Care Home: The Limes

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What the care home does well People who live at The Limes regard it as home. One person told us for example, `it`s our home so we chose the carpet`. He also said he has lived in a few other homes and this one is the best because it is more homely and cosy. Another person told us that The Limes is, `as sound as a pound`. He described the staff as `safe`, adding that they are `very kind` and `very nice`. There is a robust approach to supporting people`s physical and emotional health. The service works positively with a range of health professionals and staff support people to attend all health appointments. Since the last inspection, the service has responded well to a number of errors in medication. People are treated as individuals and staff work hard to meet their individual needs. One person for example has weekly newspapers in large print and another person, who have expressed an interest in Buddhism and engineering has been taken to local places of interest. People know how to complain but no complaints have been made by people living there or their representatives in the two years since we last visited. People living there and staff who support them all told us that they feel they feel safe living at The Limes. The manager is new to post but people have confidence in the way the service is being managed. Everybody we asked told us that all levels of management are approachable. What has improved since the last inspection? A number of improvements have been made to the premises since we last inspected. The lounge has been refurbished with the new decoration, new furniture and new carpet. Three bedrooms have been re-carpeted also and the kitchen has been refitted, providing a modern, pleasant and well maintained living space for the enjoyment of people living there. At the last inspection, we did not make any requirements for improvement but made three good practice recommendations. We consider these to have been met as staff are more aware of their roles and responsibilities including arrangements for taking breaks. In addition, following a deterioration in medication administration, steps have been taken to support staff performance. Systems have been reviewed to ensure that staff administering medication are less distracted to minimise the risk of mistakes. What the care home could do better: Some aspects of the environment have improved and the manager is aware of other shortfalls and is trying to address these. For example plans to extend the laundry have been drawn up to help staff and clients access facilities without having to go outside to avoid taking soiled laundry through food areas. In addition, the rear garden needs improvement to make it a safe and pleasant usable space for the people living there. The new manager has already identified this and is trying to ensure that the required improvements are made. We became aware from talking to people that there is not a meeting room available for private use. We experienced the effects of this by having to talk to people about their experiences of the care in a public area. The manager has identified this shortfall but it is uncertain how this could be resolved within the limitations of the current building. We identified the need for improvement to some systems to better identify and manage specific needs and risks. There are concerns about one person`s appetite and lack of nutrition. The manager should use a nutritional screening tool for anyone who may now or in the future be at nutritional risk. This will augment existing systems in place to support good nutrition where there are concerns. Another person has suffered a number of falls. Current falls risk assessment are too vague and brief and are not satisfactorily reducing the number of falls that this person is experiencing. Changes have been made to ensure that medication is administered safely with fewer errors. It is important now, that a robust system is in place to help managers check that people are receiving their medication as it is prescribed to support their health and well-being. With this in mind, we have suggested that the service gives serious consideration to implementing a carry forward system so that it can check that the amount of medication in stock tallies accurately with the amount that should be in stock. Currently, there is only a system to tell the manager how much medication is in stock and without additional information this becomes meaningless. It is important that written medication protocols are introduced to tell staff how and when to administer medication prescribed `as required`. This will ensure staff have clear directions to avoid the risk of error. Using a number of different sources of documentation, we were not able to always fully evidence the provision of sufficient staff. We feel that this highlights shortfalls in administration rather than shortfalls in staffing levels. However, documentation must be kept up-to-date and accurate. Our discussions with the manager highlighted the need for some improvements in respect of compliance with newly introduced deprivation of liberty safeguards. The organisation needs to provide the manager with a policy and additional training to help her to understand her responsibilities. The manager will need support to review how and whether the service currently complies with this legislation. Discussion showed there to be some uncertainty about people`s capacity combined with some blanket rules which limit everybody`s freedoms based on the needs of possibly the minority of people. Key inspection report Care homes for adults (18-65 years) Name: Address: The Limes 39 Queens Road Donnington Telford Shropshire TF2 8DA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Deborah Sharman     Date: 1 4 0 7 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 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: The Limes 39 