Care Home: Wrekin Cottage

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What the care home does well People who live at Wrekin cottage are happy to do so. They enjoy the activities, look forward to their annual holidays and are supported to have contact with their families. Staff that that we spoke to care about the standard of service that they provide. Staff feel that they are sufficiently trained to undertake their job role and to support people effectively. Robust checks are carried out on new staff before they start in employment to ensure, as far as possible, that they are safe to work with vulnerable people. People who live at Wrekin cottage feel able to report concerns that they have and have done so. What has improved since the last inspection? Bathrooms and toilets have been decorated and are now more inviting places to spend time in. Temperature regulators have been fitted to taps to protect people from the risk of scalds. Staff had identified that water from one outlet was excessively high and because it was considered unsafe, the room had been locked so that it was inaccessible to people. We made a requirement at the last inspection for the service to review one person`s medication with the prescribing medic. This has been done and the person is now taking less medication. What the care home could do better: The last six months have been unsettled for Wrekin cottage. In this time, there has been a major reorganisation and in addition the registered manager has not been at work. In her absence, three different people have consecutively had day to day responsibility for managing the service with insufficient support from senior managers, although this is beginning to improve now. We found files to be disorganised and this does not help staff to monitor peoples care or to find information they need easily. Care plans have suffered during the time of instability and have not always been kept up to date or been changed when peoples needs have changed. This has meant for example, that systems have not been put in place to ensure dental advice has been carried out and records show lack of improvement in oral health for one person over a significant period of time. Lack of service monitoring by managers has meant that a request for staff to carry out bowel monitoring in respect of one person, has not been implemented. Therefore it has not been possible for staff to accurately know whether to administer bowel function medication to promote this persons dignity, health and comfort. There have been five allegations, which the service has acted upon. Staff are aware of incidents which have happened and for the most part how they can protect people from the risk of these things happening again. We were not able to clarify whether the damp problem we reported at the last inspection, has been resolved. However, it was agreed that parts of the building retain a strong musty damp odour. A recommendation made by an independent contractor in November 2007, to fit an additional smoke alarm in the corridor has not been met. We identified an issue which in the interests of the persons dignity, good hygiene and infection control, must be resolved quickly. The service continues not to have systems in place to help it to measure and improve its own performance. Key inspection report Care homes for adults (18-65 years) Name: Address: Wrekin Cottage Forbes Close Ironbridge Telford Shropshire TF7 5LE     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: Deborah Sharman     Date: 1 3 1 0 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: Wrekin Cottage Forbes Close Ironbridge Telford Shropshire TF7 5LE 01952432065 01952432209 nicky.rowe@care-ltd.co.uk www.selfunlimited.co.uk Self Unlimited care home 16 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 16. 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 category: - Learning Disability (LD 16). Date of last inspection Brief description of the care home Selfunlimited is a registered charity established in 1966 formerly known as Cottage And Rural Enterprises (Limited). The Company has communities nationwide and its headquarters are based in Leicester. Selfunlimited, Ironbridge is a residential development that occupies a small cul-de-sac in the Ironbridge area of Telford. The development was purpose built and is situated close to local amenities and is a short journey from Telford Town Centre. Wrekin Cottage was individually registered with us in September 2006 as part of a wider plan to modernise and develop the service. Changes to its registration mean that the home is now registered to provide accommodation and personal care to a maximum of sixteen adults with learning Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 16 2 2 1 0 2 0 0 8 Brief description of the care home disabilities below the age of 65 years. Wrekin cottage is set in beautifully maintained and attractive gardens. In addition to the cottages on site service users have access to workshops, a community centre, communal dining room and games area. Weekly fees are explained in the Service User Guide. 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: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: Two Inspectors carried out this unannounced key inspection on 13 September 2009 from 10am to 7pm. 