Review of compliance. Spion Kop Care Home Limited Spion Kop Care Home. East Midlands. Region:

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1 Review of compliance Spion Kop Care Home Limited Spion Kop Care Home Region: Location address: Type of service: East Midlands Park Lane Pinxton Nottingham Nottinghamshire NG16 6PS Care home service without nursing Date of Publication: September 2012 Overview of the service: Spion Kop Care Home is owned by Spion Kop Care Home Limited. The care home is in Pinxton village in Derbyshire and provides personal care and accomodation for up to six adults (males) who have mental health needs. Two people were living at Spion Kop at the time of this visit. Page 1 of 18

2 Summary of our findings for the essential standards of quality and safety Our current overall judgement Spion Kop Care Home was meeting all the essential standards of quality and safety inspected. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, carried out a visit on 16 August 2012, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff, reviewed information from stakeholders and talked to people who use services. What people told us We spoke with two people who use the service. People told us they were happy with the care and support they received, and felt that their needs were being met. People had agreed to the care and treatment, and had signed their care records to support this. One person told us ''the routines are flexible and I do the things I like to do. I feel I am doing well here and I aim to live more independently in the future''. Another person told us'' I can't fault the place or the staff. I have been on two holidays this year, which I enjoyed''. People said they liked the staff and felt that they get the help they needed as there was usually enough staff on duty. People told us they received their medicines at the times they needed them, and in a safe way. People said they liked living at Spion Kop as it was comfortable, safe and clean and it felt like 'home'. They particularly liked their bedroom with ensuite facilities. What we found about the standards we reviewed and how well Spion Kop Care Home was meeting them Outcome 02: Before people are given any examination, care, treatment or support, Page 2 of 18

3 they should be asked if they agree to it People consented to their care, treatment and support they received. Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights People experienced care, treatment and support that met their needs and protected their rights. Outcome 09: People should be given the medicines they need when they need them, and in a safe way The provider had appropriate arrangements in place to manage medicines and to protect people against the risks associated with medicines. Outcome 10: People should be cared for in safe and accessible surroundings that support their health and welfare The premises were clean, safe and well maintained to protect people who use the service and others against the risks of unsafe or unsuitable premises. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs There were enough staff with the appropriate knowledge, experience and skills to meet people's needs. Other information Please see previous reports for more information about previous reviews. Page 3 of 18

4 What we found for each essential standard of quality and safety we reviewed Page 4 of 18

5 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. A moderate impact means that people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 5 of 18

6 Outcome 02: Consent to care and treatment What the outcome says This is what people who use services should expect. People who use services: * Where they are able, give valid consent to the examination, care, treatment and support they receive. * Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed. * Can be confident that their human rights are respected and taken into account. What we found The provider is compliant with Outcome 02: Consent to care and treatment Our findings What people who use the service experienced and told us People living at the home told us they had agreed to the care, treatment and support they received. They had signed their care records to support this. People were aware of their rights to refuse or withdraw their agreement to their care and treatment. People felt that their wishes were respected in regards to their care and treatment. Staff explained things in a way that helped them to make decisions about their care and welfare. Other evidence Discussions with staff and care records we looked at showed that people had consented to the care and treatment. People's care records included information relating to their capacity to make decisions about their care and welfare. We saw that information was available to people in regards to their right to have an advocate to assist them in understanding their options, and to enable them to make decisions. The provider may wish to note that policies and procedures were not in place for obtaining peoples' consent to their care and treatment, and to gain and review consent from people who lacked the capacity to make certain decisions. Page 6 of 18

7 Staff told us that no one using the service was subject to protection measures relating to the Deprivation of Liberty Safeguards (DoLS). Records showed that all staff except for a new and a relief member of staff had attended recent training on the Mental Capacity Act and DoLS, to ensure they understand the principles of the act and the safeguards. We saw that people's rights were respected. For example people using the service wished to smoke and were supported to do so in the designated area of the home. People consented to their care, treatment and support they received. Page 7 of 18

8 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us People told us they were happy with the care and support they received, and felt that their needs were being met. One person told us ''the routines are flexible and I do the things I like to do. I feel I am doing well here and I aim to live more independently in the future''. Another person told us'' I can't fault the place or the staff. I have been on two holidays of my choice this year, which I enjoyed''. People said they received care and support from regular staff who were aware of their needs and preferences. This means that people could expect to receive consistent care. People told us they were involved in social and leisure activities of their choice, and were encouraged to maintain a healthy lifestyle. People told us that staff recognised when they were unwell and responded to changes in their needs. Two people's care records we looked at supported this. Other evidence Three staff we spoke with felt that effective communications were in place to ensure they received essential information about people's needs. We observed and heard a good level of communication and contact between staff and Page 8 of 18

