Rose Cottage (Middlesex) Ltd Rose Cottage Inspection report 42 Hanworth Road Feltham Middlesex TW13 5AY Tel: 02085815576 Website: www.prcare.co.uk Date of inspection visit: 24 February 2016 Date of publication: 04 May 2016 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? Good Good 1 Rose Cottage Inspection report 04 May 2016
Summary of findings Overall summary The inspection took place on 24 February 2016. It was an unannounced inspection. This was Rose Cottage's first inspection since being registered by the Care Quality Commission (CQC) on 04 July 2015. Rose Cottage is registered to provide accommodation and personal care for up to five adults. The service supports people with learning disabilities, including autism, and people who may also have a physical disability. At the time of the inspection there were five men using the service. The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had notified the Care Quality Commission that there had not been a manager in post since December 2015 and stated they were in the process of recruiting to the post. In the interim the provider was acting as the manager. People covering the manager's duties were not clear on their roles, leading to poor monitoring of some aspects of administration. Training was not up to date. Safer recruitment guidance was not consistently followed. Staff were working long hours and did not always have adequate breaks between shifts. Some data management records were inconsistent, unclear and not easily accessible. Audits and maintenance checks were not routinely being carried out. Policies and procedures had been reviewed but the content had not been updated to reflect current legislation. There were risks to people's wellbeing as the environment was not always well maintained. A number of rooms had mould. Not all rooms, including toilets, were thoroughly cleaned. Since the last CQC inspection, The Fire Authority carried out an inspection in July 2015. The service implemented the recommendations, however not all emergency routes were clear and / or accessible. Additionally staff we spoke to could not give a clear indication of how a single member of staff would evacuate service users during the night in the event of a fire. On 19 March 2016, the provider responded to a request for further information on the above issues around the environment and advised a number of rooms had been redecorated which addressed the above concerns and the fire routes had been made accessible. There were good individual risk assessments in place and an appropriate number of staff on duty. Files 2 Rose Cottage Inspection report 04 May 2016
indicated staff supported people to attend regular medical appointments. Staff administered and stored medicines safely. The people who used the service were involved in a number of activities in the community and feedback received from other professionals was positive. Relatives were also positive about the service. Staff were caring and person centred. We found the service to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005 (MCA) for one person who used the service. The manager agreed to seek advice on making a DoLS application for a second person. Staff knew the needs of the people who used the service and there was a family atmosphere in the home. People using the service were given choice and involved in day to day decisions. Care plans were up to date and reviewed within the last year. We found two breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report. 3 Rose Cottage Inspection report 04 May 2016
The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? The service was not always safe. Fire safety required improvement. There was a risk to people's wellbeing because the environment was not always well maintained. However since the inspection, the provider confirmed they had addressed the issues around environment. Not all aspects of the recruitment process were followed. Staff were working long shift patterns, sometimes without a break for long periods. The provider told us they had access to bank and agency staff but on the rotas we saw they had not utilised bank or agency staff to ensure the existing staff did not work long hours that placed people at risk. People we spoke to thought the service was safe. Risk assessments were good, there was always enough staff on duty to meet individual needs and medicines were well managed. Is the service effective? The service was not always effective. Staff had the appropriate skills to work with people who used the service, but required their training to be updated. Staff had established good communication with the people using the service. The service was working within the principles of the MCA. People's diets were healthy, well balanced and met individual need. Other professionals contributed regularly to the wellbeing of people who used the service and medical referrals were made as necessary. Medicines were well managed. Is the service caring? Good The service was caring. 4 Rose Cottage Inspection report 04 May 2016
People told us staff were caring and respectful. People were included in day to day decisions. Privacy and dignity was maintained. People's cultural backgrounds were acknowledged. People's individual preferences were recorded in their care plans. Staff promoted people's independence. Is the service responsive? Good The service was responsive. People had comprehensive care plans and risk assessments which reflected their individual needs. There were a wide range of activities which staff supported people to attend. There was a complaints procedure in place that relatives knew how to use Is the service well-led? The service was not always well led. There was no registered manager in post or a clear plan of how to manage the service in the absence of a registered manager. Data management and monitoring systems were not always effective or accessible. Some audits had not been completed since 2015. There was no record of training in 2015. Some records were kept up to date. Most of the feedback from satisfaction surveys sent out in November 2015 was positive. Staff said the interim manager was available. Relatives and professionals considered the home to be managed well. 5 Rose Cottage Inspection report 04 May 2016
