Care Home: The Laurels

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What the care home does well People have help to dress, wash and eat if they need it, and with hearing aids and eyeglasses.District nurses visit to give health care.Everyone`s room has a door lock to be private.People get up and go to sleep when they want to, and choose when and where they eat.People choose what they eat from a menu with foods from around the world.Some people have help with communication and food from the Asian Women`s Centre next door.People can go out alone if safe, or with staff such as to the shops or cinema.Some people make their own breakfast, snacks and drinks.Staff keep good records about people`s money. What has improved since the last inspection? After listening to people, there is more choice of foods from around the world and for healthy living. The Laurels has an award for excellent food safety. Staff had training about peg feeding, and they are waiting for checks that they do this safely, so that they can help someoneto eat when they are hungry rather than waiting for nurses. The home is kept cleaner to keep people healthy. Staff left but the home tries to make sure that people have help from staff they know. They have meetings and supervision more often. Two people moved to a flat of their own.Staff had peg feed training and are having safety checks so that they can help people to eat when they are hungry rather than waiting for nurses.The home is kept cleaner to keep people healthy.Staff left but the home tries to make sure that people have help from staff they know. What the care home could do better: Some people worry about when they will move to a new home; staff aren`t sure so can`t prepare them. Other people and families want to know more about the home closing and future short stay services. Transport charges need to be clear and fair.Meetings need to take place with advocates so that people and families have support the way they want and need, or reasons for any delays.The medication system could be safer. Some people need a dentist and new clothes.People get bored watching TV and want more to do in the home, and some people cannot ask for this.Some people want to worship and to celebrate their culture.People and families need to be listened to and be told what will happen about a concern or complaint. Some people are in the home to be safe, and two people were hurt in accidents.We are not sure if there are always enough staff, and they need to tell each other more about people. More training is needed, and checks about how well they do their jobs.There are not enough toilets but there is a bath or a shower on each floor. Some bedrooms are small, don`t have a sink or there are holes in the wall by the sink.Manager checks and repairs to the home are needed to make it safe, healthy and to protect people.The home did not send us reports to keep people safe or when management changed.Managers did not do what the law says since our last visit. We wrote to the council after our visit to make the building safer, and to help two people feel safe. Key inspection report Care homes for adults (18-65 years) Name: Address: The Laurels 65 Frederick Road Stechford Birmingham B33 8AE 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: Tina Smith Date: 2 7 1 0 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 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. They reflect the things that people have said are important to them: 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 42 Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 42 Information about the care home Name of care home: Address: The Laurels 65 Frederick Road Stechford Birmingham B33 8AE 01217845222 01217845232 Telephone number: Fax number: Email address: Provider web address: Katymeakin@Birmingham.gov.ukwww.birmingham.gov.uk Social Care and Health care home 17 Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 17 0 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 17 The registered person may provide the following category of service only: Care Home Only (Code PC); 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) 17 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 42 A bit about the care home The Laurels offers short breaks for up to 17 adults who have learning disabilities at any one time. Some have physical disabilities. It is near shops, buses and has a car park. There is a ramp at the front, a lift and people in wheelchairs can move around safely. Everyone has their own room. Some rooms are too small, or dont have a sink. There are not enough toilets but there is a bath or a shower on each floor. There are not enough toilets but there is a bath or a shower on each floor. People can make snacks in a kitchen, and there are two lounges and a room to play pool. Care Homes for Adults (18-65 years) Page 5 of 42 The service user guide has information. Fees are £9.94 a night, or £65 a week. Extra meals are £2.90 each. Care Homes for Adults (18-65 years) Page 6 of 42 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 Care Homes for Adults (18-65 years) Page 7 of 42 How we did our inspection: This is what the inspector did when they were at the care home We talked to most people and staff at the home. We had surveys from families telling us that they wanted to come to the home. We checked the care records of 4 people, staff and running the home. The registered manager sent us the AQAA (Annual Quality