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. We have been told that people who live at Wrekin Cottage prefer to be called residents and we therefore refer to them as residents in this report . Information about the performance of the home was sought and collated in a number of ways. Prior to inspection, on two occasions, we had requested information and data about the home in an annual return which is called an AQAA. However, the service did not receive these requests and therefore we did not have this information available to Care Homes for Adults (18-65 years) Page 6 of 30 us prior to inspection or for use at the time of writing. We have agreed a date for the return of this information. We tried to send out surveys to people living, working and visiting the home, but again in error these were not posted so this information was not available to us for the purpose of planning and judging the service. Therefore, during the course of the inspection we used a variety of methods to make a judgement about how service users are cared for. The new Team Leader who had day to day responsibility for the service and his manager were available to answer questions and support the inspection process. We also talked to three residents. We looked in detail at how a new resident has been supported to choose the home and to move in. We looked also at how two further residents are supported in detail using care documentation and by talking to them and staff. We had the opportunity to talk in detail to the parents of one of these people who were visiting. We followed up information provided at a Safeguarding meeting to verify steps taken by the home to safeguard people in light of the allegation made. We also looked at what the home has done to meet the requirement and recommendations we made at the last inspection in 2008. 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: The last six months have been unsettled for Wrekin cottage. In this time, there has been a major reorganisation and in addition the registered manager has not been at work. In her absence, three different people have consecutively had day to day responsibility for managing the service with insufficient support from senior managers, although this is beginning to improve now. We found files to be disorganised and this does not help staff to monitor peoples care or to find information they need easily. Care plans have suffered during the time of instability and have not always been kept up to date or been changed when peoples needs have changed. This has meant for example, that systems have not been put in place to ensure dental advice has been carried out and records show lack of improvement in oral health for one person over a significant period of time. Lack of service monitoring by managers has meant that a request for staff to carry out bowel monitoring in respect of one person, has not been implemented. Therefore it has not been possible for staff to accurately know whether to administer bowel function medication to promote this persons dignity, health and comfort. There have been five allegations, which the service has acted upon. Staff are aware of incidents which have happened and for the most part how they can protect people Care Homes for Adults (18-65 years) Page 8 of 30 from the risk of these things happening again. We were not able to clarify whether the damp problem we reported at the last inspection, has been resolved. However, it was agreed that parts of the building retain a strong musty damp odour. A recommendation made by an independent contractor in November 2007, to fit an additional smoke alarm in the corridor has not been met. We identified an issue which in the interests of the persons dignity, good hygiene and infection control, must be resolved quickly. The service continues not to have systems in place to help it to measure and improve its own performance. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can decide whether to move into the home because they can have a trial stay at the home to help them to decide if they like it. Admission assessments and initial care plans should be reviewed and strengthened to help staff support new people and fully meet their care needs. Evidence: We examined the file of the person most recently admitted to make sure peoples needs were being fully addressed. There was a social work assessment on file but the homes assessment consisted of pages of handwritten notes which were not dated or signed. This person had a trial period for a week to ensure that they wished to live in the home and that their needs could be met. Records had only been kept for three of the days of this trial period and were not detailed enough to ensure his needs had been properly assessed. The Service user guide has been updated very recently and is now in an easy read format with pictures making it easier for people living in the home to understand. This Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: had some useful information on the facilities available and on the service people living in the home can expect to receive. This now needs to be explained to all current and prospective residents. We asked to see contracts for people we case tracked and were told that these are held at the organisations head office. One contract was seen on computer and although this person had been living in the home for nine months the contract still referred to his previous placement and had not been updated or signed. New residents should be issued with up to date contracts at the time of admission which are explained and signed by all parties. 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. Plans of care are in place but the home does not always keep them up to date and accurate. This does not tell staff how to provide the support people need. Staff are committed to promoting rights and choices. However, people are not always able to make full decisions about their lives due to other limiting factors. Evidence: We spoke to staff who said they had found it difficult to keep care plans up to date this year as they have been like a ship without a captain. We looked at three peoples care plans. Where care plans had been updated recently, they did not contain guidance about significant issues or reflect changes in peoples needs. Dental advice given on a number of occasions over a period of months was not included in a care plan and care records demonstrate a lack of improvement in dental hygiene as a consequence. Toileting care is not included in guidance for staff for one person and