Key inspection report
Care homes for older people
Name: Address: Alexander Heights Winsley Hill Alexander Heights Limpley Stoke Bath BA2 7FF 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: Roy Gregory
Date: 2 1 0 5 2 0 1 0 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 Older People
Page 2 of 33 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 Older People 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home
Name of care home: Address: Alexander Heights Winsley Hill Alexander Heights Limpley Stoke Bath BA2 7FF 01225722888 01225723017 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Avonpark Care Centre Limited Name of registered manager (if applicable) Jean Carole Chapman Type of registration: Number of places registered: care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Alexander Heights is a residential care home registered to care for 28 older people. The home is not registered for Nursing Care. Intermediate Care is not provided. The home is located within a Care Village in Limpley Stoke near Bath. The accommodation is on the first floor of a purpose built unit, with access via a passenger lift or stairs. There is a terraced area, adjoining a conservatory style lounge. People have access, if they are independent or have support, to well-maintained gardens at ground level. Accommodation is in single rooms, each with en suite facilities. One suite provides a twin bedroom, sitting room and bathroom. Communal areas consist of the conservatory, a dining room with servery, a games room and small lounge. Meals are prepared in a central kitchen that serves all the site. Alexander Heights also shares use of laundry facilities with the other units on site, which comprise independent living Care Homes for Older People Page 4 of 33 0 Over 65 28 Brief description of the care home apartments and houses, a nursing home and a care home for older people with dementia. The care village occupies a rural site between Bath and Bradford on Avon. A regular bus service stops at the main entrance and there is plentiful parking on site. The weekly fees for the home are dependent on the size of the room occupied. Information provided to visitors to the home, as at June 2009, showed that a smaller room costs £670, a larger room £720, and the suite £1000. Additional charges for chiropody, hairdressing and personal items apply. Care Homes for Older People Page 5 of 33 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 Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited Alexander Heights unannounced on Thursday 20th May 2010 between 9:10 a.m. and 5:30 p.m. and returned the following day, from 9:05 a.m. to 11:35 a.m. During the inspection we met with a number of residents, in the communal rooms and individual rooms. This allowed for discussion about their experience of care provided, and for observation of care interactions, including the service of meals. It was possible to share lunch with four people in the dining room. We visited all areas of the home. During the first day of this key inspection one of our pharmacist inspectors specifically examined the homes arrangements for the storage, handling and record-keeping of medicines. This included seeing to what extent the use of medicines linked with individual care plans and records. Sarah Robinson, the manager, was available throughout the inspection time. We spoke with various staff on duty each day, including care workers, the head of care and the Care Homes for Older People
Page 6 of 33 activities co-ordinator. At the end of the inspection we gave feedback to Sarah Robinson. Documentation examined during the inspection included initial assessments, care plans and records of care, risk assessments and records of staff training and supervision. We looked at the homes record of complaints and comments they had received and how they had responded to them. Prior to the inspection we had received the homes Annual Quality Assurance Assessment, which gave some descriptive and numerical information. We also had the benefit of an improvement plan that we requested after the previous inspection in September 2009. This showed how requirements and recommendations that we had made were being addressed. During the inspection we met with visitors to two people who live at the home. We also had a discussion with a GP who regularly attends people in the home. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visits to the home. They take into account the views and experiences of people who live there. Care Homes for Older People Page 7 of 33 What the care home does well: People considering seeking a placement at the home were provided with good information, and were encouraged to visit and experience life there. People admitted received a reader-friendly welcome pack, which gave key information such as meal times, the nature of services provided and provisions made for peoples security. Throughout our visits we saw kind, attentive interactions between care staff and the people in their care. People living in the home received evident support to hair, makeup and nail care. People we spoke to in the home said staff always respected their privacy and dignity. A person with few care needs told us they felt they lived an independent life, and another person spoke of getting up and going to bed when they wished. Most people in the home are registered to receive GP services from a local practice, which is able to provide routine visits twice a week. One of the GPs told us during our visit that staff in the home were effective at recognising health concerns and getting them referred to a doctor or nurse as appropriate. The home and surgery had worked together to reduce the number of hospital