Assurance Assessment). This tells us about the home and what they are planning. Care Homes for Adults (18-65 years) Page 8 of 42 The registered manager was not available so we spoke to him by telephone the next day about what we found and what they must do. What the care home does well People have help to dress, wash and eat if they need it, and with hearing aids and eyeglasses. District nurses visit to give health care. Care Homes for Adults (18-65 years) Page 9 of 42 Everyones room has a door lock to be private. People get up and go to sleep when they want to, and choose when and where they eat. People choose what they eat from a menu with foods from around the world. Some people have help with communication and food from the Asian Womens Centre next door. Care Homes for Adults (18-65 years) Page 10 of 42 People can go out alone if safe, or with staff such as to the shops or cinema. Some people make their own breakfast, snacks and drinks. Staff keep good records about peoples money. What has got better from the last inspection After listening to people, there is more choice of foods from around the world and for healthy living. The Laurels has an award for excellent food safety. Staff had training about peg feeding, and they are waiting for checks that they do this safely, so that they can help someone Care Homes for Adults (18-65 years) Page 11 of 42 to eat when they are hungry rather than waiting for nurses. The home is kept cleaner to keep people healthy. Staff left but the home tries to make sure that people have help from staff they know. They have meetings and supervision more often. Two people moved to a flat of their own. Staff had peg feed training and are having safety checks so that they can help people to eat when they are hungry rather than waiting for nurses. The home is kept cleaner to keep people healthy. Care Homes for Adults (18-65 years) Page 12 of 42 Staff left but the home tries to make sure that people have help from staff they know. What the care home could do better Some people worry about when they will move to a new home; staff arent sure so cant prepare them. Other people and families want to know more about the home closing and future short stay services. Transport charges need to be clear and fair. Meetings need to take place with advocates so that people and families have support the way they want and need, or reasons for any delays. Care Homes for Adults (18-65 years) Page 13 of 42 The medication system could be safer. Some people need a dentist and new clothes. People get bored watching TV and want more to do in the home, and some people cannot ask for this. Some people want to worship and to celebrate their culture. People and families need to be listened to and be told what will happen about a concern or complaint. Some people are in the home to be safe, and two people were hurt in accidents. Care Homes for Adults (18-65 years) Page 14 of 42 We are not sure if there are always enough staff, and they need to tell each other more about people. More training is needed, and checks about how well they do their jobs. There are not enough toilets but there is a bath or a shower on each floor. Some bedrooms are small, dont have a sink or there are holes in the wall by the sink. Manager checks and repairs to the home are needed to make it safe, healthy and to protect people. The home did not send us reports to keep people safe or when management changed. Care Homes for Adults (18-65 years) Page 15 of 42 Managers did not do what the law says since our last visit. We wrote to the council after our visit to make the building safer, and to help two people feel safe. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Tina Smith 77 Paradise Circus Queensway Birmingham W Midlands B1 2DT 01216005300 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 set out 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 16 of 42 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 17 of 42 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. Information about the home is clear and people have assessments before or shortly after admission so that their needs are met for short stays or in emergencies. However a home designed for short stays continues to be used longer term, which can affect peoples emotional wellbeing. Evidence: The AQAA told us that 15 people and families use the service. Some surveys told us that people and relatives have information about the home and its planned closure. On our last visit people were having short stays as well as living in the home for long periods, and we advised that they need permanent homes for their emotional wellbeing. On this visit we wanted to see how the admission and discharge process ensures peoples needs are met. We examined four care records and spoke to four people and staff. Information about people is first gathered by social work and health professionals. If the home decides needs can be met then visits by people and families take place at the persons own pace. This occurred in two care records. There is no specific system for a smooth transition of younger people from services for children to adult services. The Care Homes for Adults (18-65 years) Page 18 of 42 Evidence: AQAA told us that the home could improve information they seek and share with staff about people before admission so that people have the right support from the start. In an emergency admission, an assessment takes place within five days. Two people arrived as