Care Home: The Grange Nursing Home

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What the care home does well A service user commented on what they thought the home does well in the survey they completed with support from their key worker, `the home gives me the choice of what I want to do each day and what I want to eat and drink.` A healthcare professional who completed a survey confirmed that, `the care service always see advice and act on it to meet the people`s social and health care needs and improve their well-being`, and commented that, `the staff are caring and kind and pay attention to detail.` The service users` care plans are person-centred and record their likes, dislikes and preferences to inform the carers. A service user`s person-centred plan review, sampled, was illustrated with colourful drawings and symbols to help the service user to understand the information recorded. Support plans identify service users` religion and beliefs and show that the home supports them to follow these. What has improved since the last inspection? The communal living areas of the home had benefited from refurbishment, tailored to suit the service users needs, and they had been involved in choosing the colour scheme and soft furnishings. Plans are in place to provide an activity room with a domestic scale kitchen to enable service users to partake in the activities of daily living and develop their independence skills. What the care home could do better: Full re-assessments of the service users` needs with care management could be completed to ascertain if they need to continue to live in a nursing home, to gain their views on the kind of accommodation they would prefer, and their preferences about the numbers of people they would like to share accommodation with. Fundamental changes could be made to the staff rota to ensure there is flexibility in the support provided to the service users. This would enable them to attend social clubs and entertainment in the evenings, and more choices would be available to service users about how they spend their time in the evenings, if more staff were avilable to support them. The health and personal care plans could be rationalised to provide holistic care plans for the service users, which both the nursing and care staff could contribute to. All the staffing posts could be filled so that the staff do not have to work long hours covering different roles, and service users who have been provided with one to one care could be enabled to be involved in choosing the staff to support them so that they are provided with consistent support. Five of the six staff members, who completed surveys thought that `more staff were needed to meet the individual needs of the service users.` All mandatory training should be up to date to protect the service users and the staff should also be trained to support the specialist needs of the service users. A clear management structure should be in place with consistent leadership and commitment to ensure that the person-centred care planned for the service users is delivered. Key inspection report Care homes for adults (18-65 years) Name: Address: The Grange Nursing Home Farnham Road Liss Hampshire GU33 6JE     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: Christine Bowman     Date: 3 0 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 38 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 38 Information about the care home Name of care home: Address: The Grange Nursing Home Farnham Road Liss Hampshire GU33 6JE 01730895590 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): grangeliss@robinia.co.uk Solor Care Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 15 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 15. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home The Grange Nursing Home is a care home providing accommodation and nursing care for up to fifteen younger adults with learning and physical disabilities. The Grange Nursing Home is a large detached house located in the small rural village of Liss. The accommodation for service users is on the ground and first floor, connected by stairs and a passenger lift. It comprises of eleven single and two double bedrooms, none of which have en-suite facilities. There are three lounge/dining rooms on the ground floor, and the home has a large, secure garden, which is accessible for service users, Care Homes for Adults (18-65 years) Page 4 of 38 Over 65 0 15 Brief description of the care home and well maintained. Also within the grounds is a sensory room and a hydrotherapy pool. Robinia Care Limited owns the home; this is a national company who own a number of care homes within Hampshire and other local authorities. Care Homes for Adults (18-65 years) Page 5 of 38 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: This was an unannounced key inspection. Before we visited the home, we looked at the last key inspection report completed after the site visit on 17th January 2007, the Annual Service Review, and other information gathered about the service since that time. The manager sent us the Annual Quality Assurance Assessment (AQAA), when we asked for it. This document gives us up to date factual evidence about the running of the home, informs us of what they think they are doing well, how they have improved the service over the previous twelve months, and of their plans for further improvements. Four service users, six staff members, and one healthcare professional completed surveys giving us their views on the service provided at the home. The site visit was carried out over six hours and we met the majority of the fourteen people who currently live at the home, the manager, the operations manager and four staff members. We looked at the service user guide, care plans, medication records, staff files, maintenance and other records. We looked at all the communal areas of the home and sampled the bedrooms of four of the people, who live there. Care Homes for Adults (18-65 years) Page 6 of 38 Care Homes for Adults (18-65 years) Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: Full re-assessments of the service users needs with care management could be completed to ascertain if they need to continue to live in a nursing home, to gain their views on the kind of accommodation they would prefer, and their preferences about the numbers of people they would like to share accommodation with. Fundamental changes could be made to the staff rota to ensure there is flexibility in the support provided to the service users. This would enable them to attend social clubs and entertainment in the evenings, and more choices would be available to service users about how they spend their time in the evenings, if