Care Home: The Gardens Nursing Home

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What the care home does well The home provides a good quality of personal care and health care. There is good relationship between the staff and the people who live in the home. The staff are aware of each person`s individual needs and preferences, and they support them to make appropriate choices and decisions about their lives in the home. Almost everyone who we spoke to said that they are happy in the home. All the staff who we spoke to were enthusiastic about their work. They said that the training is very good, and provides them with the specialised information and skills that they need. The home has good procedures for quality assurance, that includes regular surveys of the people who live in the home and their relatives, with a report of the results. What has improved since the last inspection? The care plans that we saw showed an improvement in how they involve people in making decisions about their lives in the home, and in recording their wishes and choices in a person centred way. However this improvement was not consistent, and there is room for further improvement. Everyone in the home is supported as far as possible to take part in their choice of social and community activities. The activity co-ordinators try to build activities around what each person likes, and whether they prefer one to one or group activities. The care staff have a `5 minute pledge` where every member of staff is encouraged to spend at least 5 minutes for each resident on each shift doing something the resident likes. This has enabled the care staff to change and improve their approach to integrating activities into daily life. What the care home could do better: The information provided before the person moves into the home includes information and assessments from other services, including social worker, their previous placement or hospital. However this information is not always taken account of when planning the person`s care. This means that the staff do not always have accurate information so that they can meet each person`s assessed needs appropriately. The staff do not always follow each person`s care plan, particularly with regard to personal preferences for how they receive their care. We found some discrepancies in the recording of medication. The home does not have a robust procedure for auditing medication so that errors are recognised and corrected without delay. Antibiotics prescribed for one person may be given to another person at the request of the home`s GP. This procedure is contrary to professional codes of practice and to the Royal Pharmaceutical Society guidelines for administration of medication. All staff have training in the Mental Capacity Act (MCA) and Deprivation of Liberty Standards (DOLS). However in some cases actions were taken that should have been referred for a DOLS assessment.The home has good procedures for quality assurance, but the proprietor does not make regular monthly monitoring visits to the home, so that they can monitor and take actions to improve the quality of life for the people who live in the home. Key inspection report Care homes for adults (18-65 years) Name: Address: The Gardens Nursing Home High Wych Road Sawbridgeworth Hertfordshire CM21 0HH     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: Claire Farrier     Date: 0 3 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 35 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 35 Information about the care home Name of care home: Address: The Gardens Nursing Home High Wych Road Sawbridgeworth Hertfordshire CM21 0HH 01279600201 01279721297 janet.usedon@ramsayhealth.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ramsay Health Care UK Operations Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 54 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: Date of last inspection Brief description of the care home The Gardens is a care home with nursing, providing accommodation and care for 54 adults with a neurological disorders and physical disabilities as a result of acquired brain injuries. It is owned by Ramsay Healthcare Ltd, which is a private company. The home was opened in January 1992 and consists of a two-storey purpose built building. It is situated in a complex of Ramsay Neurological services that includes a private hospital, The Rivers, and another home, The Jacob Centre. Care Homes for Adults (18-65 years) Page 4 of 35 Over 65 2 54 54 0 54 54 2 8 1 1 2 0 0 8 Brief description of the care home The home is located in a rural setting on the outskirts of Sawbridgeworth, not far from the outskirts of Harlow. There is a shop for the residents of The Gardens and The Jacob Centre, situated in The Jacob Centre, and a pub that also serves food across the road from the Ramsay complex. Other community amenities, including shops, banks, cafes and leisure facilities, can only be accessed by use of the homes transport. Most of the bedrooms are single with en-suite facilities. There are three double bedrooms. There is a passenger lift. The home has a patio garden accessed from the ground floor dining room. The home is fully accessible for the residents. The Statement of Purpose and Service Users Guide provide information about the home for referring professionals and prospective clients. The current charges range from £1025 to £2000 per week. Care Homes for Adults (18-65 years) Page 5 of 35 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: We carried out this unannounced inspection over three days. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We talked to as many people who live in the home as we could, and we also met some visiting relatives. We talked to some of the staff and the manager and we looked around the home. We looked at some of the records kept in the home. We also looked at a sample of care plans so that we could see how people are involved in planning their own care and support. We discussed what we saw during the inspection with the manager. The home sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CQC before the inspection, and their assessment of what the service does in each area. The AQAA is a self-assessment that focuses on how well outcomes Care Homes for Adults (18-65 years) Page 6 of 35 are being met for people who live in the home. It also gave us some numerical information about the service. Evidence from the AQAA has been included in this report. Care Homes for Adults (18-65 years) Page 7 of 35 What the care home does well: What has improved since the last inspection? What they could do better: The information provided before the person moves into the home includes information and assessments from other services, including social worker, their previous placement or hospital. However this information is not always taken account of when planning the persons care. This means that the staff do not always have accurate information so that they can meet each persons assessed needs appropriately. The staff do not always follow each persons care plan, particularly with regard to personal preferences for how they receive their care. We found some discrepancies in the recording of medication. The home does not have a robust procedure for auditing medication so that errors are recognised and corrected without delay. Antibiotics prescribed for one person may be given to another person at the request of the homes GP. This procedure is contrary to professional codes of practice and to the Royal Pharmaceutical Society guidelines for administration of medication. All staff have training in the Mental Capacity Act (MCA) and Deprivation of Liberty Standards (DOLS). However in some cases actions were taken that should have been referred for a DOLS assessment. Care Homes for Adults (18-65 years) Page 8 of 35 The home has good procedures for quality assurance, but the proprietor does not make regular monthly monitoring visits to the home, so that they can monitor and take actions to improve the quality of life for the people who live in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 35 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 35 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 home has access to appropriate services and training to enable the staff to meet the needs of the people who live in the home. However some of the information on peoples needs is inaccurate, which means that the person may not receive the support that they need. Evidence: The Statement of Purpose and Service Users Guide provide information on the services that are available at The Gardens. Information is also on the Ramsay Healthcare website www.ramsayhealth.co.uk. On the website the page on Our Specialist Rehab Services states, The young persons unit based at the Gardens Neuro Unit is geared to meet the specialist needs of young adults ranging from 18-35 years of age onwards. In addition to the highly specialised care we have a designated clinical nurse lead whose interest is in younger people with learning difficulties. But learning disability is not included in the homes printed Statement of Purpose and Service Users Guide as a service that is provided. We looked at the care plans for six people to check that they contain accurate Care Homes for Adults (18-65 years) Page 11 of 35 Evidence: information on their assessed needs. The Annual Quality Assurance Assessment (AQAA) states, We undertake thorough, holistic pre-placement assessments by gathering written information from all parties involved, visiting the prospective resident and assessing them in person. They are designed to provide information on which to judge the suitability of the placement and to ensure teams are able to prepare appropriately for admission. On each persons admission documents that we looked at there was a comprehensive medical history together with basic information about the patterns of peoples lives, and any specific needs that they may have relating to their culture and personal preferences. The information provided before the person moves into the home includes information and assessments from other services, including social worker, their previous placement or hospital. However the front sheet in one care plan states that the person has a learning disability, but the assessment from their social worker states that they do not have a learning disability and they have capacity to make decisions. The staff who we spoke to were not aware of this. The main care plan contains appropriate information on this persons needs. But this inaccuracy implies that previous information was not taken into account in their assessment. The AQAA stated that before admission steps are taken to ensure that any specialist and individual equipment that may be required is in place, and training and guidance is provided for complex needs where appropriate. A respiratory unit is in development at the centre, and before residents were admitted staff underwent training in the care of residents with tracheotomies. Staffing levels are assessed to meet the needs of the current residents, and take into account individual needs for one to one or two to one care. Training is provided to meet specialist needs including neuro skills. The staff who we spoke to said that they have sufficient information and training so that they can provide the care and support that each person needs. The AQAA gave an example of good practice in showing that they meet the needs of the people who