Rose Cottage Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. The inspection took place on 24 February 2016 and was unannounced. The inspection team consisted of two inspectors. Prior to the inspection we looked at all the information we held on the service including notifications of significant events and safeguarding. We contacted the Local Authority's Safeguarding Team for any relevant information held on the service. During the inspection we met all five people using the service and observed their interactions with staff. We spoke to the acting manager, the acting deputy manager and two staff members. We viewed three people's files, including their care plans and three staff files to verify recruitment and training. We looked at medicines management for two people who used the service. We looked at data records including maintenance and servicing checks and audits. After the inspection we asked three family members of people living at Rose Cottage, their GP, the Community Learning Disabilities Team, a college co-ordinator and a Challenging Behavioural Analyst for their views and experience of the service. 6 Rose Cottage Inspection report 04 May 2016
Is the service safe? Our findings The service had implemented all the necessary steps to remedy the risk of fire as directed by the Fire Authority in July 2015.However, people living in the home were at risk, as from our discussion with staff, we identified a specific fire risk regarding how a single member of staff would evacuate service users at night. Additionally not all fire routes were clear, including the staff room and laundry room which were obstructed by stored items such as paint and equipment. Staff were unable to confirm if curtains on the means of escape routes were flame retardant. The home had a new fridge freezer and we observed the old one was in the garden with its doors on and unsecured causing potential danger of it falling on someone. People's wellbeing was at risk due to a number of rooms having mould. We observed a bedroom with a broken light fixture and toilets that were not thoroughly cleaned. Two bedrooms had a slight malodour. We looked at staff rotas which indicated staff were working up to 15 hours a day and an average of 75 hours per week. They were also doing sleep ins. Not all staff had two days off per week. Long shifts raised concerns around staff alertness and their ability to provide safe care. The provider advised us that they had bank and agency staff to cover shifts as required. However, on the rotas we saw which indicated long hours, they had not utilised bank or agency staff to ensure the existing staff did not work long hours that placed people at risk. On 17 March 2016, we requested that the provider update us on the issues identified above. On 19 March 2016, the provider responded that they had cleared the fire routes and confirmed the curtains had previously been made fire retardant. The fridge / freezer had been removed. The kitchen, staff room and bedroom with the broken light had been redecorated. The provider acknowledged the long shift patterns and attributed these to the home being a family run business. People's benefits were managed by their families. We saw a finance record for one person that indicated how much had been spent on activities such as lunch. The provider carried out checks to ensure staff were suitable to work in the service. We viewed three staff files and saw application forms, copies of passports, Disclosure & Barring Services checks, references, induction training and ongoing training. The provider did not carry out sufficient checks on all staff as one file only had a single reference. There had been no notifications regarding serious incidents or safeguarding reported to the Care Quality Commission or to The Community Learning Disabilities Team. Staff told us they had received safeguarding training, however records showed no training had been undertaken since 2014. Staff were able to identify types of abuse and how they would respond. We saw an incident and accident book. The last incident recorded was 01 October 2014. 7 Rose Cottage Inspection report 04 May 2016
People's files contained individual risk assessments. One person told us their relative had always displayed challenging behaviour. They said staff have an "extremely low key way of settling any behaviour before it happens and are quick to respond to keep everyone safe". Staff supported people to make decisions regarding their care. People moved freely about the home and we observed staff supporting one person to get dressed appropriately to go into the garden himself. The kitchen was open to people helping themselves to snacks and tea. The service had four staff and a manager. At the time of the inspection three staff and the manager were on duty. Staffing was sufficient to meet people's needs and the continuity of staff meant staff knew the people using the service and their routines well. There were enough staff to provide support to people in the community. During our inspection staff supported people to college, a music class and to the shops. Medicines were being managed safely. We saw people's Medicine Administration Records (MARs) charts. Only two members of staff administered medicines. There were signatures at the front of the file and all medicines had been signed for. One person took a controlled drug. There were written guidelines for administering the drug which was kept in a locked controlled drugs cabinet. The accompanying controlled drug register was also appropriately signed and managed. 8 Rose Cottage Inspection report 04 May 2016
Is the service effective? Our findings Staff did not have the updated training they needed. We observed that staff had the skills to meet the needs of the people in the service, however in the files we viewed there was no record of training in 2015. Staff did not have a training matrix to monitor training or a development plan to ensure they had the appropriate level of skill and competence to meet the needs of the people using the service. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Relatives of the people who used the service said they felt staff at Rose Cottage were providing a good level of care to people using the service. One relative said "He is settled there. I never expected he would live away from home." Another said "Basically they take very good care of (person's name)." The professionals we spoke to also indicated a good level of care. Professionals said staff were "quite transparent around difficulties", "They work well and engage with local services". One professional told us that a person with challenging behaviour wanted to go to college. The college required 2:1 staffing for the person. Rather than waiting for funding to be agreed on, staff implemented the 2:1 staffing immediately so the person did not miss out on their course. Rose Cottage is a small five bed service. Staff said they spoke to each other as things came up and had an informal handover when three of the four staff for the day began their shift at 7am. Staff used various methods of communication with the people who used the service. They tried different options with people. One person who used the service had a communication keyring with pictures; however he preferred to have people talk to him. Staff respected this. His relative said they were "very pleased (staff) have been working on his communication skills. The speech and language therapist has been back in. I know (person's name) has made some progress in indicating his wishes I've seen him be more interactive with people." Another person spoke very little English. Staff and the person's relative confirmed that staff had learned key words in the person's language to communicate with him. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). 9 Rose Cottage Inspection report 04 May 2016
We checked whether the service was working within the principles of the MCA. We found one person had a DoLS authorisation in his file and had an Independent Advocate who visited regularly. After a discussion, the manager agreed to seek guidance for a second DoLS application. Staff we spoke to had undertaken Mental Capacity Act training and understood the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some people in the service had behaviour that challenged. Relatives told us this was managed well. One relative told us: "He used to be angry and shout but now he is calming down and relaxing." One person had a Positive Behaviour Support Plan which provided clear guidance for staff on proactive prevention, early warning signs and how to respond to incidents and recovery. Care plans indicated the needs of people who used the service and that they were able to make choices. We observed staff supporting people to undertake various activities in the community. Staff and relatives confirmed staff were willing to support people to try new activities and take their lead from the person about whether or not to continue. One relative told us that when her relative first moved to Rose Cottage staff "tried all kinds of new things for him" and "He can access as much as he wants to access". People were given a choice of meals. Different dietary requirements were recorded in people's care plans. One person needed a wheat and gluten free diet. A comprehensive diet plan was recorded for him. His relative said that they had discussions with staff and "they've been very careful with what they do for him". When he was initially placed, a dietician was involved but now staff manage his diet. Another person had religious dietary needs which staff catered for. We observed people using the service helping themselves to drinks in the kitchen. One relative told us three people using the service attended a group they ran. People brought a packed lunch to the group which was healthy and staff were conscious of keeping sugar intake down. Staff told us they involved people using the service in shopping and cooking and encouraged them to eat healthily. We saw where required, some people were weighed monthly so any changes in weight could be monitored and addressed. There was a record in people's files of healthcare appointments attended. People who used the service were regularly supported to health appointments. Rose Cottage had a good relationship with their GP practice and we saw evidence of the GP making house calls. One medical professional stated "As far as I am concerned they are involved in healthy lifestyle decisions. I am quite happy with the way things are going. I have no concerns." We saw evidence of one person's epilepsy being managed with regular medical appointments, another person had a referral to the Continence Service and a third person was supported to regular psychiatric appointments. We observed people using the service moving around the house and garden as they pleased. People who used the service were involved in the decoration of their rooms and the house. Some communal rooms had just been wallpapered and staff told us, people using the service had picked the wallpaper. Staff and family confirmed people using the service had their rooms decorated to their own tastes. 10 Rose Cottage Inspection report 04 May 2016
Is the service caring? Good Our findings Relatives and professionals who worked with people using the service told us that staff were caring and respectful. One relative said staff were kind and caring. Staff "are very nice because they are like older brother role models". Another relative said "He is enjoying life there. Staff are very friendly with him. He's really fine." A professional told us "I find them to be positive and person centred in their approach" People's cultural backgrounds were acknowledged. One person had religious pictures in his room and staff supported him to attend the temple when he wanted to go. One relative said her relative liked Indian food and this was catered for. Staff supported one person to see Indian films. A wall in the lounge displayed holiday photos and one person enjoyed telling us about these. People's interests were recorded in their care plans. Independence was promoted through activities such as gardening and college. Another example involved one resident who attended a daycentre. Initially staff supported him to go to the centre, then they began to let him lead the way, they shadowed him and his goal was reached when he walked to the centre independently. Staff told us they went shopping one to one with people who used the service for toiletries and clothes so people could choose what they wanted to buy. We saw in the daily logs people were able to make decisions and their views were respected. For example there was a record of one person refusing an outing. Privacy was also respected. Staff knocked on bedroom doors. One care plan indicated a person liked to spend time in the bath and he should be given the time to do so. We observed staff asking people what they would like to do in a caring manner. They interacted positively with people using the service and were led by what people indicated they would like to do. Staff said they "try to understand them (people using the service) and not ignore them. I try to involve them in everything I do like cooking and cleaning their room". "Make them feel like it is their home at the end of the day." Staff knew the people using the service well. Family members could visit whenever they chose to. One relative said they saw staff every week so communication is good. They told us they were always able to drop in if they were passing. "It's like extended family. They're very open." 11 Rose Cottage Inspection report 04 May 2016
