Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Lammas Lodge Lugwardine, Hereford, HR1 4DS Tel: 01432853185 Date of Inspection: 23 April 2013 Date of Publication: May 2013 We inspected the following standards as part of a routine inspection. This is what we found: Consent to care and treatment Care and welfare of people who use services Safeguarding people who use services from abuse Supporting workers Assessing and monitoring the quality of service provision Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 1
Details about this location Registered Provider Overview of the service Type of service Regulated activity Parkcare Homes (No 2) Limited Lammas Lodge is a care home for people with a learning disability providing accommodation and personal care for up to seven adults. Care home service without nursing Accommodation for persons who require nursing or personal care Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 2
Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 4 Our judgements for each standard inspected: Consent to care and treatment 6 Care and welfare of people who use services 8 Safeguarding people who use services from abuse 10 Supporting workers 12 Assessing and monitoring the quality of service provision 14 About CQC Inspections 15 How we define our judgements 16 Glossary of terms we use in this report 18 Contact us 20 Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 3
Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 23 April 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with carers and / or family members, talked with staff and reviewed information given to us by the provider. What people told us and what we found When we visited we saw most of the people who lived there. People were not able to give us their views because of their special needs. People looked well cared for and the staff were able to describe how each person preferred to be supported. People's care needs had been assessed with the involvement of relatives and professionals. The manager was increasing the level of involvement of people's families. One person's relatives told us that they had confidence that the staff knew the family's role in making decisions. We saw there were care plans and risk assessments in place which had been kept under review. People were being supported by some staff who knew them very well. Five new staff had recently joined the team and the improved staffing levels meant that people were being offered more activities. A team of specialists employed by the providers reviewed people's emotional, behavioural, communication and medication needs regularly. Incidents were monitored and the more serious incidents had been appropriately referred to the local authority. The manager was working with external agencies to make improvements and reduce the risk of incidents reoccurring. They were making good progress towards completing their action plan. Systems were in place to monitor the quality of the service. The staff team felt supported by the new manager and morale had improved. Suitable training and staff supervision arrangements were in place. You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 4
There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 5
Our judgements for each standard inspected Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was meeting this standard. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Reasons for our judgement People were not able to tell us if they felt involved in their care because of their special needs. The staff we spoke with were able to describe how each person preferred to be supported. We saw that staff were aware of how best to encourage people to take part in activities and daily living tasks that would benefit them. We found that people could use their bedrooms whenever they wanted. These had been personalised to encourage people to use them for activities as well as for sleeping. Communication aids were being improved to help people better understand their environment and choices available to them. Care plans contained guidance about what each person's preferred routines were and how they liked their support to be provided. The guidance included the need for staff to respect people's wishes and what restrictions were needed to help keep them and others safe. For some people restrictions were in place, such as no unsupervised access to the kitchen. These were in line with the risk assessments included in people's care plans. Everyone needed staff support to go into the community and access to the front road side garden was limited because of the dangers. The manager was aware of the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). They said there were no restrictions used that would come under DoLS. Staff awareness training had been provided. People were not able to understand and take part in formal planning about their care or medical treatment. Each person had relatives and professionals involved in their lives. The manager gave us examples of how they were increasing the level of involvement of people's families. The company had developed a format to record decisions made in a person's best interest. One person's relatives told us that they had given significant input into writing the care plan. They had confidence that the staff knew the family's role in making decisions. The relatives had recently attended a care review and had felt able to discuss issues with the Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 6
manager and staff present. They had found the manager open about any shortfalls and helpful in agreeing a way forward. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 7
Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Reasons for our judgement People were not able to tell us if they felt involved in their care because of their special needs. People looked well cared for and seemed comfortable within their home. We could see from records that people had their daily personal care needs met. The staff spoke about the people in the home in a caring and respectful way. They were able to describe how each person preferred to be supported and what staffing levels and skill mix was needed to meet their needs. We saw that care staff quickly responded to people's requests or signals that showed they wanted something or needed staff support. One person's relatives told us that recently the care plan was being reliably followed. There had been some occasions when planned activities had not been provided. They had been reassured that the manager had picked this up before they raised the issue and steps had been taken to improve the planning. They had no other concerns about the current service. They had recently attended a care review which had been positive. Afterwards their social worker had checked that the care plan and monitoring records were all in order and had been satisfied, making only a few minor recommendations. We looked at the care records for two people who lived at the home and at how their care needs were met. We saw there were care plans and risk assessments in place which had been kept under review. The guidance about people's needs was clear and informed the staff how to give the support required. A team of specialists employed by the providers reviewed people's emotional, behavioural, communication and medication needs regularly. Their guidance was included in the care plans. The manager had already identified that minutes should be kept from these meetings to better evidence the care planning process. They had also decided it was important to involve each person's 'Key Worker' in these meetings as the care staff had a lot to contribute to the evaluation process. Staff told us the manager was involving them and listened to their views and ideas which had improved morale. The manager showed how incidents were recorded and evaluated for each person. There had been a reduction in some behaviours and associated incidents. A recent safeguarding meeting had been held to review several incidents. It was acknowledged by external professionals that recent improved staffing levels and a new structured staff Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 8
induction were helping people feel more settled and reducing incidents. One person's family had not been informed for three days about a recent serious incident. They had met with the manager who agreed this was unacceptable and had committed to ensuring contact was made within 24 hours. A solution had also been agreed to help reduce the risk of the incident reoccurring. The relative told us the meeting was positive and now the staffing levels had been improved more activities were being arranged to better meet their child's needs. The manager told us activity plans were under review as people needed more planned activities based around what they enjoyed and would benefit from. They were discussing with the providers about having a third car which would also help increase the opportunities for people to go out. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 9
Safeguarding people who use services from abuse People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement The manager told us that systems were in place to help make sure they were aware of all incidents. They said they were up to date in sharing information with other parties and in putting them into the company's incident and accident internal monitoring system. The care staff we spoke to felt they had the right training to deal with incidents when people became upset or aggressive. They said incidents were discussed in detail afterwards to debrief and assess what worked well and what could be learnt and changed for the future. Safeguarding alerts to the local authority had been made appropriately by the manager or deputy. These included incidents where one person hurt another person living in the home, where a medication error had been made or when staff had used significant level of physical restraint to control aggressive behaviour. Minutes from a recent safeguarding meeting showed that the providers and manager took incidents seriously and acknowledged shortfalls. They were working positively with other authorities, providing information that was requested and retraining staff to help reduce the risk of repeat events. One person's physical intervention techniques were being reassessed under the safeguarding procedures. This was being carried out with the support of professionals as they had not proved effective on one occasion. In an effort to try to control the situation staff had used methods that were not approved therefore putting the person at increased risk of harm. The manager had made a safeguarding alert about the situation and had been open about the problems experienced. An action plan was in place to help safeguard the person and staff if an incident this challenging reoccurred. All permanent staff, other than a new worker, had received training in the techniques permitted for physical intervention. The registered manager told us that 82% of the care staff had attended training on the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). This legal framework was designed to help protect the rights of people who live in care homes. The registered manager told us that people's representatives had been consulted about Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 10
decisions when they lacked the mental capacity to make their own decisions. So far they had judged that none of the restrictions used to keep people safe that had been so restrictive that they had required a referral for authorisation under DoLS. The training chart showed that all staff had attended safeguarding training. The staff we spoke with said they had been given training and were clear of their duties to report any poor practice or concerns about abuse. They said they knew how to do this and would feel able to. They found the manager approachable and the area manager visited the home at least twice a month. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 11