live in the home. A resident was discharged to another care home. They were readmitted at the request of the family as they felt that the person had deteriorated since the discharge and that The Gardens better suited their needs. Care Homes for Adults (18-65 years) Page 12 of 35 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal choices about how they would like their care to be delivered are not always documented clearly so they cannot be sure to receive consistent care and support. Evidence: We looked in detail at a total of six care plans, three on each floor. The care plans have improved since the last inspection, and most are written in a person centred style that shows the involvement of each person. The Annual Quality Assurance Assessment (AQAA) stated, In the last 12 months we have re-developed our care planning and risk management documentation to ensure it is based on up to date evidence and best practice, as user friendly as possible and reflects the balance of medical and social care models that is appropriate for our client group. We have introduced a new all about me booklet that provides a pen profile of the resident including their needs, choices, aspirations, background, family, hobbies, interests, skills, etc. This is part of our work on maximising person centred care. We saw some good examples of the person centred style. For example, on communication for one Care Homes for Adults (18-65 years) Page 13 of 35 Evidence: person, Talk to me, please, Wait for my answer please. Give time for me to write sentence. And for personal hygiene, Id like to be encouraged to hold the shower with assistance and to wash myself independently. However for another person the care plan for communication stated, Works with SALT (speech and language therapist) to improve communication skills. But there are no further details of the persons needs for effective communication. However daily recording is often still task oriented, for example, Oral care with no other details, for a person who has a goal of cleaning their teeth as often as possible. Where people have set their own goals, they are not monitored through the monthly reviews, and there is no evidence that people who have set their own goals are involved in monitoring them. The reviews that we saw were written in the third person, and although giving the views of the person concerned, had no indication that they were fully involved in the review. The AQAA stated, Residents are encouraged and facilitated to make their own decisions wherever possible. This includes respecting the right to make decisions and choices that others may consider to be unwise. Mental capacity assessments are undertaken as appropriate and views of advocates, relatives, staff, professionals sought where the resident is assessed as lacking capacity for that particular decision necessitating a best interests decision. We saw evidence that Mental Capacity Act (MCA) assessments are made to assess whether people have capacity to make decisions. The AQAA gave one example of this, A young resident was assessed for capacity in the decision making process regarding a transfer to another care setting, although this was their parents request we as a provider needed to ensure that the move would be in the best interest of the resident. In one care plan we saw a MCA assessment that was carried out by the physiotherapist, due to the persons history of taking off the seat belt on their wheelchair, resulting in a risk of falls. The assessment was that the person does not have capacity, as they are unable to retain and weigh up the factors to make a decision. The decision was therefore made on the grounds of best interest, to provide a pin release seat belt that the person could not release. However this could be a deprivation of of the persons liberty, by physically restraining them. But there was no referral for a DOLS (Deprivation of Liberty Safeguards) assessment in accordance with the MCA. The organisation has a philosophy that promotes equality and diversity in the care home. The AQAA stated, We promote anti-discriminatory practice in all aspects of our work with residents, relatives and staff through policy, guidance, training & development. We promote and support individuality and the freedom to be who you are and achieve whatever you can/want. This applies to residents, relatives, staff, Care Homes for Adults (18-65 years) Page 14 of 35 Evidence: visitors and external stakeholders. The care plans and All About Me booklets contain details of each persons cultural needs. Care Homes for Adults (18-65 years) Page 15 of 35 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. The people who live in the home are supported to live full and active lifestyles. Evidence: The homes action plan following the last key inspection stated that an additional activity co-ordinator had been employed who works alternate Saturdays. There were also plans to build into the budget a further 15 hours for out of hours activities. However it was recognised that due to difficulties in recruitment, it may take some time to find the right candidate. The Annual Quality Assurance Assessment (AQAA) that the manager completed before this inspection stated that there are currently plans to look at the feasibility of extending the activities team to cover more of the out of hours service. We met the two activities organisers, who described how they ensure that everyone in the home is supported as far as possible to take part in their choice of social and Care Homes for Adults (18-65 years) Page 16 of 35 Evidence: community activities. They try to build activities around what each person likes, and whether they prefer one to one or group activities. One to one activities may be