emergencies two days before our visit and their assessments had not started, but there was information about their needs from social workers. Their independence was promoted on our visit and we saw staff explain the homes systems to them. Written information about the home is accessible as photos and symbols are used, and it explains the services, staff and fees. The statement of purpose says that the service offered is for short stays and not residential care. On our visit there were 14 people in the home; ten were having short stays. Four people were living in the home for the past 6 months to 2 years. One person was transferred from a home that closed. As the council should have a closure plan for its services which meets peoples needs, moving several times should be avoidable for their wellbeing. Two people are having transitional visits to permanent accommodation. Two plans were not progressing in a timely way and we were told that the advocacy service has a waiting list. We recommended managers seek statutory advocates for serious best interest decisions such as accommodation moves. Care Homes for Adults (18-65 years) Page 19 of 42 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. Timely reviews are not taking place to ensure that all peoples needs continue to be met and risks managed. People and families are not always given the information and support they need or request from staff. Evidence: The AQAA told us that reviews are not up to date. One relative told us that they would prefer care staff taking over a health related task during short stays, which was also a request on our last visit. So we wanted to check on these matters, and information given to families about their requests. Care plans promote independence and are formed from the information gathered in discussion with people, their families and other professionals, and through risk assessments. It was not always recorded when reviews were arranged, or followed up if cancelled. After short stay visits people often complete questionnaires, so that the home have some views about their experience . Meetings with guests and families have not taken place, and annual surveys have not been used since our last inspection. We saw an Care Homes for Adults (18-65 years) Page 20 of 42 Evidence: undated survey in a care record about someones cultural and religious needs not being met. Other surveys showed us that a number of people want more activities in the home and get bored. Care plans have not changed since these comments were made. We found a variety of unresolved issues showing us that the home could do more to ensure reviews take place to meet needs and make best interest decisions, in keeping with mental capacity laws. For example, one persons last review of short stays was in 2007. Risk assessments and a behaviour plan dated 2008 were not reviewed after a variety of incidents in 2009 when the person, staff and other people using the service had minor injuries. A care plan that included restrictions on a persons freedom of movement was not regularly reviewed by a multi-professional group. Medication changes needed query as well as resolution of the management of someones financial affairs. Managers were not clear about progress with health services to meet one persons nutritional needs more effectively, which we queried with the council after our visit and were assured this is progressing. Staff meetings discussed clashes between people, and it is not clearly resolved how people for short stays are matched with people who are always in the home, so that both peoples safety and wellbeing is effectively managed. One person told us that they are fed up waiting to move and did not know when this would take place. Managers said that they are not kept sufficiently informed by social workers to prepare people for moves, but knew some were due to take place. People need clear information so that they do not worry. People have help to manage small amounts of money, if necessary. Good records are kept and tallied, and there are daily manager checks. Unspent money usually goes with people when they leave the home. Replacement clothing had been discussed at a staff meeting for people living there, but care records did not show us how this had been followed through. Care Homes for Adults (18-65 years) Page 21 of 42 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. Some people can decide what they want to do each day and their independence is promoted; others get bored just watching TV. There are some outings in the community. Most dietary needs are met and arrangements are made to meet cultural preferences. Evidence: People get up and go to sleep when they want and can choose when and where they eat. Four people asked to go out during our visit. A staff escort was provided to two people and two others went out together after this was assessed. This showed us that people have flexible choices and support, and that they also make friends in the home. Relationships with families are maintained for people living in the home, and on our visit one person asked staff about their role in an upcoming family event. There is a pay phone in a public place which does not provide privacy, but some people bring mobile phones. Some people attended day services or college from the home,outings and social clubs in Care Homes for Adults (18-65 years) Page 22 of 42 Evidence: the community. On our visit no activities took place other than watching TV