more staff were avilable to support them. The health and personal care plans could be rationalised to provide holistic care plans for the service users, which both the nursing and care staff could contribute to. All the staffing posts could be filled so that the staff do not have to work long hours covering different roles, and service users who have been provided with one to one care could be enabled to be involved in choosing the staff to support them so that they are provided with consistent support. Five of the six staff members, who completed surveys thought that more staff were needed to meet the individual needs of the service users. All mandatory training should be up to date to protect the service users and the staff should also be trained to support the specialist needs of the service users. A clear management structure should be in place with consistent leadership and Care Homes for Adults (18-65 years) Page 8 of 38 commitment to ensure that the person-centred care planned for the service users is delivered. 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 38 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 38 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 does not make all the required information available to prospective residents and their representatives to give them confidence about the homes ability to meet their needs. Procedures are in place for the assessment of prospective service users needs. Evidence: The home had recently reviewed the Statement of Purpose (SOP) setting out their aims and objectives, which included the provision of person-centred, outcome focussed care and an enabling service offering choice and inclusion within the home and service delivery. Up to date contact details of the Care Quality Commission were included to inform stakeholders. The SOP recorded that there was a Registered Manager in post, which has not been the case for more than a year, and although the numbers of staff employed at the home was recorded, the required details to inform care managers and relatives, about their relevant qualifications and experience was not. The Service User Guide, compiled in symbolic format, had been supplied to each service user informing them of what to expect from the service and of the terms and conditions of their residency. Care Homes for Adults (18-65 years) Page 11 of 38 Evidence: There had been no new admissions to the home since 2004, and the manager stated that comprehensive re-assessments of need of the current service users had been planned with care management over the next year. One of the four service users, who completed surveys, recorded that they had been asked if they wanted to move into this home, one smiled in response to the question, one recorded that they hadnt been asked and the fourth did not respond. The personalisation agenda, initiated by the Government, supports re-provision for younger adults with respect to their choice of accommodation, sharing preferences, and lifestyle choices, and would offer alternatives for the people who live at the home, if they do not need to be placed in a nursing home for the remainder of their lives. Most of the service users had lived together as children in a nursing home, but developments in medication and treatment for people with epilepsy has made it increasingly possible for people to live more normal lives and receive their healthcare support in the community. The admissions process, as described in the AQAA, included: Any new potential service users undergo a full assessment with the input of the service user, family, friends, the Community Learning Disability Team (CLDT), social services and independent advocate if necessary. This will be completed with the correct communication method for the potential service user. This process will include compatibility with others living in the home, the assessment and management of risks, physical and mental health needs, nursing needs, cultural and faith needs, education and training, suitable accommodation and personal support, communication and any potential restrictions on freedom of choice. Its important that the individual is involved as much as possible as they are potentially going to be living here and that we listen to their views and opinions. An assessment can also identify positive areas where we can support them in setting new aims and objectives. If any further specialist training is required prior to moving in, then the home manager will seek this training so we can meet the needs of the prospective Service User. No admission would occur if we were unable to meet the needs of an individual. An introductory period would take place prior to any decision being made. Three service users files inspected included sufficient information about the individual needs and preferences of the service users to enable person-centred plans to be completed. Care Homes for Adults (18-65 years) Page 12 of 38 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. Service users individual plans reflect their assessed and changing needs and personal goals. Practices within the home demonstrate that service users are encouraged to make decisions about their lives and to take risks as part of an independent lifestyle. Evidence: The three service users care plans sampled were person-centred and recorded their likes, dislikes and preferences to inform the carers. One service users support plan viewed included clear instructions to the staff on how they liked to be supported with their personal hygiene, eating and drinking, mobility and making choices. The AQAA recorded, each service user has an individual support plan that is reviewed at least every six months and as required to reflect their changing needs. This is designed around their initial assessment and covers all aspects of an individuals life. Support plans outline the needs, risks and support needed by the individual ranging from the very basic support to how specialist requirements will be met. A service users person-centred plan review sampled had been completed over the previous six Care Homes for Adults (18-65 years) Page 13 of 38 Evidence: months, and was illustrated with colourful drawings and symbols to help the service user to understand the information recorded. It confirmed that important people in their life, such as parents, care management, key worker, and the occupational therapist had attended, highlighted what was working and not working for the service user and included an action plan for the future. Support plans identified service users religion and beliefs and showed that the home supported them to follow these. One service users care plan showed that the home provided them with special food in keeping with their cultural