art and craft, reading the newspaper, manicure etc. The care staff have a 5 minute pledge where every member of staff is encouraged to spend at least 5 minutes for each resident on each shift doing something the resident likes. This has enabled the care staff to change and improve their approach to integrating activities into daily life. The AQAA stated, All of our residents, including those with profound disabilities, are assisted to spend time in communal areas, gardens and the community wherever possible. It is rare that someone is bed bound and this will normally be only for a period of time e.g. due to illness. Residents are facilitated to participate in as many activities as possible and in accordance with their individual preferences and aspirations. We spoke to some visiting relatives, who said that there were no activities taking place, and people watch TV too much. But the evidence that we saw during our time in the home shows that one to one activities may not be apparent to visitors. We saw the activities profile and attendance sheet for the six people whose care we tracked. The activities profiles show each persons hobbies, interests and activities, and whether they prefer one to one or group activities. The attendance sheets show attendance at very few activities, and care staff should be encouraged to record their 5 minute pledge time, both as evidence that this takes place, and to confirm for themselves that they are providing good inclusive care for the people in the home. During our visits to the home we observed a quiz, a birthday party, and people being supported by staff to decorate a Christmas tree. On first floor one person said that they wanted to go out, and a care worker took her as a 5 minute pledge activity. The people who we spoke to all said that they know about the activities, and can choose whether to take part or not. One person chooses not to take part in group activities, and this is noted in their activity planner, with a record of activities that they have been told about, and declined. Another person enjoys the group activities, and said that they especially enjoy flower arranging and the regular quizzes. The Council mobile library visits the home every 3 weeks, and there is a church service once a month, and a visit from an outside entertainer once a month. This year the staff of The Gardens and The Jacob Centre (the sister home on the same site) put on a pantomime, which both the staff and residents who we spoke to were greatly looking forward to. There is a party or family event approx every three months. At Easter and during the summer there is a whole day of activities that include families, with activities for visiting children. There are two minibuses shared by the two homes, both suitable for wheelchairs, with a dedicated driver. There is one scheduled outing each week, for example to Southend, the zoo, ice skating, riverboat trips. There are other informal outings, for shopping or to local facilities. Care Homes for Adults (18-65 years) Page 17 of 35 Evidence: Everyone who we spoke to had no complaints about the food in the home. We observed lunch on the first day of this inspection. It looked appetising, and the people we spoke to said that it tasted good. The care staff gave good one to one assistance where it was needed, with a chatty approach, saying what each spoonful was so that the person knew what they were eating. People were given choices, for example, Do you want this drink, or do you want a hot drink? Tea or coffee? Two sugars? Care Homes for Adults (18-65 years) Page 18 of 35 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The practice of administering medication to people for whom it has not been prescribed and suppled is contrary to the Royal Pharmaceutical Society guidelines and the NMC Code of Practice. The health of people in the home may be put at risk from this malpractice. Evidence: The Gardens provides care for people with a high level of need including tracheotomy care and PEG feeding. There are four trained nurses on duty throughout the day and three at night. Among the facilities provided for people living at the home are a physiotherapy gym and a team of physiotherapists. A specialist wheelchair seating service from Stanmore Hospital visits weekly to provide assessment, reassessments and individualised seating systems. The Annual Quality Assurance Assessment (AQQA) stated, We provide individualised programmes of care, therapy and support based on residents needs, wishes, preferences and aspirations. Individual routines are flexed on a day to day basis according to the needs and wishes of the resident. The teams adapt their schedules to accommodate both the normal and ad hoc needs and preferences of individuals. Care Homes for Adults (18-65 years) Page 19 of 35 Evidence: Choices such as what to wear and how to style hair belong to the resident and staff support them accordingly, without imposing of their own preferences or those of family members. The care plans that we saw provide details of each persons personal care needs, and their preferences for the support that they need. Most of the people we spoke to said that the staff provide good personal and nursing care, and that they are confident that they can meet their needs. However one person has a preference for a female care worker, and this is clearly stated on their care plan. But on several occasions a male care worker has been allocated to provide intimate personal care. The Gardens has a GP who visits the service twice a day, provides 24 hour on call cover and has a practice registered at the centre specifically for The Gardens and the adjoining Ramsay Healthcare service, The Jacob Centre. A consultant in neuro rehab visits the home