9 people using the service. Staff approached people in an understanding and appropriate manner. We saw that the care and daily routines were centred around people's needs and preferences. People had opportunities to take part in social and leisure activities of their choice. Discussions with staff and records showed that people were offered regular health checks. Staff responded appropriately to changes in their needs and worked closely with relevant professionals, to ensure that people's health needs were met. Two people's records we looked at included personal information about their needs and preferences and what was important to them. The care records were up-to-date and detailed and showed how people's needs were being met. People's care plans were reviewed at regular intervals and as changes occurred. Monthly reviews reported on the effectiveness of people's care, treatment and support. People had signed their care records to show they had been completed with them, and that they had agreed to the care and treatment. The records showed that people's care and treatment was delivered in a way that ensured their safety and welfare. People experienced care, treatment and support that met their needs and protected their rights. Page 9 of 18

10 Outcome 09: Management of medicines What the outcome says This is what people who use services should expect. People who use services: * Will have their medicines at the times they need them, and in a safe way. * Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf. What we found The provider is compliant with Outcome 09: Management of medicines Our findings What people who use the service experienced and told us People told us that they received their medicines at the times they needed them, and in a safe way. People were aware of medicines they were taking and the reasons for this. Other evidence We saw that people's care records included a summary of medicines they were taking, including the reasons why they were taking these and the possible side effects. This meant that people had access to information about the medicines they were taking. Staff had access to up-to-date guidance relating to the handling of medicines. We looked at two people's medication administration records (MAR) dated August The MAR were clearly printed and we found no discrepancies on these. We also checked whether people's medication had been given as recorded and found no discrepancies. At the time of our visit no one was taking any medicines that required storing in the fridge. On occasions where people were prescribed medicines that require storing in a fridge, these are kept in a separate secure medicines fridge. Records showed that the fridge temperature was checked each day, and that the temperature was within the required range. This meant that any medicines stored in the fridge were kept securely at the correct temperature. Page 10 of 18

11 At the time of our visit no one using the service was prescribed a controlled drug (CD). Should a person be prescribed a CD the service had a cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations and a CD record book. We saw that people's medicines were stored safely. Unwanted or expired medicines were returned to the dispensing pharmacist to ensure these were disposed of correctly and records were kept of this. A senior member of staff described procedures they followed to ensure that all medication ordered was correctly prescribed. However records were not kept to show this. We have since received assurances that procedures have been updated and records have been put in place, to show that medicines ordered are correctly prescribed. Staff gave people their medicines. We saw that the list of signatures and initials of staff approved to give medicines was up-to-date, as this included all relevant staff. This meant that a current list was available to check staff's signatures against their initials on the MAR, in the event of a query relating to a person's medicines. We checked the training records, which showed that staff had received recent training in the handling of medicines to enable them to give out people's medicines correctly. The manager told us that staff competency to safely administer people's medicines had been assessed, however this was not recorded. The manager agreed to put in place appropriate competency assessments for all staff. We observed staff on duty giving out people's teatime medicines. The member of staff did not follow appropriate procedures to ensure that one person received their correct medicines. Despite checking the MAR against the directions on the medicine bottle, the member of staff proceeded to give the person one medicine that they were not prescribed to take at teatime. The person told the member of staff that they did not take the medicine at this time, and the member of staff took appropriate action to ensure that the person received their correct medicines. We acknowledged that the member of staff was anxious as two inspectors observed them administering the medicines. Following our visit we received assurances that appropriate action was being taken to prevent a similar event happening in the future. Records showed that the home's community pharmacist carried out six monthly audits relating to the management of people's medicines. The registered manager also completed internal medicine audits; this was last completed in Novemeber This means that checks were in place to ensure that people's medicines were handled appropriately and safely. The last audit completed by the community pharmacist dated listed no required actions. We saw that policies and procedures were essentially in place to ensure that peoples' medicines are handled appropriately and safely. However the provider may wish to note that the procedures did not detail the use of household remedies or adverse reactions to medicines. The manager agreed to review the policy and procedures. Page 11 of 18

12 The provider had appropriate arrangements in place to manage medicines and to protect people against the risks associated with medicines. Page 12 of 18