beliefs. In October, the AQAA recorded that the Hindu Festival of Light had been celebrated by arranging a small party with Indian food, vegetable curries and sweet puddings. The AQAA recorded that all the service users had specialist communication needs and Communication Passports were in place to help staff to understand the best way of involving the individual in daily life. One service users communication passport informed the staff that they make vocal sounds to express their feelings and explained the best way to respond when the service user became agitated. Risk assessments were included with respect to accessing the community, challenging behaviour, using the homes transport, accessing the garden, swimming, personal hygiene, medication administration, epilepsy, moving and handling, mealtimes and communication. Risk assessments included a description of the activity, highlighted what could go wrong and included actions to make the activity safe. Risk assessments sampled had been updated within the previous six months and had been signed by the staff to confirm they had read and understood them for the protection of the service users. One service user, who used a wheelchair mostly, had guidelines for walking illustrated with photographs to ensure their support was given appropriately. Care Homes for Adults (18-65 years) Page 14 of 38 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported to engage in a range of activities that take account of their needs and preferences. They are supported to maintain personal relationships and be part of the local community, but there are limitations on their ability to extend their social contacts and to have their independence promoted through the routines of everyday life. They are offered a healthy diet which reflects their individual taste and dietary needs. Evidence: Service users had colourful schedules on the notice boards in their bedrooms to remind them of the activities they had been involved in planning. Colour photographs of the service users participating in the activities were included on the timetables. One service users plan confirmed they took part in a variety of activities throughout the week, including cookery, games, cycling, art, skating, drama, physiotherapy, current Care Homes for Adults (18-65 years) Page 15 of 38 Evidence: events and swimming in organised sessions at the daycentre or at the home in the day time during the week. The combined timetable for all the service users, completed for September to December, showed how the weekday working days were organised to include one to one sessions, small group sessions and free time. One to one sessions included drumming, communication, art, sailing and multi-sensory experience for some individuals. Other service users participated in these sessions in small groups. Sessions were an hour in duration and offered the service users a wide variety of experiences from music, art and physiotherapy to gym, horse riding, horticulture, cookery, activity centre and trampolining in addition to those activities already mentioned. On the day of the site visit, the Grove Resource Centre was closed for the Christmas vacation, therefore the weekly schedule was not in operation. Throughout the day, service users were observed enjoying swimming sessions in the homes own pool, and relaxing in The White Room, which is the homes own multi-sensory provision, equipped with a variety of colourful bubble tubes, music, lights, water bed, ball pool, tactile pictures and mobiles for their enjoyment. Most of the service users were not interacting with the sensory environment, but asleep when we visited them in the afternoon. Some brightly painted canvasses, which were the results of service users artistic endeavours, were displayed in the corridors, confirming their efforts were valued and thereby promoting their self-esteem. The organisation provided the home with transport, suitably adapted for the needs of wheelchair users, and the rota confirmed that a driver was employed two day per week to enable the service users to access the community. The AQAA recorded, we have started to look at external providers of day services and will be looking into doing more activities from home such as art cafe drop in sessions, sailing and horseriding. We actively promote social intergration within the local community and surrounding areas. The service users at The Grange are encouraged to use public transport with the support of staff and we have just applied and received travel tokens and an annual train pass.The service users also often access the community by train and enjoy trips to local amenities and further a field to places such as Woking, Porstmouth and Petersfield. A large collage of photographs, displayed on a corridor wall, showed service users and their families participating in social events arranged at the home. These included themed celebrations and the summer open day, which involved a barbecue. There were also photographs of service users on holiday on the Isle of Wight and in Somerset and enjoying trips to Butlins in Bognor Regis, and visits to London and Brighton. The manager stated that a Christmas fair had been held at the Grove Care Homes for Adults (18-65 years) Page 16 of 38 Evidence: Resource Centre and some of the service users had made jewellry for this event, and had sold cakes on a stall. As most of the service users had lived together since they were children, their families knew each other very well. Social activities arranged in the evenings and at weekends, recorded in service users support plans included visiting the local pub, bowling, gardening, swimming and visiting the sensory room. The manager was asked about the possibily of service users joining social clubs and attending discos to meet and make friends with other young people. He stated that the rota, which had historically been arranged around the needs of the service users when they were children, was being looked into to allow for the flexibility of providing more social activities in the evenings. The current rota showed that all the day staff, including the one to one provision for individuals, finished their shifts between 5:00 pm and 7:00 pm, leaving only one nurse, one waking night staff and two sleep night staff on duty. One of the four service users, who completed surveys with support from the staff, confirmed that they always make decisions about what they do each day, one that they usually did and two did not respond. Two of the four also recorded that they can do what they want to do during the day, in the evening and at the weekend, and two did not respond. Since the previous site visit the communal living areas had been opened up to allow unrestricted access to the