Supporting workers Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was meeting this standard. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Reasons for our judgement The people we met were not able to tell us their views about the staff. We saw people engaging with staff in a way that showed they felt comfortable with them. For example one person was sitting close to staff and reading aloud to them. We saw that support was given in a flexible and patient way. This approach resulted in one person going on an outing even though they initially declined to get in the vehicle. For six months the service had been using agency staff to cover several vacant posts. Five permanent staff had been recruited and were getting to know people's complex needs. The manager told us that they anticipated that regular use of agency staff would stop by May 2013. The staff we spoke with were able to explain what people's needs were and how these were met. They told us that staff vacancies had made it difficult to meet some people's needs, particularly accessing activities away from the home. They felt staffing levels were improving and this was having a positive impact. We spoke to two of the new staff who told us they had been made to feel welcome. They had worked alongside experienced staff for several shifts, additional to the normal staffing levels, so they could get to know people and their needs before taking on care duties. The manager told us that the usual staffing levels during the day were six. To meet one person's needs at least two of the six needed to be male. Staff confirmed that this was adequate to enable people to get out regularly into the community as long as one particular person was settled in their behaviour. If they were unsettled and there was likely to be an incident at least four staff needed to be on the premises. This limited community activities for others. They said the new manager had made improvements and the correct staffing was now provided unless there was short notice sickness. Three of the new staff were male which had made it possible to rota at least two male workers on each shift. Staff said the manager had responded to concerns raised about staffing levels at night and had arranged for a second worker to sleep over each night. This meant there were two night staff awake and two sleeping over who were on call. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 12
Staff told us the handover meetings held between each shift, and other communication systems worked well and kept them informed. They felt that the staff meetings that were held every four to six weeks were helpful and new ideas were welcomed. They said staff supervision sessions were now being provided regularly by the new manager and these were useful and supportive. A de-brief was held after incidents where people were violent or where physical intervention was used. Staff felt they were given suitable training for the responsibilities they were given. We saw the training records which showed that training was monitored and refreshers were planned in. Distance learning by computer was used for some topics such as safeguarding. One person's relatives told us that during 2012 their son had been taken on outings by staff who were not fully trained to meet his needs. They were now confident that this was no longer happening and most of the staff had received the required training. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 13
Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive and to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. Reasons for our judgement The manager took up the post in October 2012 on a temporary basis. They had recently been confirmed as the permanent manager. They showed us an action plan they had been working to on to improve the service. We could see that the action plan was a working document and progress was being made. They had completed several actions, such as recruiting a full staff team. The provider's quality assurance team had completed an audit of management and health and safety arrangements at the home in October 2012. This had led to an action plan that the manager had also addressed, such as a review of the fire risk assessment. The manager was able to tell us about the progress in other areas. One aim was to increase the involvement of people's families. The manager told us that soon after they started they had visited people's relatives to help improve communication links. They had recently met with families again to provide an update on progress at the service and to hear their views and ideas for improvements. They planned to develop links further with a relatives and friends forum. To try to involve people in decision making about their home, meetings called, "Your Voice" were held every few weeks. Not everyone wanted to attend these or stay for the whole session. We saw that the manager had listened to points raised at these meetings and had taken action as a result. The manager said that no formal complaints had been received since our last inspection. The area manager visited at least every month and carried out checks to monitor the quality of the service. We saw that these checks did pick up where there were shortfalls and set actions for the manager. We saw evidence that health and safety hazards had been assessed and reviewed regularly. Effective systems were in place for servicing equipment and monitoring risks such as hot water. Staff had been given training to enable them to deal with emergencies such as a fire or an accident. A plan was in place to improve some parts of the house, such as a new kitchen. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 14
About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social 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 essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 15
How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 16
How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact 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. Moderate impact 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. Major impact 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 We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 17
Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 18
Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 19
Contact us Phone: 03000 616161 Email: enquiries@cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: www.cqc.org.uk Copyright Copyright (2011) 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. Inspection Report Lammas Lodge May 2013 www.cqc.org.uk 20