admissions when people were receiving end of life care. Both residents and staff said there was time during the day to have plentiful interaction, particularly in the afternoons. One person living in the home told us lots of the staff make a point of coming in for a chat. We noted that staff frequently called on people who chose to remain in their rooms, to see if any assistance was required. We saw that family visits were facilitated at any time, and relatives told us they always felt welcomed. A visitor who called in several times a week at different times of day said they observed a lot of one-to-one interaction between staff and the people living in the home. They were very pleased with this aspect of care as far as their relative was concerned. The main meal of the day was a three-course lunch. There were two choices of main course. As we saw, people could choose alternatives if they did not want either main choice. The dining room provided a pleasant ambience, whilst tray service was also good. People were unhurried. All people we observed at lunch appeared to enjoy their meals. One person said, I regard myself as fussy but Im generally well pleased. Another person said good choices, theres always something I like. There was good availability of information regarding how to make a complaint. The record of complaints received showed each was given a reference number, and it was possible to track how matters were received and responded to. There was a record of minor complaints and how they had been addressed quickly. This is good practice, because it demonstrates that peoples dissatisfaction at any time is acknowledged as important. Bedrooms presented as individual, with personal items around. Standards of cleaning in private rooms were high, with no unpleasant odours. The home has benefited from a stable care staff team, most of whom have gained NVQ [National Vocational Qualification] to level 2 or 3. There was a training plan that Care Homes for Older People
Page 8 of 33 showed staff were required to undertake refresher courses as they became due. We found staff to be very positive about their work, and well motivated. They felt they had good opportunities for training and that management were in touch with the daily realities of their work. Two people had been recruited to the care team since the previous inspection. Recruitment records showed the outcome of vetting checks was awaited before confirming appointment. There was evidence of a thorough interview process. What has improved since the last inspection? What they could do better: A shortfall of the pre-admission assessment form was that it did not show who completed it, or when. These details need to be included so it is clear that it has been used to make a professional decision about admission and that the person undertaking the assessment has accepted responsibility for this. We were concerned that for some people, the pre-admission assessment had not been fully completed. For many people, aspects of their care plans were not particularly relevant, because they were not associated with risks that had been identified for them. For example, there were care plans for each person concerning breathing issues and sleep patterns, even if assessments showed these were not areas of concern. Sarah Robinson and the head of care had begun a process of making care plans and related daily recording more personalised, and we agreed this should extend to ensuring that individual care Care Homes for Older People
Page 9 of 33 plans will include only those aspects of care where a clear need has been identified. People should also be more directly involved in agreeing the contents of their care and social needs plans, and signing their agreement to them. Our pharmacist inspector identified aspects of poor practice in the homes handling of medicines and has made four requirements for improvement. These are aimed at improving the safety of storage arrangements for controlled drugs, and ensuring that in respect of anticoagulants and topical applications, people receive their prescribed medicines safely. We suggested that there should be a night care plan for each person. This would ensure night staff felt included in and supported by the care planning process. Some care plans relating to specific health needs gave too little guidance on their management. Overall, our previous requirement that care plans must fully reflect peoples needs, has not been met in full, but we noted considerable efforts to address it and are not restating the requirement. Apart from the homes own efforts, they have sought advice and guidance from the quality team of Wiltshire Council social services, which was ongoing at the time of our visit. The overall profile and awareness of activities in the home could be promoted by a notice board or photo album in a prominent place. This would show people and their visitors what was going on, and encourage social engagement to be seen as a core part of what the home offers people. All staff had received training in abuse awareness and safeguarding procedures within the previous two years. But there was an urgent need for staff, including the manager, to receive training in their responsibilities under the Mental Capacity Act 2005, including deprivation of liberties safeguards. Despite the improvements made to the servery area, we found that some build-up of dirt was beginning to occur through insufficient detailed cleaning, both there and in the bathrooms. We have recommended the management should seek ways to strengthen the monitoring of cleaning standards, so that shortfalls can be identified and made good at the earliest opportunity. We also identified that the bathrooms generally were uninviting, with tired decor, and should be made more homely and up to date. For the staff that we spoke with, their only area of discontent was a lack of one-to-one supervision. Records showed that most staff had received individual supervision only twice in the preceding year. The actual quality of supervision appeared variable. All care workers must receive regular individual supervision. We suggested that the head of care could be trained to take on some of the individual supervision of staff. 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 Older People Page 10 of 33 Details of our findings
Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 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 and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. 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 them 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. There is a process for gaining useful information about prospective residents to ensure their needs can be met, but it is not always followed in full. Prospective residents and their families are encouraged to visit to see for themselves what is being offered. Information available to people is kept up to date so that prospective residents and their relatives can know what to expect from the service. Evidence: The services statement of purpose and service user guide had each been updated as required following the previous inspection. They were readily available to visitors and residents in the main corridor, along with copies of our previous inspection reports of the home. People admitted also received a reader-friendly welcome pack, which gave key information such as meal times, the nature of services provided and provisions made for peoples security. There was a pre-admission assessment form designed to capture a wide range of
Care Homes for Older People Page 12 of 33 Evidence: information and thus to enable a decision as to whether an offer of a place in the home was appropriate to meet a persons needs. We saw some examples of assessments of people that had been admitted since our previous inspection, using this form. Some were very effective. They showed time had been taken to gain a wide appreciation of peoples holistic needs and of why a care home place was being sought. In contrast, however, we saw two records where the form had been used, but very few of the questions had been answered. For all people admitted, a set of detailed baseline assessments were completed very soon after admission, to establish whether there were risks relating to nutrition, history of falls, pressure areas and so on. This information was used to inform commencement of peoples care plans, but it is important for home staff to be aware of a persons needs before they are admitted, and for the person themselves to know the home will be able to meet their needs. A shortfall of the pre-admission assessment form was that it did not show who completed it, or when. These details need to be included so it is clear that it has been used to make a decision about admission and that the person undertaking the assessment has accepted responsibility for this. People that we spoke to about their admission experiences mostly said they had relied on relatives to view the home and to make a final decision about accepting a place. They felt they themselves had received good information. One person described detailed discussions with management about the nature of service they were seeking. They considered the assessment and admission process had been a good experience that set the scene for how they have experienced living in the home since. Care Homes for Older People Page 13 of 33 Health and personal care
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 health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they 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. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them 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 have good access to health care provision. Care plans are undergoing change to make them more individualised, but are not clearly based on consultation and agreement with those being cared for. People are treated with respect and their right to privacy is upheld. The homes procedures for handling medicines are insufficient to provide completely for safety. Evidence: Care plans for each person contained the same basic elements. This meant that for many people, aspects of their care plans were not particularly relevant, because they were not associated with risks that had been identified for them. For example, there were care plans for each person concerning breathing issues and sleep patterns, even if assessments showed these were not areas of concern. Such care plans could be considered intrusive into peoples privacy, deflecting staff attention from the things that were of more importance to the individual. They also meant that staff time was taken up recording outcomes against plans that were of little relevance, because the daily recording sheet for each person in the home required a comment on each care plan element. Sarah Robinson and the head of care had begun a process of making