in one lounge. Some people entertained themselves in their room with their own music. Some people prepare their own breakfast and snacks after asking staff to open the kitchenettes. The pool table room is also kept locked to protect others. We asked about plans for Halloween and Diwali but staff said that people arrange their own celebrations if they want to, using the homes facilities. As some people need support to express views, make choices or to participate in activities and worship, we were not satisfied with this response - especially for people living in the home. We did not see people taking part in daily living activities such as setting tables in the dining room. There was no improvement in identifying peoples interests or in daily records kept about activities since the last inspection. We recommend there are individual activity plans and full consultation with people about celebrations and worship. Staff cannot always converse in peoples preferred languages or communication modes but staff made efforts to talk with people. The Asian Womens Centre next door provides activities and food for some people in the home. Peoples likes, dislikes and dietary needs are taken into account when menus are planned. Alternatives to the balanced menu on display can be provided at mealtimes. People said that they like the food. Staff do not have training to recognise or prevent malnutrition and did not monitor food intake for a person with a history of self neglect. Care Homes for Adults (18-65 years) Page 23 of 42 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. Personal support ensures dignity is respected. Health needs are met by primary health care professionals. Reviews need to take place to ensure wellbeing and health. People need to be better protected by the homes medicine management. Evidence: People can choose to have support from male or female staff with bathing, showering, dressing, and some people manage by themselves. In two care records the need for night time checks were not assessed and people should be asked for consent. Complex health needs are met by district nursing services for catheter, stoma care and peg feeding. After our visit we learned that staff are waiting competency assessments by health professionals to take over peg feeding, which will improve on occasional delays. Sensory needs are met, for instance by ensuring hearing aids and spectacles are maintained and used. Manual handling assessments are undertaken where transfers, aids or equipment are needed such as hoists. However risk assessments, behaviour plans and personal safety were not reviewed after incidents and injuries we noted in various records. Regular reviews have not been held about medication, restraint and restrictions on movement, or to evaluate the effectiveness of behaviour management plans. Some people have Care Homes for Adults (18-65 years) Page 24 of 42 Evidence: community learning disability nurses and services actively involved. People living in the home have GPs but we were told that they do not all have a local dentist. Staff escort people to health appointments if family are unable to, but they are charged transport fees. We were told there is no council transport charging policy for care homes There is a system for medication security and storage. Families sign a form so that they know the homes medication policy in order to protect people. Medication brought in by people or ordered is usually checked into the home by two staff. People took part in the administration of medication, as able. One person showed us an inhaler they managed but managers were not aware of this, and confirmed that there are no lockable facility in peoples rooms. Some medication guidelines were completed with families and health professionals. For instance, staff were trained to understand and manage drugs for epistasis in an emergency. There were no guidelines for medication prescribed as required or for homely remedies, which means that staff do not have clear instructions on their purpose, maximum dose or frequency. We queried as required medication given regularly, and one with an incorrect name on the label which has not been administered for several months. A manager contacted a doctor and chemist during our visit to check prescriptions and prevent undue restraint or side effects in combination with other medication. The homes medication policy and system needs review. There are no photos on the medication administration record to make sure it is given to the right person. Temporary staff are used, so this is important to prevent medication errors. Safe monitored dose systems have not been arranged for the medicines of people living in the home. This is another example where the homes policies and systems are not designed for the needs of people longer term. Daily temperatures are in the safe range for the drug fridge, but no temperatures are taken of the extremely hot room where medication is stored. We made an immediate requirement to ensure medicines remain effective for peoples conditions and symptom relief. Staff have accredited training about medication which is kept up to date but managers are not checking competence and knowledge. Each month managers audit medication this is not often enough to protect the health of people living in the home. We were told that any discrepancies are acted upon but records do not say whether peoples health was queried with doctors on two occasions medication was missed