staff were unclear about what was expected of them. Dignity and infection Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: control have been compromised as a result for this person. Guidance we looked at for another person describes his favourite snacks but elsewhere prohibits staff from allowing him to have these. The persons religious denomination is recorded along with a prompt to seek more information about this, but after several months this had not been done. Where we found an updated care plan containing information about a change in need and the need for health monitoring, the monitoring had not been carried out by staff, indicating the ineffectiveness of the care planning system and its monitoring. We looked at whether the people whose care we were sampling had had their care needs reviewed by their placing authorities. We could see that one person had had annual reviews supported by Wrekin Cottage staff. A new resident had had an intial formal review shortly after moving in, but the service was not able to demonstrate whether a multi agency reviewed planned but cancelled six months later had taken place. We looked at how people are supported to make choices about their lives and saw some evidence of good practice. People have been supported to choose their holidays. An increase in charges to reflect the full holiday costs, may inhibit peoples future choices. Minutes of residents meetings show us how people are engaged and consulted about issues affecting them but it was not always possible to find evidence of how peoples feedback had been acted upon. For example in meeting minutes we saw one person had asked on more than one occasion for his favourite meal and reassurance his request had been heard was recorded. The service was not able to demonstrate that he had been enabled to have this meal in the weeks that followed. Relatives explained to us how their daughters work experience organised by day services had been halved to share the opportunity with more people. They described how this had given her pleasure and purpose and talked of her distress when the long term arrangement which she considered to be her job, changed. They felt she was not consulted about the change. Also, a safeguarding incident between two residents has lead to the one person having to limit her freedoms to an extent within her own home in order to reduce any future risk to herself. Risk assessments had been formally carried out for a range of risks for the people whose care we were looking at. These were detailed, up to date and showed steps in place to minimise risks identified. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Opportunities to take part in activities has fluctuated over the last few months. People are supported to maintain contact with their family and friends. People have healthy, well presented meals and snacks, at a time and place to suit them. Evidence: When we arrived we found arrangements being made for a group of people, supported by staff to have a day at the sea side. Another person was getting ready to have lunch out with her parents to celebrate a family birthday. We looked at the lifestyles of the people whose care we sampled to judge how they spend their time. Records showed us that one of these people had three goals, special things he would like to do. Staff told us that he had been supported to do two of these Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: things although records did not confirm this. A third goal, a holiday request had not been met as a result of increases in the way people are charged for holidays. A second person was looking forward to her holiday of choice abroad the following week. She had a full time table of activity but was upset that her work experience had been reduced from fortnightly to weekly. Staff told us that over the last six months opportunities for activity and trips out had reduced because of staffing shortages and this was confirmed in minutes of residents meetings where an apology was made to residents for this. Peoples experiences have varied however. Relatives told us that other than the reduction in work experience, activity levels have been maintained for their daughter because her keyworker makes it happen. Cooked meals at lunchtime have been replaced with packed lunches. One resident we spoke to said she misses the cooked lunches and had initially been given sandwiches that she didnt like. However, this no longer happens she said and packed lunches also now have healthy options included. We saw people enjoying their evening meal which looked appetising with generous portion sizes. People are consulted about meals and are able to request their favourites. However, meal records are sporadic and the service was not able to demonstrate that it had provided one resident with his favourite meal as he had requested and as he was promised. On one occasion, using records, we were able to see that one person who dislikes salad was provided with an alternative. 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 adequate 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 usually met although staff do not always follow procedures and this can leave gaps in peoples health care. The care home supports people with their medication in a generally safe way but improved management systems are required to demonstrate this more accountably. Evidence: We looked at peoples care and health records. We could see that staff consulted the doctor following an unusual incident which was potentially a sign of a health problem. The doctor requested a sample so that further tests could be done and the service could not assure us that the doctors request had been acted upon. This is not sufficiently accountable practice. Another person takes laxatives and following a period of constipation, the staff reviewed this with the Doctor who gave permission for the usual laxative dose to be increased as