service users, who had originally been cared for in smaller groups with their own staff. Access to the gardens had improved for wheelchair users by the addition of ramps from the French doors of the lounges to the garden. Plans were in place to provide an activity area to include a kitchen with a height adjustable table to enable service users to participate in some domestic activities, as the homes kitchen was not domestic. Plans for the next twelve months, as recorded in the AQAA, included, to look further into accessing external facilities to promote lifestyle and independence and to support individuals in building friendships external from Robinia. A pictorial menu enabled service users to make choices about what they would like to eat and preferences were clearly recorded in care plans sampled. The AQAA recorded, the chef organised some meetings around menu planning with the service users and key workers. She used photos and cookery books to offer choice of a variety of foods. This information was then put together to ensure a healthy option of food could be offered each day. On the day of the site visit service users were offered the choice of three different meals and lunch was staggered to enable service users to receive the support they needed and to decide when they would like to eat. Care Homes for Adults (18-65 years) Page 17 of 38 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. Service users receive personal support from the staff according to their needs and preferences, but are sometimes limited in their choice of staff. Their healthcare needs are met in individual ways, and safe procedures are in place to promote their access to medication. Evidence: Person-centred plans illustrated how the service users were involved in making decisions about their lives. Support plans entitled, About my support gave clear instructions to the staff on how the individual was to be provided with support according to their needs and wishes. Support plans highlighted any sensitive and personal support and the importance of promoting service users dignity, independence, rights and privacy. Staff individual training and development logs sampled, included an induction portfolio covering the Skills for Care Common Induction Standards, which provide an introduction to the caring role and promote the service users right to be treated as an individual with respect to equality and diversity issues. In the support plans sampled, no clear preferences had been made about having personal care provided by male or female staff, however the staff rota shows that there are times when this choice would be limited. The AQAA recorded that, staff Care Homes for Adults (18-65 years) Page 18 of 38 Evidence: support individuals to go shopping where they will choose what personal items they would like to buy such as clothes, hair and make up products. Key workers were allocated to individuals to provide consistency and continuity of care and although staff retention had not been good over the previous two years, the AQAA recorded that there was a core group of loyal staff who had built good relationships with the service users over a period of time. The AQAA recorded, each service user is assigned a key worker along with a co-worker and we have introduced monthly key working sessions. These sessions include a review of the past month and look at the coming month setting aims and objectives, consider maintenance issues and medical appointments. As the Grange is registered as a nursing home, the responsibility for healthcare and medication was taken by the nurse on duty and this support was provided twenty four hours each day. The home employed two full time registered nurses to cover the health and medication needs of the service users during the day and one full time registered nurse to cater for the same needs at night. The manager stated that a parttime bank nurse was in the process of induction and working alongside the night nurse. Both the full time registered nurse and the regular waking night staff were male, which does not promote the privacy and dignity of any female service users who might require personal assistance at night. However, the manager confirmed that female staff would always be available should they be required, on sleep-in duty. Separate files, completed by the registered nurses were maintained for service users health issues. Health action plans sampled in two service user files recorded health professionals involvement, medical history, a full healthcare record and daily notes completed by the nurses. The company employed their own occupational and physiotherapists from whom advice and support was available, and referrals through General Practitioners (GP) provided support from the Community Learning Disability Team (CDLT) and included a psychiatrist, psychologist, dietician, physiotherapist and epilepsy specialists. A healthcare professional who completed a survey confirmed that the care service always seek advice and act on it to meet the peoples social and health care needs and improve their well-being. Records of weight, dietary and mobility needs were recorded and detailed records were maintained of seizures experienced by service users. Information about how the service user communicated that they felt unwell or were in pain was included and recorded in a person-centred way, and details of how individuals maintained a healthy lifestyle. One service users plan recorded that they enjoyed swimming, keep-fit and dancing. One service user had a stay in hospital recently, the manager stated, and the staff had supported them flexibly to ensure they had the right support. Care Homes for Adults (18-65 years) Page 19 of 38 Evidence: Service users medication administration records included a photograph to ensure the medication would be administered to the correct service users and information about how they like to take their medication was included. Most of the medication was blister-packed at the local pharmacy for safety and convenience and colour-coded for the time of day it was to be given. Medication was stored appropriately in a locked trolley chained to a wall, and a metal cabinet, suitably secured to a wall, was available for the storage of controlled drugs. Service users controlled drugs sampled, agreed with the amount recorded on the register. Over the previous three months a drug error had occurred and a service user had been given a double dose of their medication. The agency nurse responsible for this error had not followed the clear instructions provided to ensure the service users safety, and had not worked at the service since that time. The AQAA recorded that the disposal of drugs was provided by a specialist disposal service. There was