in the audits. We were told that staff were spoken to and the medication did not concern life threatening conditions. On our visit we found medication and prescribed creams that did not all tally with the medication administration records. Some tablets could not be accounted for in the homes administration or disposal records. We could not always tell if medication went home with people or to day centres because records do not have a way to account for this. So people cannot be sure they are having medication as prescribed by doctors. Care Homes for Adults (18-65 years) Page 25 of 42 Evidence: Care Homes for Adults (18-65 years) Page 26 of 42 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. We cannot confirm that complaints or the rights of people are always taken seriously, promoted and protected, and the home does not keep the Commission sufficiently informed of serious matters affecting people. Evidence: An Easy Read complaints procedure is summarised in the service user guide. The AQAA told us that there were three complaints since the last inspection. The homes complaints log had one serious matter; two complaints could not be accounted for. There was no summary log about the process and outcome, as required at our last inspection. The Laurels Team Plan 2009/2010 states that complaint timescales are not being met. Staff discussed matters raised by families in meetings that should have been investigated as complaints to improve the service, such as clothing going missing and incidents where people were upset by other service users. The one complaint we saw took several months to conclude and although an apology was accepted we were told that the homes explanation for an injury was not. We were notified about two accidents resulting in significant injuries since the last inspection. On our visit we checked and confirmed that lessons were learned and new checks are in place to prevent similar accidents. We were notified when the home raised one safeguarding concern following service user aggression. We came across other concerns which seriously affected people including a mental health emergency, falls and unexplained cuts, familial financial abuse, a dismissed staff member and two restraint matters. The homes managers confirmed that the Care Homes for Adults (18-65 years) Page 27 of 42 Evidence: Commission have not been sufficiently notified about incidents, which means we cannot be sure that appropriate action is always taken to make people safe or to protect and promote their rights. The Laurels provides a place of safety for some people, because of abuse or self neglect in the community. We were told they contribute to care programme approach meetings about peoples wellbeing and safety but are not always invited to multi-agency safeguarding meetings. During and after our visit we raised concerns about two people from matters people told us about and from our own observations. This was managed by the council under safeguarding procedures which we were notified about. Fourteen staff are booked to have or refresh training about abuse and adult protection procedures. We were not provided with the restraint policy we asked to see and were told that the home do not use restraint. This did not match our findings. Regular reviews have not been held with families and other professionals about physical and chemical restraints. Some of the managers attended training about mental capacity laws affecting peoples rights and legal duties. We were told that the home were advised by the council that Deprivation of Liberty Safeguards (DOLS) were not necessary for two people having short stays. We queried DOLS for a person with restrictions on their contact with family for their safety. Discussions showed us that managers do not understand their roles in mental capacity law or restraint in sufficient depth, or when to notify the Commission. The home sought an advocate to promote a persons rights but there is a waiting list; we advised that they may qualify under the council contract for a statutory advocate for a more timely best interest accommodation decision to ensure their emotional wellbeing. Care Homes for Adults (18-65 years) Page 28 of 42 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises do not meet minimum standards but are clean and secure. Good facilities are not used to their full potential to benefit people. Maintenance checks and repairs must protect peoples health and safety. Evidence: The home is in a cul-de-sac in a residential area. The sign is missing letters or is obscured. The front door is kept locked. The door to a sloped garden is kept open and has a handrail to the Asian Womens Centre. This protects people from intruders as well as those without road sense, but provides freedom of movement in the grounds. People use the garden to smoke, to access the Centre and for games in good weather. Transport is borrowed on weekends to take a group out if staff on duty are trained and safe to drive it. People used a procedure to ensure their safety if they wanted to go out in the community. They ask to use the kitchenette and pool table room as these are kept locked for safety, along with rooms only used by staff, such as the laundry, main kitchen and office when not in use. The Laurels has good facilities that were not used to their full potential on our visit. Only one lounge was used. A quiet room for watching films had a disconnected TV, difficult to re-connect, and a person