twice a week. We spoke to the GP during the inspection. He said that this system works well for the benefit of the residents. He has a good relationship and communication with the nursing staff and with the visiting consultant, and he has confidence in the abilities of the nursing staff. However the residents at these homes have no choice of GP and cannot change GP if they wish to. The GP said that he is available at all times if needed, and if he should be away a locum GP is available. The GP told us that on occasions he may prescribe antibiotics over the phone. He said that a stock of antibiotics is kept in names of specific residents, and that he may request that these are given to another person for practical reasons. We saw no evidence of this practice during our visit. However one of the nurses confirmed that this practice may take place, and they showed us a stock of antibiotics that may be used for other people if instructed by the GP. The label would be changed by hand, and the medication would be disposed of when the persons own supply was received from the pharmacy. The manager was not aware of this practice, and said that it there should be no practical reasons, as any prescriptions can be collected from the local pharmacist when needed and without delay. This is confirmed in the Annual Quality Assurance Assessment (AQAA): We have also established a swift service from our pharmacy so if the GP prescribes something or amends an existing prescription it can usually be implemented on the same day. However it is a concern that both the GP and a registered nurse described a malpractice that is contrary to their professional codes of practice and to the Royal Pharmaceutical Society guidelines. We made a spot check of medication on the ground floor. The storage facilities are very cluttered, and some medication, including rectal diazepam, was not in a locked cupboard. We were not able to fully reconcile the stock of medication with the records of what was administered. In some cases the date when the package was opened was Care Homes for Adults (18-65 years) Page 20 of 35 Evidence: not recorded, and in others the date was recorded, but not the time. One person has a prescription for Baclofen, 2 tablets four times a day. The box contained 43 tablets, and there was no record that any tablets had been disposed of or wasted. The MAR (medication administration record) chart does not record how many tablets were given on each occasion, and the odd number of tablets remaining indicate the possibility that only one tablet was administered on one or more than one occasion. Several people have prescriptions for Ad Cal, which is supplied in boxes containing four tubes. The boxes are labelled with the persons name and prescription details, but the individual tubes have no label. This means that it is difficult for the nurses who administer medication to be certain that each person is receiving their own medication, and it also impedes the accurate audit of medication. The Clinical Services Manager told us that medication is audited every two months, but the audit does not include reconciling the stocks with the administration records to ensure that medication has been administered correctly. She said that she also carries out a random monthly spot check that includes reconciliation, but this has not found the errors that we found during our visit, including poor practice in recording how many tablets are given and poor practice in recording opening dates. Care Homes for Adults (18-65 years) Page 21 of 35 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. The home has good procedures for responding to complaints and for safeguarding people from the risk of abuse. But the procedures are not followed consistently, and some people are not confident that their concerns will be addressed. Evidence: The Annual Quality Assurance Assessment (AQAA) stated, We listen and respond positively to concerns and complaints, using them as one of our seeds for positive change. The service ethos includes good customer care and positive handling of complaints and suggestions. The benefits of acknowledging, addressing and learning from mistakes are recognised, as are the benefits of resolving any misunderstanding/misperception. To this end, our standard practice is that complaints are listened to, acknowledged, investigated and responded to sensitively, positively and in a timely fashion. The complaints record shows seven complaints received by the home in the past twelve months. Three became safeguarding referrals, and the others were dealt with and responded to appropriately. A response letter from one complainant stated, The few concerns we had before have been satisfactorily dealt with and the communication was perfect. The homes resident satisfaction survey for 2009 showed improvement in the number of people who were aware of the comments and complaints process, and who were satisfied with the response to their complaints. However we spoke to two visiting relatives who said that they still feel that their concerns are not listened to. One said that they have made a written complaint, but the manager said that she had not received the letter. Care Homes for Adults (18-65 years) Page 22 of 35 Evidence: There have been three safeguarding referrals and investigations during the last year, and appropriate actions were taken in all cases. Induction training for new staff includes training on the Mental Capacity Act (MCA) and the Deprivation of Liberty Standards (DOLS). Existing staff have e-learning so that they understand the necessity of assessing peoples capacity to make decisions about all aspects of their lives. The Service Users Guide states, The Gardens is committed to ensuring the safety