Queens Road Donnington Telford Shropshire TF2 8DA 01952402295 01952410779 enquiries@prokare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): prOKare Ltd. Name of registered manager (if applicable) Miss Samantha Wilkinson Type of registration: Number of places registered: care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 6 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: Mental Disorder, excluding learning disability or dementia (MD) 6 Date of last inspection Brief description of the care home The Limes Care Home provides personal care and accommodation to six adults with a mental disorder. It is owned by PrOKare Ltd and was first registered in July 2001. Situated in a residential area of Donnington the Home is within easy walking distance of local amenities, i.e. shops, public houses, transport, and in close proximity to Telford Town Centre. The Home is a detached two-storey property with communal Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 6 Brief description of the care home sitting and dining areas, six bedrooms offering single occupancy, including three bedrooms on the ground floor benefiting from en-suite facilities. The property well maintained, with decor and furnishings providing a warm, homely and comfortable ambience. Consultation with people who live at the home takes the form of regular meetings, discussions and involvement in the development of care and activity plans. Fees. The standard weekly charge is currently £1361.00. The e mail address for the service has changed. From September 2009 please e mail enquiries@procare.co.uk Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: One Inspector carried out this unannounced key inspection on 14th July 2009 from 9.30am to 7.00pm. No one knew we were going and they were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by us as key. These are the National Standards which significantly affect the experiences of care for people living at the home. Prior to the inspection, we looked at information we hold about the service, referring to the previous key inspection report from 2007, the Annual Service Review report 2008 and incidents the service has notified us about since 2007. We used this information to plan the focus for our inspection. We had requested the services AQAA or Annual Quality Assurance Assessment but as it Care Homes for Adults (18-65 years) Page 6 of 30 was not due for return to us until 14 July 2009, the day we inspected, this was not available to us prior to the inspection. We did not send surveys out to people living there prior to inspection as we planned to talk to them about their experiences of the care and support provided. During the course of the inspection we used a variety of methods to make a judgement about how service users are cared for. The manager was available to answer questions and support the inspection process. We also talked to four clients and a staff member. We looked at how one person is supported in detail using care documentation and by talking to him. We sampled aspects of another persons care. We read a variety of other documentation related to the management of the care home such as training, recruitment, accidents and complaints. We toured the ground floor of the premises to see how it meets the needs of the people whose care we looked at. All this information helped to determine a judgement about the quality of care the home provides. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Some aspects of the environment have improved and the manager is aware of other shortfalls and is trying to address these. For example plans to extend the laundry have been drawn up to help staff and clients access facilities without having to go outside to avoid taking soiled laundry through food areas. In addition, the rear garden needs improvement to make it a safe and pleasant usable space for the people living there. The new manager has already identified this and is trying to ensure that the required improvements are made. We became aware from talking to people that there is not a meeting room available for private use. We experienced the effects of this by having to talk to people about their experiences of the care in a public area. The manager has identified this shortfall but it is uncertain how this could be resolved within the Care Homes for Adults (18-65 years) Page 8 of 30 limitations of the current building. We identified the need for improvement to some systems to better identify and manage specific needs and risks. There are concerns about one persons appetite and lack of nutrition. The manager should use a nutritional screening tool for anyone who may now or in the future be at nutritional risk. This will augment existing systems in place to support good nutrition where there are concerns. Another person has suffered a number of falls. Current falls risk assessment are too vague and brief and are not satisfactorily reducing the number of falls that this person is experiencing. Changes have been made to ensure that medication is administered safely with fewer errors. It is important now, that a robust system is in place to help managers check that people are receiving their medication as it is prescribed to support their health and well-being. With this in mind, we have suggested that the service gives serious consideration to implementing a carry forward system so that it can check that the amount of medication in stock tallies accurately with the amount that should be in stock. Currently, there is only a system to tell the manager how much medication is in stock and without additional information this becomes meaningless. It is important that written medication protocols are introduced to tell staff how and when to administer medication prescribed as required. This will ensure staff have clear directions to avoid the risk of error. Using a number of different sources of documentation, we were not able to always fully evidence the provision of sufficient staff. We feel that this highlights shortfalls in administration rather than shortfalls in staffing levels. However, documentation must be kept up-to-date and accurate. Our discussions with the manager highlighted the need for some improvements in respect of compliance with newly introduced deprivation of liberty safeguards. The organisation needs to provide the manager with a policy and additional training to help her to understand her responsibilities. The manager will need support to review how and whether the service currently complies with this legislation. Discussion showed there to be some uncertainty about peoples capacity combined with some blanket rules which limit everybodys freedoms based on the needs of possibly the minority of people. 