living in the home did not know where DVDs were kept. An array of arts and crafts equipment, indoor and outdoor games, sports, music and books Care Homes for Adults (18-65 years) Page 29 of 42 Evidence: were not used or made accessible to people on our visit. The council has planned to close the home since 2007 as it does not meet environmental minimum standards. A few of the bedrooms are too small and do not have wash hand basins. There are not enough communal toilets for the service size. However there is good wheelchair access throughout, larger rooms and modern profiling beds, and space for essential aids and equipment. The council Health and Safety Officer trains the staff, but two avoidable accidents have taken place involving the homes facilities. As on our last inspection, there is no ongoing maintenance programme, repairs are too slow and checks are not robust. We wrote to the council with various concerns about lack of upkeep of the premises and about some unsafe working practices. The home and especially the kitchen were clean. All staff have food safety training and a 5H award from Environmental Health was achieved, which is excellent food hygiene. However there was unlabelled opened food in a kitchenette people used, sometimes unsupervised, which was not fully acted upon during our visit to protect peoples health. The AQAA told us that the homes risk assessment could be improved and that only 25 per cent of staff had training about infection control. There was no plan to improve this. Some redecoration and refurbishment took place but infection controls were not prioritised. For example, a leak in the boiler room was repaired during the past year, however this left the laundry in a poor state hampering organisation and cleaning to prevent cross contamination risks. There are holes in plaster around two wash hand basins in peoples rooms. At the time of our visit there was a national swine flu epidemic, so places where infection could harbour were important to keep clean. There was safe storage for cleaning equipment but this was not used for mops on our visit or noticed and acted upon, despite management reminders in staff meetings. The AQAA showed us which maintenance checks were up to date and we checked those due. Fire drills are held quarterly, and the alarm is tested weekly. There were no records available about a five year electrical circuit test to prevent fire, and servicing of the lift was overdue. CQC were not notified when the lift had broken down. Servicing of the heating system was due but not booked. Hot water is generally kept within the safe range to prevent scalds, however monthly testing by a contractor shows no access to three thermostatic valves and high risk of bacteria unless the water flow is increased to 60 degrees. This was not acted upon and there was no legionella risk assessment available. Two bedrooms in use by people had inaccessible call systems. The home has extension cords but these were not arranged so two people could not reach help quickly in an emergency. Overall, there are ineffective management controls and we made an immediate requirement to protect people. We were satisfied that the council acted within 48 hours to Care Homes for Adults (18-65 years) Page 30 of 42 Evidence: act or plan in a feasible timescale to eliminate hazards and minimise risks to peoples health and safety, and prevent the spread of infection. We requested further information about an anomaly in the response provided. Care Homes for Adults (18-65 years) Page 31 of 42 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff and roles keep changing and rotas are not accurate. Efforts are made to provide consistent temporary staff to cover shortfall and vacancies to meet peoples essential care and support needs. People are protected by checks of new staff, good inductions and there is a plan to address outstanding training needs. Evidence: There are day and night care teams, kitchen and domestic staff, and a handyperson. The statement of purpose says that staffing is arranged so that people have help to settle in when they are new. Three or four care assistants and a senior are on day shifts depending on the number and needs of people using the service. We had varied views about a new system of approval for additional staff. A request was not approved on the weekend when there were unexpected admissions and the home was full. On our visit there were 15 permanent staff and three or four vacancies for care assistants, we could not be sure. The Laurels have found it difficult to attract staff to temporary posts. There are regular changes due to a wider council reprovision plan and staff are moved between services. Staff work overtime or consistent casual bank staff or agency staff are used who know peoples needs. Care staff do peoples personal laundry and there is a contracted service for linen and towels. Care Homes for Adults (18-65 years) Page 32 of 42 Evidence: On our last visit recruitment records were not available in the home to be checked. On this visit there was evidence that seven new staff had clear police and government list checks before they commenced work. We looked at two staff files more closely. Staff fitness was checked, but there was no information about employment history or reference checks which are held at a central council location. Managers check agency staff meet specifications. New staff have Skills For Care inductions within probationary periods when