Quality Assurance Assessment we can concluded that the manager has improved practices to ensure the home is run in the interest of those living there. Staff spoke positively of the manager and stated that she is approachable and strives to improve the standards of this service. We have been told that support from her line manager who is external to the home is consistent. Care Homes for Adults (18-65 years) Page 28 of 34 Evidence: The manager works alongside care staff and we observed that communication between her and her team is good. She is supported by two senior staff. The senior staff carry out varies audits to ensure such systems as medication and health and safety are monitored closely to ensure good practice. We saw written records to confirm this. However as reported under the environment part of this report staff must be more vigilant in their monitoring. The water temperature records seen showed that temperatures had fluctuated for some months. Staff had not recorded in the comments section what steps they were to take to rectify this and no action had been taken until the day we visited. This could compromise the safety of people in the home. This raises questions as to whether staff are fully aware of identifying concerns and how to report them on. We were told that improvements had taken place in the frequency of staff supervision which for some is every two months. A supervision planner was available to show this. The service should continue to improve the frequency of staff meetings. Staff said these are currently four times a year which is below the recommended minimum level of six times a year. Staff also told us these meetings were useful to share information. There is also a monthly meeting with the area manager, when the unannounced visit to the service in undertaken. The area manager writes a report and this is discussed with the manager and any changes required are actioned. Six reports for these visits indicated that at times only two staff was recorded as being on duty. There was no explanation as to whether this was in line with the needs of the people in the house or why staffing levels were below the minimum of three. Also the manager and staff have raised concerns about staffing levels in light of the changing dependency levels. The monthly visits should give an accurate overview of how the service is operating this will enable them to highlight shortfalls. The service has a quality assurance monitoring system and documentation for this was seen. The service has identified changes needed to improve the service based on feedback from individuals and their representatives. We saw that improvements made since we last visited have had positive outcomes for the people who live at Swiss House. They now have a driver on shift which has improved peoples access to outdoor activities. This is particularly important where people due to limited mobility require transport to access their community. There have also been improvements in the environment to include ongoing redecoration and maintenance. The manager has addressed the health and safety concerns highlighted at the last inspection visit. It is evident that the daily running of the home has improved. Care Homes for Adults (18-65 years) Page 29 of 34 Evidence: There is a system to ensure that repairs are carried out promptly and that the environment is safe and fit to live in. The home has a maintenance record which shows that repairs are picked up and managed. Certificates for the maintenance of equipment such as lifting equipment and fire equipment are up to date. This ensures that they are safe and suitable for use. Care Homes for Adults (18-65 years) Page 30 of 34 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 31 of 34 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 19 13 The registered manager must ensure risk assessments are specific in their guidance. They must say exactly what staff must do to eliminate the risk. Monitoring records relating to known risks must be consistently filled in. This is to ensure the management and monitoring of risks is robust and protects people from harm. 24/03/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 2 13 Ensure that the current rate of fees charged is recorded on peoples individual contracts. To continue to explore specialist community activities such as sensory placements and swimming where people have expressed a wish to pursue these. To provide individuals with keys to their bedrooms where it Page 32 of 34 3 16 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations is their wish to have these. 4 18 Risk assessments for the use of the hoist should state the sling size to be used. This is to ensure people are moved safely with the appropriate equipment. Make necessary arrangements to include on individual risk assessments for privately owned mechanical beds the date of service. This is to ensure people are not at risk of injury from faulty equipment. Staff ratios should be kept under review to ensure they are appropriate to meet the increased dependency needs of individuals. The monthly provider report should monitor and comment on staff numbers to ensure the service is actively monitoring this area. The care manager should complete the management qualification. This is to ensure she has the necessary management expertise for the continued management of the home. Testing of water outlets must be recorded and clearly show what action has been taken to ensure safe water temperatures and prevent the risk of scolding. 5 29 6 33 7 37 8 42 Care Homes for Adults (18-65 years) Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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