no record on the staff training matrix of the nurses having up to date medication administration training, but the nurse on duty stated she had received training from a pharmacist. Care Homes for Adults (18-65 years) Page 20 of 38 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. Policies and procedures to enable service users, their relatives and representatives, and the staff to complain about the service are in place, and the service takes action to put things right. The care home does not always safeguard service users from abuse, neglect or self-harm. Evidence: The statement of purpose included a complaints procedure, giving a response time of twenty-eight days to report back to the complainant, and this information was available in the service user guides in an appropriate format for the service users. The procedure was also on display in the home. Two of the four service users who completed surveys with support from the staff, confirmed that they knew who to speak to if they were not happy and knew how to make a complaint, and the other two did not respond to the question. Key worker sessions enable the staff, who know the service users well, to ascertain if anything is upsetting them and to take actions to put things right. Six staff members, who completed surveys recorded that they knew what to do if someone has concerns about the home. The AQAA recorded that there had been one complaint over the previous twelve months and the complaints log included a letter to confirm that the procedure had been followed. The home held copies of the local authority safeguarding policy and procedure and the No Secrets guidelines to provide information and guidance to the staff with respect to the protection of vulnerable adults. The training schedule showed that this training Care Homes for Adults (18-65 years) Page 21 of 38 Evidence: was provided on a regular basis by the organisation, but the staff training matrix recorded that only four of the team of the seventeen care and nursing staff were up to date with this training, three showed that the training should have been updated in 2009 and there was no record of this training for the remainder of the staff team. The AQAA recorded that four safeguarding referrals had been made over the previous twelve months and four investigations had been carried out. A safeguarding investigation carried out in 2008 had resulted in the dismissal of the registered manager for failing to follow safeguarding procedures to protect the service users, and the referral to the Protection of Vulnerable Adults register of a staff member. As part of the agreed action plan, urgent Protection of Vulnerable Adults (POVA) training was to be put in place for the staff team. The training and development files of two staff sampled confirmed that they had received POVA training in 2008, but this had not been updated or recorded on the staff training matrix. Action plans as a result of recent investigations had resulted in better record keeping and improved outcomes for some service users. Over the previous year, a visit to the home from social workers, had highlighted the fact that the positioning of door handles restricted the service users access and prevented them from moving freely around their home. The manager stated that originally there had been three separate living areas where small groups of service users stayed with their own staff. The door handles had been lowered and service users were moving freely around the three communal living areas on the day of the site visit. Risk assessments to positively promote their independence were in place, however, the number of unexplained small injuries and bruises some service users had experienced over the previous six months had increased. The layout of the home with its three large communal living areas, connected by corridors, was not condusive to the effective supervision of fourteen predominantly mobile, sometimes unsteady, young adults, who were likely to experience epileptic seizures, whilst choosing to move freely around. Ater 7.00pm there is a decrease in the numbers of staff available to support the service users, as recorded on the staff rota, making supervision more difficult. Service users monies were stored in a locked safe and records sampled, confirmed that transactions had been recorded, receipts kept, and balances signed and dated to safeguard their interests. Care Homes for Adults (18-65 years) Page 22 of 38 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, which provides pleasant, clean and comfortable accommodation, has been adapted to meet the service users needs, but it is not on a domestic scale. Evidence: The Grange is a large detached country house, situated in its own grounds and located on the outskirts of the village of Liss. The village centre with public amenities such as shops, public houses, restaurants and a train station is within walking distance of the home, and the AQAA records that the service users access these facilities often. The AQAA recorded that the home is in the process of refurbishment to make it more modern to suit the needs of the service users. The home was on two levels with a staircase and a lift provided for access to the upper floor. There were three large communal living areas on the ground floor, linked by corridors, and plans were in place to provide an activities room with a kitchen for the service users, a height adjustable table, a modern area of seating and lots of storage space for activity materials. The three communal living areas had been furnished with new, comfortable chairs and provided the service users with pleasant, clean and fresh spaces to live in. The AQAA recorded that that an external designer had worked with the service users and the staff in choosing the colour schemes and the soft furnishings. Leather bean bags, a Care Homes for Adults (18-65 years) Page 23 of 38 Evidence: rocker, a window seat, a box of sensory equipment and a large flat screen television had been provided in one of the living areas for the service users comfort and entertainment. One of the other lounges had also been provided with a large widescreen television for the service users to enjoy. Two of the lounges had been fitted with French windows, which opened out onto a newly designed terraced area with seating and tables, providing an outdoor entertainment area. There were also swings and a trampoline for the service users to enjoy and plans for the development of a sensory garden. Ramps had been provided, to enable wheelchair users easy access to the garden and to the homes swimming pool, which was also located close by. The home provided a multi-sensory room called The White Room located on the other side of the main