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 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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. People are, in part, provided with information about the service to help them to decide whether to move in and to understand their rights and responsibilities. Evidence: We looked at how the service helps people to decide whether to move in and how it supports them once they have moved in. Although the person had chosen not to read it, we could see that he had been provided with a brochure all about the home. This explains the weekly fee and who to contact in the event of there being a concern. This person who had been living at the home for more than four months had not been issued with a contract to ensure that he was fully aware of his rights and responsibilities. Prior to moving in, we could see that the service carried out an assessment of his needs, so that they could be sure that The Limes was the right place for him. They Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: also gathered information from other parties to help them with this decision. This included a visit to him at his previous address. Since admission, the service has continued to assess any needs he may have by involving a range of other professionals such as a a psychiatrist, psychologist and occupational therapist. We can see that a number of people including the client were involved in reviewing the placement after the first three months. Reports prepared by the service are very detailed and show that they have been closely monitoring how he has been settling in. After a difficult start, the indication is that he appears to be settling. However, discussion with him indicates that he is not happy living away from an area he is familiar with and would prefer to move back to this area. Care Homes for Adults (18-65 years) Page 12 of 30 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. Written guidance is available to inform staff how to meet peoples needs and risks. But this should be further developed to cover all known needs and risk areas. People are supported to make choices and decisions about their lives on a day-to-day basis. However some restrictions put in place to meet the needs of some residents are impacting on the choices and freedoms of all residents. Evidence: We looked at the guidance that is in place to help staff know how to meet peoples needs and risks. Up to date guidance was available for most if not all areas of need. Additional written guidance is needed in respect of nutrition where people have a poor appetite and also in the support that people need to manage their finances. However, discussion with the persons key worker reassured us that staff are aware of these needs. Perusal of accident records showed us that one person has sustained several falls. The advice of a physiotherapist has been sought. However a more robust response to Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: trends in accidents is required. The physiotherapist could have been contacted sooner in this case and falls risk assessments are not sufficiently timely or detailed. However, it is positive that a range of equipment to support this persons mobility is in place. These include a grab rail on the bed, shower chair and a walking stick which is used. The appropriateness of his footwear is also under review, but measures to reduce risk in the meantime should be considered. By talking to people and observing staff interaction with clients, we could see that people are treated respectfully and are offered choices on a day-to-day basis. We could see that there are alternatives on the menu for people to choose from and other options are offered when menu options are declined. We talked to someone who told us that he is fully in control of when he goes to bed and when he gets up in the morning. We talked to someone else who told us that as it is our home we chose the new carpets from samples provided. Some choices are restricted. For example we found that in order to meet the needs of one person, food is locked away from everybody. Again, in order to meet the needs of another person, there is a blanket rule to lock all external doors and the side gate. This will be considered later in this report, under management standards, in relation to deprivation of liberty safeguards. Care Homes for Adults (18-65 years) Page 14 of 30 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. Each person is treated as an individual and the care home is responsive to his race, culture, religion, age and disability. People can take part in activities that are appropriate to their age and culture and are part of their local community. People enjoy a choice of healthy meals but systems need augmenting to support people who are identified as being at nutritional risk. Evidence: We talked to 5 people about their lifestyle. We could see that the frequency of activity depended on the preferences and personal motivation of those involved. Two people that we spoke to are evidently very occupied with a full programme of activities and like it this way. One of these people said he doesnt have time to be