competence is checked, along with annual appraisals of performance and learning needs. Since our last inspection there were changes in the management team which CQC were not informed about. Since July 09 the registered manager was moved and based in another home and an acting day to day manager was put in place and is also responsible for a small grouphome, not included in the homes registration. We queried a worker listed both on night and daytime rotas, which would breach European working time rules. We were informed that they moved to the day team - the rotas we saw are therefore not accurate about the night team and there has been a shortfall. Two staff told us that they have good support and work well as a team, trying to solve problems together. The Team Plan 2009/2010 shows that managers are providing sufficient supervision, but there is poor staff attendance at training or cancelled training which they know needs improvement. Most staff need mandatory training refreshed but we are told it is not always available when they have the capacity to release staff. The number of NVQ qualified staff is below minimum standards, however staff are due to enrol for NVQ and learning disability qualifications. It is planned for all staff to attend emergency first aid training as well as additional training about peoples conditions, communication modes and rights, such as epilepsy, autism, diabetes, Makaton signs, sensory impairments, minimising confrontation and mental capacity. Care Homes for Adults (18-65 years) Page 33 of 42 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 Commission is not kept informed about serious matters affecting people, and their views expressed to the home are not acted upon. There is insufficient oversight and risk management of the premises, quality and working practices to promote and protect peoples health, safety and welfare. Evidence: The registered manager has undertaken appropriate training but has a minimal role with the home since July 2009 - completing the AQAA and official documents, forming the managers rota and sleeping in on occasion. Most other tasks are delegated. We found insufficient oversight and accountability by registered persons. For example, since our last inspection there was insufficient action to comply with requirements we made for peoples safety. The service continues to be used for purposes it is not designed for and changes have not been made to benefit peoples welfare. Managers running the home day to day do not feel in control of admission and discharge or staffing level decisions. The registered manager confirmed they are now responsible for the oversight of two care homes and a grouphome. This is not reflected in the homes published information or Care Homes for Adults (18-65 years) Page 34 of 42 Evidence: AQAA, and the Commission was not informed as legally required, including change of the responsible individual on behalf of the council. The AQAA lacked analysis and accuracy, and we were not provided with all the information we asked for. On our visit the acting manager was on leave. Managers left in charge were surprised to see the registered manager who came over for about two hours when phoned by staff. All our questions could not be answered or records provided including reports of unannounced visits by the council for quality monitoring. One manager had returned the day of our visit from a two year secondment elsewhere. Another manager did not feel sufficiently supported following a period of illness. An acting senior was being inducted to their role. This means that the Commission were not informed of several changes of the homes management team since July 2009. Management and staffing arrangements and systems are stressful - managers appear to need to spend a lot of time finding staff cover. We discussed this with the manager and council after our visit. We were told that d decision was made about the homes future at a recent council Cabinet meeting. None of the managers we spoke to were aware of the outcome. A councilor had recently visited the home and expressed some concerns we saw noted about complaints and about the roof. We have concerns about the upkeep of the premises and insufficient health and safety culture. Managers continue to report repair needs, but these are not responded to in a timely way. Minimum maintenance checks and servicing does not appear to have oversight, and the reports of contractors about health and safety risks are not acted upon. There were avoidable accidents where people experienced lasting harm. Infection controls were insufficient to protect health. On our visit we were impressed by the capability and flexibility of the day to day managers, seniors and staff we met. There were well established systems to meet peoples essential support needs, access to health care and safety. Apart from staff rotas, records were accurate and secured so people have confidentiality. Managers were knowledgeable about people but communication systems need to improve, for example when a new service user felt unsafe. Managers have administrative support and the benefit of a team approach as the home generally runs smoothly. Human resource policies use best practice, so for example there are specifications and checks by the managers about agency staff and their training. We could not confirm from the information in the home that all legally required recruitment checks are robust, as per an agreement with the