building. This room was equipped with a waterbed, ball pool, mobiles, coloured lights, bubble tubes, cushions and different textures and sounds for the service users to enjoy and explore. There were colourful pictures displayed in the corridors, some of which had been created by the service users, and a large display of photographs of all the events of 2009, showing service users enjoying themselves on holidays, taking trips out, and at social events. Plants in the hallway enhanced the environment and made it more homely. The kitchen was not domestic so service users involvement in the activities of daily life could not be safely promoted. There were plans in place, however, to provide an activity area to include a domestic kitchen to enable service users to develop some independent skills in this area. Most of the service users bedrooms were located on the first floor and those sampled had been appropriately personalised with photographs of family and friends, soft toys, televisions and other personal items including pictures and posters. The AQQA recorded that, some of the service users are currently in the process of putting ideas together in their person-centred plans to refurbish their bedrooms to make them more modern, and one bedroom has already been completed. Solid but domestic furniture was provided in the bedrooms and hand basins were provided for the service users convenience. The shared bathrooms were equipped with aids to support the service users. The home was clean and fresh on the day of the site visit and appropriate infection control facilities were in place to protect the service users. Conflicting information was recorded with respect to infection control training. The AQAA recorded that ten staff had received training in the prevention and control of infection, but the staff training matrix recorded that only the chef and one senior carer had received this training. Care Homes for Adults (18-65 years) Page 24 of 38 Evidence: At the time of the site visit communal areas were shared by a group of fourteen young adults, also sharing a staff group. Efforts had been made to make the living areas homely and the home provided facilities such as a swimming pool and sensory room, which the operations manager stated, is made possible by economy of scale. However, the facilities were not domestic in scale. Consultations carried out with service users prior to the compiling of the National Minimum Standards for Care Homes for Adults (18-65), showed that small family scale homes were clearly preferred. The standards refer to small homes as homes providing accommodation for less than four service users and large for up to six. Standard 24.3 refers to new homes having no more than ten people sharing a staff group and states that existing larger homes, be organised into clusters of ten people on this basis by 1st April 2007. This is an issue to be explored over the forthcoming year with care management when full reviews of each individuals needs will be looked into in detail, including the kind of accommodation individuals would prefer to live in, the people they would choose to share with them, and the lifestyle choices they would make as individuals. Care Homes for Adults (18-65 years) Page 25 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by safely recruited staff, who are given a good introduction to the caring role, but work long hours, and are not available in sufficient numbers to support their individual needs. Staff confirm their mandatory training is up to date, and that they undertake specialist training to support the service users needs, but records do not verify this. Evidence: The AQAA recorded that a five of the sixteen staff members had achieved a National Vocational Qualification (NVQ) in Health and Social Care at level 2 or above, which is well below the 50 target homes were expected to achieve by April 2008. Over the previous twelve months the AQAA recorded that six staff had left the employment of the home, and over the twelve months prior to that time, the Annual Service Review (ASR) included a staff member comment that, there have been a lot of resignations and a lot needs to be done to retain staff. Two staff thought there were never enough staff to meet the individual needs of the service users, and one that there sometimes were. Six staff surveys received as part of this key inspection continued to confirm there were never enough staff to meet the individual needs of the service users, and a comment on what the home could do better included, employ, recruit staff instead of cutting down on the current numbers to provide quality care, as quality and cost go hand in hand, and we need more staff. Care Homes for Adults (18-65 years) Page 26 of 38 Evidence: It was apparent from the rota that the staff were working excessive hours. Most of the permanent full time staff worked between fifty and seventy two hours per week covering a variety of roles from senior support worker, support worker, to providing individual support for three service users, and covering sleep-in duties. This lack of clarity in roles could be confusing for the service user and could result in their care being provided by very tired staff. This loyal and dedicated team were providing as much support as they are able and possibly not taking enough time off to refresh themselves between shifts, which were mostly twelve hours long. Agency staff were needed just to cover some essential shifts, even when the permanent staff were working excessive numbers of hours. One to one time was provided by a variety of staff, and the two female service users, who received this support, were supported by male staff more than 50 of the time. One staff team was predominantly male with up to five male staff working together and the other team consisted of three female staff working together. This situation does not allow for choice with respect to service users receiving intimate care. There was little flexibility in the rota for arranging evening activities and social outings, which adults of this age group would usually choose to take part in. All the daytime staff, including one to one support for three individuals, finished their shifts between 5:00 pm and 7:00 pm, leaving one nurse, one waking night staff, and two sleep in staff on duty. Supporting fourteen young adults to remain in the three communal rooms, should they wish to do so, to decide when they would like to go to bed, to prepare for bed and take baths or showers, or spend time in their bedrooms over the two floors safely, would be a very difficult task to organise with the numbers of staff available, especially as the AQAA records that they all need support with undressing, washing and bathing and with other