required. Discussions at inspection now indicate that this person suffers with loose bowels. The care plan states that bowel movements are being monitored Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: but records were blank and people agreed that this hasnt started yet. In the absence of monitoring, staff cannot know how to administer the laxative. Systems are not sufficiently developed to support her to manage her toileting routine independently and with dignity. The problem of non flushable wipes had not been solved in a way that was acceptable to personal dignity or hygiene. However, this same person is supported to attend regular blood tests and has been supported by staff under medical supervision to come off two medications which were negatively affecting her physical health. This, without detriment to her mental health is a good outcome for her. She has also been supported to attend the optician regularly as well as the dentist, although there was no evidence of the dentists advice being implemented and dental hygiene remained a concern to the dentist over a 12 month period. We looked at medication management for the three people whose care we looked at. One person takes no medication. The second person only takes one medication and from looking at records and stocks, he appears to be receiving it as it is prescribed to promote his good health. The third person has been medically support to reduce the amount of medications she takes to good effect, but in order to administer her laxative properly, staff must begin to monitor bowel movements in accordance with her care plan. We tried to audit one boxed medication as this was packed separately to the other medications. By checking the number of tablets delivered against the number of administrations and the number of tablets remaining in stock, it should be possible to see if the records have integrity and can with assurance indicate that the medication is being administered as the doctor intended. This is a system that the managers should use to check the safety of medication administration practice. We were not able to do this because the system used to record medication delivered to the premises is not sufficiently robust. We explained this to staff and managers who understood what they must do to improve this. There has been one medication administration error since we last inspected. Medical advice was sought and no harm came to the resident. The matter was investigated thoroughly and steps were taken to ensure that the staff member who made the error was competent to continue to administer medication. A system to check the ongoing competency of staff to administer medication is just beginning to be implemented with one staff member having been assessed to date. 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 adequate 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 or people close to them, feel able to complain. Their concern is looked into and action is usually but not always taken to put things right. The care home takes action to follow up any allegations. Evidence: Since the last inspection, 5 matters affecting peoples protection have been reported in a timely way to Social Services. Residents evidently feel able to speak up and report matters that concern them either about their peers or about staff practice. Since we last inspected, 3 residents have spoken up and reported matters which have been taken seriously, have been reported to Social Services and have been investigated. Similarly, staff have used the whistle blowing policy to report concerns which are subject to ongoing investigation. One safeguarding complaint has been resolved and was not upheld at an early stage of investigation on the basis of mistaken identity. Other matters are still be investigated. During the investigations, the service has taken some steps to ensure that people are safeguarded. We noted that in respect of an incident between two residents, the emphasis had been Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: on protecting the victim and this has resulted in some limitations being imposed on her. Her family are happy with the measures implemented for her protection. A safeguarding plan was not immediately put in place to ensure the alleged perpetrator was monitored although records show that staff intervened to protect on more than one occasion. A second person became a victim allegedly a short time after the first incident and this is still being investigated. Other people may be at risk, but staff are satisfied that they are able to monitor the situation. From talking to staff, we could not be sure that other residents are taking measures to protect themselves in the way that was described or that staff are aware of the need for this. Complaints made by residents which have been referred to safeguarding investigation are recorded thoroughly. We spoke to relatives who told us they had complained about the quality of sandwiches at lunch time and about the inability to flush toileting wipes, the associated smell and infection risk. They felt they were listened to but had mixed feelings about the effectiveness of the outcomes of their complaints. None of these issues were recorded in complaints records available to us. However, the relatives felt that as a result of complaining, sandwich quality has improved but that the issues they raised about infection control toileting practice had not. Our inspection confirmed this. Systems are in place to account for how staff support people to spend their money. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Living areas are homely and peoples rooms feel like their own although the layout is not domestic in style. The premises are generally well maintained but areas of the building smell damp and musty and this is not pleasant. Arrangements for the disposal of clinical waste are not acceptable and do not promote one persons dignity. Practices place everyone at risk from poor infection control practice. Evidence: People who live at Wrekin Cottage are physically independent but have a choice of showers and baths and adapted facilities. It is positive that thermostatic valves have been fitted to hot water taps to reduce the risk of scalds. Temperatures have continued to be monitored and action has been taken to reduce risk where in one bathroom, water was found to exceed safe temperatures. Since we last inspected, bathrooms, shower rooms and toilets have been redecorated and provide a cleaner and more pleasant environment in which people can relax and carry out their personal care. We were told that cleaniness had deteriorated prior to the inspection, but we found it to be clean on the day we visited. No body was able to conclusively update us about whether the damp problem under investigation at the last inspection has been resolved or how. However, there is a notable damp musty smell in some parts of the building particularly the lower ground Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: and upstairs. We identified practice that needs urgent improvement in respect of waste disposal. One person is using moistened wipes as part of toileting care. To avoid these blocking the toilet, the person has been asked to dispose of the wipes in the sanitary bin, which is contracted to be emptied every six weeks. People described to us, the smell that this generated when the weather was hot in the summer months. Unsatisfactory alternatives were employed which increased the risk of cross contamination and at the time of inspection, this matter had not been resolved. Guidance was not available to staff about how they were expected to support the person to manage this and the practice, as well as compromising infection control, does not promote the persons independence or dignity. The team leader resolved to explore the option of obtaining flushable wipes. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are supported by a staff group who are recruited safely. People would be better supported by a staff team who were regularly supervised. Evidence: The organisation has undergone a restructure recently and a number of key staff have left. The home has also been without a registered manager since March 2009. Relatives we spoke to expressed concern about the highstaff turnover and lack of management over recent months, saying there is no one left who knows our daughter. However they spoke highly of their daughters keyworker in whom they have absolute confidence and without whom they said, the last few months would have been very very difficult. Over recent months there have been staff shortages and this has had an affect on the lifestyle of people living in the home as they have not been able to be supported to attend as many community activities. Two new staff recently started work and another permanent member of staff has been recruited. When he takes up his appointment next month the home will be fully staffed which should lead to more stability and consistency for residents. The files of 2 new members of staff were looked at there was evidence to show that Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: the organisation had examined employment and educational histories, disclosure of criminal background and taken up suitable references. This is a robust recruitment process which should help to ensure that people are kept safe. Staff are supported to learn about their role through a comprehensive induction programme. The training matrix was examined and showed that most staff had completed a varied training programme which complied with the National Minimum Standards. Some staff have not had refresher training in safeguarding vulnerable adults since 2003 and this training should be updated to ensure that residents remain safe. All staff members should complete training on the Mental Capacity Act and the Deprivation of Liberty Safeguards. Managers told us that they wish to move toward a more person centred system of Care Planning. To support people effectively in this area staff will need further training. Some staff were unsure about how to support people with sexuality and relationship issues and and need further training and supervision to help meet peoples needs adequately. Staff expressed concerns that there is now no Training Co-ordinator and that the training programme may not continue to run as smoothly. We were assured that the responsibility for co-ordinating training has been allocated to a Senior Manager who will continue to develop and monitor the training programme. Supervision sessions have not been taking place regularly largely because the manager has been absent since March 2009. Staff told us that they feel the Team Leader is helpful and supportive on a day to day basis and that he has very recently had a supervision session with them. The Team Leader confirmed that he had not known he should be carrying out recorded supervisions until last month and that he has had no training in implementing effective supervision for staff. In addition the Team Leader works a full time shift pattern working directly with residents. This leaves very little time for implementing an adequate supervision system or for auditing and checking records and this could leave people who use the service at risk. Staff meeting records were examined and these showed that these are used to discuss issues which will promote the quality of life for residents and to work out strategies to help people work consistently. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements have been unsettled for a number of months and there has been insufficient overall support for the service. However, the staff team cares about the service it provides and have worked hard to maintain services for people who remain happy and sufficiently safe. Evidence: The registered manager has been unavailable since March 2009. Since then there have been a number of changes to the management team. The assistant manager and then following his resignation, the acting assistant manager initially managed the home. Both have since resigned. Since September 2009, a newly appointed team leader is taking responsibility for the day to day running of the service. These changes in the day to day management were at a time when reorganisation and redundancies also changed line management arrangements at a more senior level. We talked to staff who described there being a lack of support from senior managers and how incredibly difficult, the last six months have been. Staff told us that the organisation listens to them but lack of action is frustrating. Minutes of Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: meetings with families describe families concerns about a lack of communication between themselves and management with e mails unanswered or not acted on. We talked to visiting relatives who echoed the concerns we were hearing. They described being very satisfied with an excellent service for 12 years but described concerns they have had about the management of the service over the past six months. They said that there has been a change and not for the good although they are satisfied that their relative remains happy and safe. They said it has not been a happy place for staff, although staff who spoke highly of the new team leader said there is now a glimmer of hope. However, we found that the team leader is not being provided with any time to manage the service. We have advised senior managers that this must be corrected and they agreed. We looked at other mechanisms for ensuring service quality. We talked to the team leader and found that like his predecessors, he has not received formal supervision. Regulation 26 visits are visits by a representative of the organisation required by regulation to check the quality of the service provided. Two regulation 26 visits by the organisations representatives have taken place recently. However, these were not carried out in the six months previously, during changes in management when the service was at its most vulnerable and was struggling. The service does not have a quality assurance system to help it to assess and improve the quality of the service it provides. We talked to the staff member responsible for the maintenance of the home and we looked at his record keeping. All the service maintenance records we asked for were available and were up to date. We could see that responsibility for some maintenance checks have been newly passed to the care staff to carry out and it is important that these continue to be maintained effectively. We followed up whether recommendations from a fire risk assessment in November 2007 had been carried out. We could see that the issues had been reassessed by the same independent company more recently in March 2009. The risk of lint combusting in an extractor has been resolved but the recommendation to provide an additional smoke detector in the hallway has not. Thermostatic valves have been fitted to hot taps to restrict water temperatures to reduce the risk of scalds. The service had locked off one room where excessive temperatures had been identified and were waiting for a plumber. 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 1 19 12 Bowel monitoring must be carried out to ensure that the laxative can be administered as prescribed to ensure good bowel function. This will ensure optimum bowel functioning for the person concerned and will promote good health and dignity. 30/11/2009 2 30 13 Suitable arrangements must 30/11/2009 be made for the disposal of clinical waste where toileting wipes will not flush down the toilet. Improved practice will promote the persons dignity and independence and will reduce the risk of cross infection to others. Care Homes for Adults (18-65 years) Page 28 of 30 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 Full written assessments should be carried out by the home prior to the admission of a new resident to ensure that the staff know all about them, what they hope for and want to achieve, and the support they need. New residents should be issued with up to date contracts at the time of admission which are explained and signed by all parties. The service should develop a system of recording in the numbers of each medication received onto the premises clearly and accurately noting the date and time of receipt. Where medication remaining in stock is carried forward this should be included in the records to show how many of each medication are on the premises at the time of delivery. This will enable the service to accurately check, using administration records whether medications have been administered as prescribed. All staff should receive a minimum of 6 recorded supervisions in any 12 month period. Supervision should be provided by staff who are suitably trained and competent to carry out this role. The registered provider should ensure that the Team Leader who is acting as manager has sufficient management time to direct and manage the service. Regulation 26 monitoring visits should be carried out monthly. The outcomes should be used to actively influence the development of the service. Recommendation not met from 2008. 2 5 3 20 4 36 5 37 6 39 7 39 The registered provider should ensure that a Quality Assurance system is implemented to enable the service to assessthe quality of the service it provides and make improvements based on findings including feedback from residents and other parties. Steps should be taken to ensure that all recommendations from the November 2007, and subsequently the March 2009 commissioned fire risk assessment are acted upon ie to provide an additional smoke detector in the corridor. Recommendation not fully met from 2008. 8 42 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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