Is the service responsive? Good Our findings People using the service had care plans which reflected their individual personal care, social, emotional, cultural and religious needs. The plans also recorded their mental health and physical health, mobility, communication and night time care. Guidance for specific individual needs such as health, diet or behaviour were recorded in the care plans. In some cases staff worked with other agencies to achieve good outcomes for people who used the service. Professionals told us staff engaged well and they had positive working relationships with staff. Care plans had been reviewed within the last year and signed off by the manager. Family members told us they were invited to attend the reviews. Care plans varied in terms of hearing the voice of the person using the service. Some care plans had few "I" statements while others were very clear about the person's likes and dislikes. We saw one person's care plan had a risk management plan for behaviours that challenged and there was clear guidance for staff. There were additional plans for aggression and wandering which had not been reviewed in the last year. We saw a review summary from the Challenging Needs Service dated December 2015 which concluded staff had the strategies to manage and support (the person's) behaviour. There were sufficient staffing levels to support people in the community with individual interests. Staff supported people who used the service to attend college and leisure activities outside of the home. Other activities included bowling, companion cycling, pub lunches, youth club and gardening. One person attended a day service and another went to a music class. Rose Cottage worked well with the Community Learning Disabilities Team and healthcare professionals. A local college also confirmed that staff supported two people to attend classes. We saw that people had televisions and computers in their bedrooms with their games/ dvds of choice. We observed one person watching a programme on the computer in the lounge which staff supported him to find. A complaints procedure was available. Relatives said they knew how to make a complaint. There were no recorded complaints since March 2011. Relatives told us they knew who to talk to about concerns and that they got on well with staff. 12 Rose Cottage Inspection report 04 May 2016
Is the service well-led? Our findings Rose Cottage had not had a registered manager in place since December 2015. At the time of the inspection, the provider was acting as the manager and another member of staff was acting as deputy manager. Between them, they were covering the registered manager's duties, but did not have a clear plan of action. The provider assured us that they were about to start actively recruiting a permanent manager. We looked at a number of maintenance and auditing files and saw that since the registered manager had left, data management was failing and some records were not being monitored and updated. Audits of MAR sheets, daily diaries, fire safety, health and safety risk assessments and portable electrical equipment were last completed in 2015. Records that were being maintained were not always well organised or accessible. For example the dates for the hot water checks had 2015 on the entries although the top of the record showed 2016. There was no record of staff training in 2015. After the inspection, the provider informed us two members of staff had completed their NVQ2s in 2015. However this was not recorded. These were a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Supervisions were last held in December 2015 and the last staff meeting was held June 2015. The provider's safeguarding procedure was dated as reviewed in 2015 but the legislation quoted in the document was out of date (2010). The medicines management and whistleblowing policies had both been reviewed in July 2015 but both contained out of date guidance. The record of the fridge/freezer temperature was up to date for January and February 2016. Rose Cottage completed service user questionnaires in May 2015 and sent out a satisfaction survey in November 2015. All the feedback was good except one relative who felt communication could be better. There was no action plan to respond to the feedback. When we spoke to the relative, they said overall they were happy with the service but felt communication / administration could improve. The relative gave examples of having to pay for missed activities and not being told about appointments they would like to attend with their relative, but they also stressed they "get on like a house on fire with all the staff" and if they had an issue they would talk to the manager. The acting manager was present on the floor and staff said they could approach them with their concerns. One staff member said "It's like a home within a home." Relatives said the registered manager, who had left, was also approachable. A professional said "Excellent service with no current concerns and good management. They work with some complex people using the service ". 13 Rose Cottage Inspection report 04 May 2016
This section is primarily information for the provider Action we have told the provider to take The table below shows where regulations were not being met and we have asked the provider to send us a report that says what action they are going to take. We did not take formal enforcement action at this stage. We will check that this action is taken by the provider. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 17 HSCA RA Regulations 2014 Good governance The registered person did not assess, monitor and improve the quality and safety of the service. Regulation 17 (2) (a) Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 18 HSCA RA Regulations 2014 Staffing The registered provider did not ensure staff received appropriate, support, training, professional development, supervision and appraisals to enable them to carry out their duties. Regulation 18 (2) (a) 14 Rose Cottage Inspection report 04 May 2016