13 Outcome 10: Safety and suitability of premises What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: * Are in safe, accessible surroundings that promote their wellbeing. What we found The provider is compliant with Outcome 10: Safety and suitability of premises Our findings What people who use the service experienced and told us People said they liked living at Spion Kop as it was comfortable, safe and clean and it felt like 'home'. They particularly liked their large bedrooms with ensuite facilities. People felt that the home was decorated and furnished to a good standard. One person told us ''my room is re-painted every other year''. People told us that were encouraged to and do their own washing and clean and tidy their room. Other evidence Checks carried out during out visit showed that the home was clean, safe and well maintained, including the outside areas. A planned maintenance and redecoration plan was in place, which showed that most areas had been redecorated in the last 18 months. This has ensured the premises are maintained to a good standard and are suitable for people's needs. The provider may wish to note that maintenance records were not always dated and signed to show when the work had been completed and by whom. Also, records were not up-to-date to show that all cleaning had been carried out at the required intervals. The following issues were noted during our visit: We saw that the health and safety risk assessments of the environment did not include all potential risks, and measures in place to minimise the risks. For example the Page 13 of 18

14 document did not include the risk of falls from first floor windows, including the landing window, which opened in full as this was a designated fire exit. The assessments did not include the risk of scalding from radiators, all hot water including sinks, access to hazardous and sharp items and potential ligature points in the home. The manager agreed to urgently update the risk assessments to include all potential risks and measures in place to minimise the risks. People had keys to their bedroom door to maintain their privacy. We found that the door catches in place could be fastened from the inside, which prevented staff from entering a person's bedroom with a key in an emergency. Staff stated that people had capacity and did not lock their door when they were present. The provider may wish to note that a fire safety audit report at the premises, dated 10 November 2011 stated that ''all doors through which a person may have to pass must not be so locked or fastened that they cannot be easily and immediately opened''. We noted that new locks had been fitted, however these did not meet the fire officers report, which advised replacing the existing locks with ''approved fastening which will enable staff to enter the bedrooms at all times''. We saw that systems were in place for checking the hot water temperatures regularly to monitor the risk of scalding from the sinks, baths and showers. Recent temperatures of the baths and showers did not exceed the required safe limits. However when we checked the hot water temperature we found that the ensuite shower in one ground floor bedroom ran at 52.4 degrees Celsius, which exceeds the safe limits and puts people at risk of scalding. The provider may wish to note that environmental health officers advise that in order to protect people from scalding, water from showers should be no hotter than 41 degrees Celsius. Following our visit the provider has put a risk assessment in place in regards to the risk of scalding. We have requested that the provider further reviews the maximimum temperature of the shower to ensure that this does not exceed safe temperatures. We saw that the home's safe contained the maximum amount of money that may be kept in safekeeping. The safe was not secure to prevent someone from taking this. The provider has since assured us that the safe was being secured as a matter of urgency. The premises were clean, safe and well maintained to protect people who use the service and others against the risks of unsafe or unsuitable premises. Page 14 of 18

15 Outcome 13: Staffing What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff. What we found The provider is compliant with Outcome 13: Staffing Our findings What people who use the service experienced and told us People told us that they had good relationships and liked the staff that supported them. One person told us ''I can't fault the staff; they are all great''. People felt that they received the help they needed as there was usually enough staff on duty to meet their needs. Other evidence Staff told us that a regular team of established staff worked at the home. This meant that people received consistent care from experienced staff who knew their needs. Three staff we spoke with felt that the numbers of staff on duty was generally sufficient to meet people's needs. Extra staff were provided to enable people to go out where they wished. At the time of our visit two people were using the service, one of which went out independently. Our visit showed that there were generally sufficient numbers of experienced staff to meet people's needs. The staffing rotas for 2 July to 26 August 2012 showed that there was mostly one member of staff on duty during the day and at night. Two members of staff were on duty on a number of day shifts. People's needs did not require waking night staff. The registered manager told us that the staffing levels were flexible to meet people's Page 15 of 18

16 needs. For example two staff were provided on a number of shifts to enable people to take part in leisure activities of their choice. Also, one to one staffing was provided to enable both people to go on separate holidays of their choice recently. The manager stated that the staffing levels would be reviewed, to meet the needs of new people admitted to the home. As previously stated, there was mostly one member of staff on duty. We saw that the provider's lone working policy stated that induction training is to be completed prior to staff been left unsupervised. The staffing rotas showed that a new member of staff had worked un-supervised and in charge of several shifts, having previously worked one day's induction. The member of staff assured us that they had previously worked at Spion Kop three years ago, during which time they completed their induction training. In the last three years they had not worked in care services. However since they started work in July and prior to taking charge of shifts at Spion Kop, they had worked several shifts with a senior member of staff at the provider's other two care homes. During this time they had received appropriate support and training to enable them to carry their work. There were enough staff with the appropriate knowledge, experience and skills to meet people's needs. Page 16 of 18

17 What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 17 of 18

18 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 18 of 18