and wellbeing of all residents...In accordance with the Mental Capacity Act 2005 staff will seek formal authorisation under the Mental Capacity Act 2005 deprivation of liberty safeguards if it is in the residents best interests to deprive them of their liberty. However one person had a MCA assessment that showed that they did not have capacity to take a decision about the use of a pin release seat belt on their wheelchair, to prevent them from standing and risking a fall. (See Individual Needs and Choices.) This should have been subject to a DOLS referral for deprivation of liberty. Another person had a risk assessment for the risk of falls, with action taken to move their seat belt so that they cant undo it. There was no MCA assessment of their capacity to agree to this action, and no consideration of a DOLS referral. Care Homes for Adults (18-65 years) Page 23 of 35 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. The home provides a comfortable and well maintained environment for the people who live there, and the staff maintain a good standard of cleanliness and hygiene. Evidence: The Gardens is a purpose built home for people with physical disabilities. It is fully accessible for the residents, and there are adequate aids and equipment for their needs, including a physiotherapy treatment room. The Annual Quality Assurance Assessment (AQAA) stated, Electric profiling beds are provided, which include a handset that residents can operate to adjust their position. Pressure relieving mattresses are provided for the majority of residents in accordance with their needs. Numerous good quality hoists are provided. Bathrooms facilities include shower with thermostatic controls, lever handles, and with adjustable height head, suitable for those standing or seated. The AQAA also commented, The 2009 satisfaction survey shows us that there is still some dissatisfaction, mainly around flooring (carpets). This is being addressed with an ongoing programme to replace all floor coverings within the Gardens. The home appeared to be clean and well maintained, and appropriate policies and procedures are in place for the maintenance of hygiene and control of infection. The laundry is used for washing the personal clothing of the residents of both The Gardens Care Homes for Adults (18-65 years) Page 24 of 35 Evidence: and The Jacob Centre, and towels and bedding provided by the service are laundered off site. The laundry meets the standards for control of hygiene. In house infection control teams are responsible for implementing processes and ensuring protocols are being followed in practice around the home. Care Homes for Adults (18-65 years) Page 25 of 35 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home are supported by a stable staff team who have the experience and training to understand and meet their needs. Evidence: Copies of staff rotas and discussion with staff members confirmed the staffing levels for the home. Staffing ratios are assessed according to dependency needs, to take account of people who need one to one or two to one assistance. The rotas show two registered nurses on each floor per shift, and six or seven care workers. There are always two trained nurses on each floor during daytime and three in the building at night times. The homes resident satisfaction survey indicated that overall people were happy with the staff skills and approach. All the members of staff who we spoke to were enthusiastic about their work and feel well supported by their colleagues and the management. They said that the training is very good, and provides them with the specialised information and skills that they need. Half of the care staff have an NVQ qualification at level 2 or above. The Annual Quality Assurance Assessment (AQAA) stated, We introduced NVQ workshops to enhance the support of candidates working towards an NVQ qualification We have increased the number of senior care and therapy assistant positions to further recognise and retain individuals with NVQ qualifications and appropriate skills. We Care Homes for Adults (18-65 years) Page 26 of 35 Evidence: have implemented a new system to enhance the support of individuals working through their common induction standards. There is a thorough recruitment procedure in place, that includes taking up references and CRB (Criminal Record Bureau) disclosures in order to ensure that the staff recruited are fit to work with vulnerable people. Care Homes for Adults (18-65 years) Page 27 of 35 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. The views of the residents and other involved people are actively sought in order to ensure that a good quality of care is provided. However the management structure does not clearly define areas of responsibility, which may result in a poor quality of care for the people who live in the home. Evidence: The manager is a RGN (Registered General Nurse), and she has a Certificate in Management Studies, which is equivalent to NVQ level IV in management. She had several years experience in community nursing and rehabilitation before being appointed to manage The Gardens in 2004. The Annual Quality Assurance Assessment (AQAA) stated, The organisational culture is actively shared at all levels through The Ramsay Way and includes commitments to quality of service, continuous improvement, recognising and valuing our teams. A new management structure of both The Gardens and The Jacob Centre is being introduced, with one Clinical Lead across both services. She will be answerable to both service managers, but line managed by Ramsays national Clinical Lead. She will be responsible for all clinical practice, assessments and admissions in both homes, with a Clinical Manager for each Care Homes