personal needs. The AQAA also records that one service user needs two staff to support them with their care day and night. The manager stated that the staff were very supportive when a service user was in hospital and stayed on extra time to make sure they received appropriate support, and observations of the staff on the day of the site visit, confirmed that they worked together well as a team and were committed to providing the best service possible with their limited resources. Interactions observed between staff and the service users were sensitive, respectful and caring. The files of two staff recruited, since the previous site visit, were requested for inspection, but neither of the staff, whose files were supplied were new to the service. Care Homes for Adults (18-65 years) Page 27 of 38 Evidence: One staff member, whose file was sampled, had worked for the home previously and had returned. However, a Protection of Vulnerable Adult First (POVAFirst) check had been received before they returned to their new post to confirm their continued suitability to work with vulnerable adults. An application form had been completed with full employment history and reasons for leaving. The other staff member had worked at the home for many years and records confirmed that two references and a POVAFirst check had been received before they were confirmed in post for the protection of the service users and that their Criminal Record Bureau (CRB) check had been updated. The manager kept a record of all the CRB numbers for the staff team. Interview notes were kept and equal opportunities forms completed to show that the recruitment process had been conducted fairly. The AQAA recorded that, we have actively recruited two full time support workers and awaiting their CRB and Independent Safeguarding Authority (ISA) checks to come through with good references prior to commencing work, and we try to involve the service users as much as possible in the interview process, interviews are conducted within the service to allow this to occur. Staff files sampled included an induction in line with the Skills for Care Common Induction Standards, which introduce new staff to the caring role, and promote the individual rights, of the people using the service, to have their equality and diversity needs respected. The six staff members, who completed surveys, confirmed that their induction covered everything they needed to know to do the job when they started very well. The AQQA recorded that, new staff are inducted into the service and allocated a coach/ mentor to support them through this process. Training is booked for them to attend as soon as reasonable practicable. A staff training matrix was in place confirming that a wide variety of training opportunities were available to the staff, and a programme of training events provided by the organisation, was posted on a notice board for all to view. According to the staff training matrix, the only mandatory training that had been updated by most of the staff team was fire training and the only staff member, who had received up to date mandatory training in all subjects, was the chef. Sufficient staff had attended first aid training to ensure that there was a first aider on duty at all times, but, with respect to moving and handling, food hygiene, safeguarding adults, health and safety and infection control there were many gaps showing a need for this training to be updated. Small numbers of staff had received training to support the service users with their specialist needs including epilepsy care, Makaton, medication administration and equality and diversity. A staff file sampled contained training certificates for communication, Strategy for Crisis Intervention and Prevention (SCIP), health and safety, the protection of vulnerable adults, infection control and manual handling, all Care Homes for Adults (18-65 years) Page 28 of 38 Evidence: of which should have been updated. It also included evidence of training in Personcentred Planning, Active Support and Person Centred Approach, medication foundation, the Mental Capacity Act awareness, epilepsy awareness, basic first aid, basic food hygiene, equality and diversity and fire training, all of which were up to date. The six staff members, who completed surveys, recorded that they were being given training that is relevant to their role, helps them understand and meet the individual needs of the people using the service, and keeps them up to date with new ways of working. Five of the six confirmed that the training also gave them enough knowledge about health care and medication. Two of the four service users, who completed surveys with support, recorded that the staff always treated them well, and that they also, always listen and act on what they say. The other two service users did not repond. Care Homes for Adults (18-65 years) Page 29 of 38 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. Service users experience of inconsistent leadership does not inspire confidence in the management of the home. Their views have been taken into consideration in part, but fundamental change is essential to incorporate their wishes and to truly personalise their care. The environment is not always safe for the service users and staff because health and safety practices are not always carried out. Evidence: Since the last key inspection three years ago, the registered manager had been dismissed for failing to follow safeguarding procedure, leaving service users and staff potentially at risk. The organisation moved the registered manager of another home to the Grange to offer stability to the staff and service users over this period. They had then recruited managers on two separate occasions, but neither remained in post. Both of the appointed managers resigned prior to applying to register to manage the home. The operations manager, and more recently, the manager of another home, had taken responsibility for the management of the home in the meantime and had completed the AQAA. A newly appointed manager is now in post. The new manager is Care Homes for Adults (18-65 years) Page 30 of 38 Evidence: a Registered Learning Disability Nurse with many years of experience, both of working with adults with learning disabilities, and of management. He stated that he also held a Diploma in Management Studies to support him in the role, and is a trainer in Makaton. The management structure of the home consists of the manager and three RGNs responsible for leading shifts and working twenty four hours per day, seven days a week. The manager pointed out that the daytime RNs covered vacant night shifts, or they are covered by bank nurses, who know the service users, and it is rare for agency nurses to