Commission about centrally held records. The home took appropriate and timely action to protect people in November 2009 after the home received information about a worker, and the Commission was informed. This resulted in dismissal in July 2009. We have concerns about the homes relationship with the Commission as we found a number of serious matters we were not made aware of. The Laurels Team Plan 2009/2010 we saw was accurate - dealing with complaints, seeking the views of people and relatives, staff supervision and training were not good Care Homes for Adults (18-65 years) Page 35 of 42 Evidence: enough and need to improve to promote and protect peoples rights. Everyone is concerned about future provision for their needs or employment. The Commission will oversee an improvement plan. The service must apply for voluntary cancellation of their registration three months in advance of closure and ensure peoples needs are met through the closure process. Care Homes for Adults (18-65 years) Page 36 of 42 Are there any outstanding requirements from the last inspection? Yes  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 Care Homes for Adults (18-65 years) Page 37 of 42 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 Description 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 Description Timescale for action 1 6 14 14(1)(2): Care reviews need 28/01/2010 to be timely and evaluate how peoples needs are effectively and lawfully met. Peoples health, wellbeing and rights need to be promoted. 2 20 13 13(2): The homes systems 27/01/2010 and medication policy must ensure medication is stored in accordance with product licenses, and protects people from undue chemical restraint. This is to protect health and wellbeing. 3 20 18 18(1)(a): Medication 27/01/2010 competence of staff must be checked periodically, to see if knowledge gained through training is applied in practice. Care Homes for Adults (18-65 years) Page 38 of 42 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 Description Timescale for action This is to protect people by safe practice. 4 20 12 Reg 12(1): Care plans and 27/12/2009 medication records need detailed guidance for individuals about homely remedies and as required medication, and if regularly needed this must be queried with the prescriber. People living in the home need regular medication reviews. This is to protect peoples health and wellbeing from side effects of combinations of medication. 5 22 22 22: A summary complaints log must be appropriately maintained to evidence the process and extent of satisfaction with the outcome, actions and learning. 27/01/2010 Peoples rights must be promoted and protected. 6 33 18 18(1)(a): Rotas need to accurately reflect staffing is sufficient to meet peoples needs at all times. 27/01/2010 People need support and supervision matching their needs. Care Homes for Adults (18-65 years) Page 39 of 42 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 Description Timescale for action 7 42 37 Reg 37: Notifications must be made to the Commission in accordance with current guidance, including changes to management arrangements. 27/12/2009 This is legally required to ensure that people are safe. 8 42 26 Unnannounced visits on 27/01/2010 behalf of the responsible individual must take place monthly to monitor quality, health and safety and evidence oversight of any necessary actions. Reports must be available in the home to be acted upon by the registered manager, and for inspection. People and the Commission need to be confident that the home has accountable oversight. 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 3 Independent mental capacity advocates should be used in accordance with the council contract so that peoples views are represented and best interest decisions about moving are progressed for their emotional wellbeing. Care Homes for Adults (18-65 years) Page 40 of 42 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 2 14 Individual activity plans are advised for people who need support to communicate and participate, and people should be consulted about celebrations, worship and social stimulation so that their needs and aspirations are met. People at risk of malnutrition or self neglect, or who are losing weight should have food intake monitoring records. An appropriate thermometer should be used to check that medication remains stable where ever it is stored, in accordance with their product licence for peoples health. People living in the home longer term should have monitored dose systems to prevent medication error. Photos on the MAR help staff to give medication to the right person. People need to be told what will happen next when they report a complaint or concern, so that they know they have been taken seriously and have the reassurance they need to feel safe. The mental capacity act codes of practice, and duties in relation to restraint, restrictions and circumstances for emergency DOLS authorisation by the home need to be clearly understood. A transparent transport charging policy should be evident in terms and conditions when staff accompany people to health appointments, especially when caring for people long term. 3 4 17 20 5 6 7 20 20 23 8 23 9 40 Care Homes for Adults (18-65 years) Page 41 of 42 Helpline: Telephone: 03000 616161 or 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 © (2010) 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. 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