for Adults (18-65 years) Page 28 of 35 Evidence: service and three team leaders in The Gardens. This structure is intended to provide more consistency of care practices across the units and services. However the management structure does not clearly define areas of responsibility and accountability between the Clinical Lead and the Service Managers. The Clinical Lead told us that she is responsible for clinical practice, and the service manager is responsible for staffing issues. However the Registered Manager has responsibility under the Care Homes Regulations for all care provided in the home. If the Clinical Lead is not accountable to the Service Manager, there may be conflicts with this line of responsibility. During this inspection the registered manager was not aware of some of the issues that arose during this inspection, particularly with regard to administration of medication (see Personal and Healthcare Support), which may be due to this lack of clarity of areas of responsibility. The organisation has good procedures for monitoring the quality of care in the home, including regular audits and annual questionnaires to people who live in the home and their relatives. The report of the Resident Satisfaction Survey for 2009 shows improvement in all areas from the previous year, with analysis and comments on all the findings. However a lower number of surveys were returned. 84 were satisfied overall, and 5 not satisfied, compared with 67 satisfied and 19 not satisfied the previous year. 84 (compared to 40 last year) know who their key worker is. However the organisation is not carrying out regular quality monitoring visits to the home. The last visit was in October 2009, but there was no report of the visit. The last available report of a quality monitoring visit was for April 2008. All the staff have training in moving and handling, fire safety, food hygiene and infection control as part of their induction. The home maintains appropriate records for the health and safety of the residents and staff in the home. Care Homes for Adults (18-65 years) Page 29 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 12(2) & (3) People must be enabled to 03/08/2009 provide a realistic input into their care plans, for example by setting their own targets and monitoring their own progress. Previous timescale of 30/04/08 met in part. 2 22 22 You must ensure that people 03/08/2010 living at the home and their families and representatives are able to raise any concerns or complaints they may have and be confident they will be acted upon. This is to ensure people living at the home can be confident they are listened to and have their concerns taken seriously. Care Homes for Adults (18-65 years) Page 30 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 14 Assessments must take account of all the information that is available about the persons needs before they move into the home. This includes assessments and information from other professionals. Accurate information must be available so that the staff can meet each persons assessed needs appropriately. 03/08/2010 2 19 12 The manager must ensure that all care plans provide adequate and appropriate details of the procedures to meet each persons assessed health care needs. Care plans need to provide adequate and appropriate details of each persons needs, so that the staff have 03/08/2010 Care Homes for Adults (18-65 years) Page 31 of 35 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 the information that they need to be able to meet their needs. 3 20 13 All medication must be 04/03/2010 administered and recorded in accordance with the Royal Pharmaceutical Society guidelines and the NMC Code of Practice. This will make sure that everyone has the care and medication that they need in a safe and effective way. 4 20 13 Measures must be put in place to ensure that medication is audited effectively, and that any errors in medication are noted and rectified without delay. This will make sure that everyone has the care and medication that they need in a safe and effective way. 5 23 13 The manager must ensure that all staff are aware of the procedures for assessments required for Deprivation of Liberty Safeguards (DOLS). People who live in the home need to be confident that their rights will be promoted 03/08/2010 04/03/2010 Care Homes for Adults (18-65 years) Page 32 of 35 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 to take decisions about any restraints to their activities. 6 37 13 The manager must ensure that all staff in the home comply with professional codes of conduct and legal requirements, in particular NMC Code of Conduct and Mental Capacity Act 2005. People who live in the home need to be confident that they will receive the care and support that they need in a safe and effective way. 7 39 26 The proprietor must make 03/08/2010 monthly monitoring visits to the home that focus on the provision of care and include the views of residents and staff. Reports of the visits must be provided to the service and be available for inspection by the Commission. The proprietor must monitor the quality of the services so that any actions can be taken to improve the quality of life for the people who live in the home. 03/08/2010 Care Homes for Adults (18-65 years) Page 33 of 35 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 1 The Statement of Purpose should clarify the services that the home provides to meet peoples needs. The paper copy of the Statement of Purpose does not include information on the services provided for younger people with a learning disability. Care Homes for Adults (18-65 years) Page 34 of 35 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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