be used to cover this important role. Senior carers were also appointed as shift leaders. A shift leader spoken with on the day of the site visit, confirmed that the nurses take responsibility for the nursing needs of the service users, and the carers are responsible for making sure all the service users other needs are met, and that they work well together. The appointed manager explained that the management structure included some senior carers supervising some of the care staff. The staff training matrix shows that except for first aid and fire training, completed by two of the three RGNs, other mandatory training including moving and handling, medication administration, safeguarding adults, health and safety and infection control was not up to date, and there was no evidence of the RGNs receiving any clinical training, not even in epilepsy care, which is the primary medical condition of many of the service users. The AQAA recorded that one of the RGNs had completed the Registered Managers Award to support them in their management duties. With respect to quality assurance the AQAA recorded, annual questionnaires are due to be sent out to families, service users, care managers and staff and the feedback we receive is to be recorded and acted upon. There were no results available on the day of the site visit. The AQAA also recorded that, to ensure that the views of people who use our services are promoted and incorporated into what we do each service user is assigned a key worker along with a co-worker and we have introduced monthly key working sessions to review of the past month and look at the coming month setting aims and objectives, and each individual service user has a review at least annually where they will meet with their care manager and other people they would like to invite and be supported to put their ideas across. Some of the changes made as a result of listening to the people who use the service included, the major refurbishment project, the planning of an activity room, improved communication systems, the plan for service users to re-design their bedrooms and supporting the service users in the evenings to access some entertainment in the community, including trips to see football matches and fireworks. Plans, as a result of listening to the people who use the service included, reviewing all day centre activities and research to see if there are any other options external to Robinia that would benefit the progress and Care Homes for Adults (18-65 years) Page 31 of 38 Evidence: development of individuals, and looking at the staff rotas to see if we can make shifts more flexible and person centred. Conducting regular service user meetings to seek their views on the running of the home was something the AQAA recorded the home could do better. As already stated, the staff training matrix did not confirm that mandatory training with respect to health and safety issues had been updated on a regular basis. As recorded under Concerns, Complaints and Protection, the number of unexplained small injuries and bruises some service users had experienced over the previous six months had increased, and there was no evidence of risk assessment training to support the staff to positively promote the service users independence.The AQAA recorded that equipment had been tested or serviced as recommended by the manufacturer or other regulatory body, and certificates sampled, confirmed that servicing had been carried out in a timely manner, for the protection of the service users and the staff supporting them, but policies and procedures with respect to health and safety were in need of updating. Care Homes for Adults (18-65 years) Page 32 of 38 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 33 of 38 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 1 4 The statement of purpose must include all the information in Schedule 1 of the Care Homes Regulations 2001 and must be correct to inform prospective service users and their representatives about what to expect from the service and to help them to make a decision about the suitability of the home to meet their needs. 01/03/2010 2 18 18 Times for going to bed, taking showers and baths and for undertaking social and other activities in the evenings should not be restricted by the availability of staff to enable service users to live ordinary lives 01/03/2010 3 20 18 The staff, who take responsibility for the administrationof medication 01/03/2010 Care Homes for Adults (18-65 years) Page 34 of 38 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 and support the specialist medical needs of the service users, should be able to evidence up to date training to confirm they are qualified to do so. For the safety of the service users 4 23 4 All staff must receive up to date training in the protection of vulnerable adults on a regular basis to ensure they have current information on the procedures to follow to protect the young adults i n their care, 5 24 16 The home must provide domestic scale facilities to meet the individual needs of the service users safely and enable them to partake in the activities of everyday living. 6 33 18 The home must employ staff 01/04/2010 in sufficient numbers to support the assessed needs of the service users. To ensure the assessed needs of the service users are met 7 35 18 A training needs assessment 01/03/2010 should be carried out for the 01/04/2010 01/03/2010 Care Homes for Adults (18-65 years) Page 35 of 38 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 staff team as a whole, and an impact assessment on all staff development should be undertaken To indentify the benefits for the service users and inform future planning. 8 39 24 An annual development plan 01/03/2010 for the home based on a systematic cycle of planning -action - review and reflecting aims and outcomes for service users should be in place. To confirm the service users wishes and needs are at the heart of the homes development plans for the future. 9 42 13 Mandatory training in 01/03/2010 moving and handing, food hygiene and infection control should be kept up to date To ensure safe practice for the protection of the service users and the staff 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 32 The ratio of staff having attained a National Vocational Qualification at level 2 or above is well below the target of Care Homes for Adults (18-65 years) Page 36 of 38 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 50 per cent to be achieved by April 2008 and must be improved to ensure that service users are in safe hands at all times. Care Homes for Adults (18-65 years) Page 37 of 38 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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