bored. He he told us that he enjoys going to college once a week, that he eats out once a week and plays ten pin bowling and goes to the gym weekly too. During a tour of the Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: environment we saw him engaged in a game of Scrabble and that he has a working computer in his room to use when he wants to. A second person confirmed that he is also busy all week. He told us that staff support him to attend church when he wants to and documentation verified this. We could also see that following a request, staff have supported him to purchase a fish aquarium and are establishing a routine with him for its care. Two other people whose care we looked at are less motivated to undertake social activity. However, one of these people told us that although he does little, this is not a reflection on the service. He added that he appreciates not being hassled about this. Whilst the other person also lacks motivation, we can see that staff have identified his personal interests and strengths and have promoted these with him to good effect. This has involved helping him to purchase a musical instrument and taking him to local places of personal interest. Staff are aware that this person is keen to have a job and are making enquiries on his behalf. One person that we spoke to was very excited about an imminent holiday. He told us that holiday destinations had been chosen as a group. He is going to Blackpool with a peer and 2 staff. Another person is planning time away with a relative. People that we spoke to are satisfied that routines are flexible and suit their needs. One person who seemed surprised at the question, confirmed that he alone chooses when to get up in the morning and when to go to bed. We were able to confirm peoples satisfaction with meals in a number of ways. There is a menu which offers choices and we could see the menu was adhered to. One person who did not want either of the menu options was offered an alternative. People told us that they like their meals and the minutes of recent residents meetings confirm this. Medical advice has been sought about one persons poor appetite and his weight and food intake is being monitored. We could not see that a nutritional screening tool has been used. Since inspection we have been told that nutritional screening tools have been recently introduced. When fully in place these will augment the existing systems. Care Homes for Adults (18-65 years) Page 16 of 30 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. 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. Medication administration practices have been changed to reduce the number of errors to better safeguard peoples health and welfare. Evidence: The service works hard and proactively to ensure that peoples physical and emotional health needs are assessed and met. We could see, for the people whose care we looked at that appointments with a full range of health professionals have taken place. This included dental, optical, chiropody, psychiatry, psychology, psychotherapy , the local doctor, surgery nurse and dietician. In addition advice has been sought from occupational therapy and physiotherapy colleagues. We have referred earlier in this report to the need to develop further strategies for assessing and responding to nutritional risk. In the two years since we last inspected, there have been a series of medication errors. We have been kept fully informed of these. One incident involving an accidental double dose of insulin to one resident was investigated as part of Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: safeguarding procedures by the local authority and this was not taken to the next level by them. Errors have always been identified quickly with steps taken to minimise immediate risk. Staff have received warnings where appropriate but have also received support to improve their practice. This has included refresher training and positively, systems have been changed to ensure staff administering medication are less distracted. Staff told us that they are more comfortable with the new systems. We looked at the management of medication for the two people, whose care we were looking at in detail. One of these people does not take medication regularly. Where short courses of medication were prescribed and refused, this was appropriately reviewed with the prescribing medic. The second person takes a range of regular and as required medication. Records indicate that this is being administered as prescribed, therefore promoting the persons health and well-being. Weekly stock checks of as required medication are being carried out with the numbers of drugs in stock being recorded. We discussed this with the manager who agreed that this is not currently a meaningful process. It will have more value if medication stocks are compared against the amount of medication which should be in stock. In order to do this, it is good practice to implement a carry forward system of medication remaining in stock at the time of new deliveries. This will alert managers to any discrepancies which will enable them to know whether peoples medication is being administered as prescribed. In addition, it is important that the manager ensures that written protocols for each persons as required medication are in place. Currently this is not the case. We found one person who is prescribed different painkilling medication to be taken as required for different medical conditions. It is vital that guidance is in place for this to ensure the correct medication is used for the correct condition and in the event of the person experiencing pain from both conditions, that staff know what action to take in order to avoid potentially overdosing the person. Guidance should be obtained from the prescribing medic and should include whether these medications can be used together in the event of several symptoms. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns with their care, they know how to complain. Satisfaction levels however are high and complaints are infrequent. The Limes safeguards people from abuse, neglect and self harm. Evidence: People know how to complain if they need to. We could see that they have been provided with information about how to complain and surveys carried out by the organisation show that people living there believe that standards in relation to complaints are exceeded. One person told us that he is very satisfied with the service and that nothing can improve. However, he said that if he did have a problem he would feel able to approach any of the staff about it. Complaints records show that there have been no complaints by service users or their representatives since we last visited two years ago. A complaint or grievance that we had passed to the service to investigate on behalf of a staff member was recorded openly in the complaint record and was resolved. We talked to a number of people all of whom confirmed their belief that people living at The Limes are safe. Financial systems are safe and people are satisfied with how their money is managed. The service has a no restraint policy and staff understand how to defuse escalating situations. We could see that where situations could not be Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: contained, staff called the police for support rather than engage in physical intervention in accordance with their policy. One incident has been investigated by the local authority under safeguarding procedures. This was in relation to one person receiving a double dose of insulin accidentally. The local authority decided not to pursue the matter further. Care Homes for Adults (18-65 years) Page 20 of 30 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. People stay in a home that is homely, clean, comfortable, pleasant and hygienic. The home makes sure that people have the right specialist equipment that encourages and promotes their independence. People like their bedrooms which are personalised, reflecting their interests and tastes. People have enough privacy when using toilets and bathrooms. Evidence: Many improvements have been made to the environment recently. The lounge has been refurbished with new furniture, carpets and curtains. People living there told us that they had been involved in choosing these. The renovations provide a calming and homely environment in which to relax. In addition, the kitchen has been refitted and new carpeting provided in some peoples bedrooms. The week before we inspected, a new lock system had been fitted throughout the premises. Consequently people were about to be provided with keys to their bedrooms. The manager has plans to improve further aspects of the premises. These include an extension to provide new laundry facilities. It is positive that risk of cross contamination is minimised as soiled laundry is taken around the outside of the building rather than through the kitchen to the laundry area. Improved laundry facilities will make infection control easier for both people working and living there. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: The existing laundry is well-equipped but the walls are not washable as they are wallpapered. Once these improvements have been made, the manager is keen to improve the rear garden space to make it more accessible and pleasant for people to use. We toured the premises and found it to be clean and tidy with no evident hazards. We could see that there are aids and adaptations available to promote peoples independence where necessary. For example, we could see a rail fitted to a bed to enable the person to safely get in and out of bed independently as well as toilet rails and frames. People have en suites with showers but a communal bath is available to provide them with a choice of bathing facility. A Private area for meetings is not available. There was nowhere available for us to speak in full privacy to people living and working at The Limes. The manager agreed that this can be a problem on a day-to-day basis. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are met and they are supported because the staff get the right training, supervision and support they need from their managers. People can have confidence in the staff at the home because checks have been done to make sure they are suitable. Evidence: People who live at the service speak highly of the staff. One person told us that the staff are very kind. We observed staff to interact with people respectfully and calmly when faced with anger. An analysis of surveys completed for the service by people living there shows that people feel that the approach of staff exceeds expected standards. Discussion with a staff member assured us that the staff member feels well-trained, well directed and well supported. The staff member reported enjoying her job, receiving monthly supervisions with her manager and felt confident that previous uncertainties about staff roles and responsibilities had been resolved. She was also able to explain that staff are now clear about the arrangements for taking breaks, whilst simultaneously ensuring that appropriate supervision levels are provided. We looked at the staff rotas and as they do not satisfactorily evidence the provision of Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: appropriate staffing levels at all times, it was necessary to seek evidence from other sources. These provided some but not full assurance that staffing levels are appropriately maintained. It would seem however, that the shortfalls are administrative as no one expressed concerns about staffing levels. We agreed with the manager the importance of maintaining documentation which accurately reflects staffing actually provided. We suggested in addition to accurately maintaining the rota, that the manager introduced a system whereby permanent as well as agency staff sign in and out of the premises. This would effectively demonstrate staffing levels as well as provide information to the fire service in the event of a fire. We looked at how 2 new staff members had been recruited. We are satisfied that all steps are taken to ensure that vulnerable people are safeguarded by this process. In addition, it is positive that the service is beginning to involve people living there in decisions about which applicants are appointed. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have confidence in the care home because it is run and managed appropriately. Where there are deficits, these are identified by the service and action is taken to address them in the interests of the people who live there. The environment is safe for people and staff because health and safety practices are carried out. Evidence: Since we last inspected the management arrangements at the home have changed. A new manager has applied to us to be registered, had attended our office the week before inspection for interview and was waiting the outcome. Throughout the inspection, we were aware that the manager, although new in post had a good understanding of the services strengths and weaknesses and expressed determination to make the improvements she had identified as required. She told us that she felt well supported, is attending regular management meetings and is receiving regular training and supervision. The manager has not undertaken risk assessment training with the company and we recommended that she makes arrangements to do this. People that we spoke to are satisfied that the service is managed well and that managers are approachable and listen to concerns. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: A range of quality assurance systems are in place to help the service to measure its own performance. Surveys were last sent to people living there in July 2008. The results have been analysed and show that at the time people were particularly satisfied with the staff approach and support to make choices, how their needs are met, access to local facilities, care planning and awareness of complaints procedures. It highlighted areas for improvement as being involved, obtaining advocacy support and independence skills without feeling restricted by risk. The latter links to our findings in relation to new deprivation of liberty safeguards. We concluded with the manager that in consultation with partner agencies, she needs to consider to what extent the service is meeting this new legislation. We were alerted to the need to carry out such a review by the existence of blanket policies to lock all external doors and the garden gate along with the blanket policy to lock all food away. Guidance about deprivation of liberty safeguards from the Department of Health is available to the manager on the premises and she said that she has received an hours briefing on the subject. The service is currently working to produce a deprivation of liberty policy and when available, this along with suggested more in-depth training will support the manager to meet her responsibilities. The manager expressed some frustration that the lack of on-site office facilities leads to delays in the provision of some work as all administration tasks are sent to head office to be carried out. We experienced this when we asked for some records such as minutes and care plans which were not available as they had been sent to head office for typing. We looked at a range of systems in place to ensure the safety of the environment and equipment within it. Everything that we requested was available and up-to-date. This included service maintenance documentation, environmental risk assessments, assessments of hazardous chemicals and accident records. A fire risk assessment has been carried out by an external independent company. The conclusion was that risks are low. However, the manager assured us that areas recommended for action had been dealt with. In addition, local authority environmental health officers visited the premises to carry out a food safety inspection in February 2009. They awarded the service 3 stars for food safety which is considered to be a good rating. Care Homes for Adults (18-65 years) Page 26 of 30 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 27 of 30 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 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 6 Care plans should include information about the management of finances and the administration of medication prescribed as required etc This will ensure that staff are informed how to support all known care needs. Falls risk assessments are in place but should be developed and improved to consider all variables and known risks. Trends in accidents should be more closely monitored and responded to. 2 9 3 4 20 20 Protocols for the administration of each as required medication should be put in place for each service user. A carry forward system should be implemented immediately prior to the delivery of new medication, so the service is always aware of how much medication should be in stock. This can then be compared regularly as part of the audit process to the amount of medication in stock. This will serve to alert managers to any discrepancies in administration. Staffing levels provided should be accurately represented in rosters. This will ensure the service can always account for Page 28 of 30 5 33 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations who is on the premises and that peoples needs are being met by a sufficient numbers of staff. The manager should consider implementing a system whereby all staff, permanent and agency sign in and out of the premises. This will support Rota documentation and staff safety in the event of a fire. 6 37 Steps should be taken to review the services compliance with new deprivation of liberty safeguards. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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