Care Homes for Older People Page 14 of 33 Evidence: care plans more personalised, and we agreed this should extend to ensuring that individual care plans will include only those aspects of care where a clear need has been identified. The daily recording sheets have served a useful purpose in developing staff awareness and competency, but will now be amended to fit individual needs better. The person-centred approach to care planning, and review of care plans, should also be based on more inclusion of the people receiving care. As an example, a person told us about their mobility needs and how they received assistance from staff, using a variety of equipment. Their care plan for assistance to mobilisation did not reflect how the nature of support given had evolved over time and it was thus out of date, yet it had been reviewed as still current over successive months. The person was satisfied that staff had a good understanding of their needs, but in the event of any mobilityrelated incident arising, there would be a discrepancy between the written care directions and the actual intervention by staff. Merging of the persons moving and handling assessment with the associated care plan would have been helpful. Few care plans were signed by the people concerned, or by representatives. People we asked about their care planning mostly saw it as a means by which staff monitored their wellbeing, if they had any awareness of it at all, although one person said they felt very much in control of what was in their care plan. In some cases, identified needs had not resulted in care plans being written. A person was presenting certain behaviours that were impacting on their ability to settle into the home. Care records showed the person required regular support, particularly from night staff, but there was no plan of care to ensure a consistent approach, which in turn could have been evaluated and amended on review. We suggested that there should be a night care plan for each person. This would ensure night staff felt included in and supported by the care planning process. Therefore, our previous requirement that care plans must fully reflect peoples needs, has not been met in full, but we noted considerable efforts to address it and will not restate the requirement. Apart from the homes own efforts, they have sought advice and guidance from the quality team of Wiltshire Council social services, which was ongoing at the time of our visit. At our previous inspection, we found that pressure area risks were assessed but associated care plans did not show fully how assessed risks were to be managed and monitored. There was clear improvement in this area. We saw that peoples risks of sustaining pressure damage were routinely re-assessed, with relevant new information contributing to that review process. It would therefore be safe to not create a pressure area care plan for every person, as such a plan would be instituted as soon as the risk assessment process indicated there was a need to do so. We saw that staff were alert Care Homes for Older People Page 15 of 33 Evidence: to indicators of health and wellbeing, with observations documented and communicated to senior staff for action. However, care plans relating to specific health needs gave too little guidance on management. Some guidance was based on monitoring in order to give correct care rather than detailing sufficiently what the correct care needs were. Most people in the home are registered to receive GP services from a local practice, which is able to provide routine visits twice a week. One of the GPs told us during our visit that staff in the home were effective at recognising health concerns and getting them referred to a doctor or nurse as appropriate. The home and surgery had worked together to reduce the number of hospital admissions when people were receiving end of life care. The surgery had confidence in systems they had with the home to exchange information about diabetic monitoring and warfarin levels. The GP reported seeing consistently good care interactions and contented residents. All people we spoke to in the home were pleased with staff provision for their privacy and dignity. We saw examples of professional care interactions. Staff invited people to make choices and to receive care and support at the times they wanted. Staff knocked on doors to be invited into peoples rooms, and asked preferences about leaving doors and windows open or closed. A member of the Wiltshire Council quality team had been shadowing care shifts by working alongside staff. They described good professional relationships between staff, which they saw translated into good standards of care. They were due to involve the staff in a presentation about preservation of dignity in delivering care. A person with few care needs told us they felt they lived an independent life, and another person spoke of getting up and going to bed when they wished. Our pharmacist inspector looked at the management of medicines in the home. Medicines were stored in a separate locked room. The lock of the medicine trolley was broken, but this was mended during the inspection. Staff we spoke to knew the people in the home well and medicines were given in a supportive manner following a safe procedure. All staff who administered medicines were given training, and information about the medicines was available for them to use. Each person had a medicine administration record which showed what medicines they were prescribed and when they had been given. Although these were generally clear there were a few exceptions. Two people were prescribed an anticoagulant medicine that requires careful monitoring and frequent dose changes. The home had clear guidelines for the use and recording of this medicine displayed in the treatment room and with the administration records, but this guidance had not been followed, and the original copy of the last blood test and dose change was not available. One person had a variable Care Homes for Older People Page 16 of 33 Evidence: dose of a medicine that depended on three daily blood tests. The regime written on the administration record did not match the most recent one that the doctor and specialist nurse had given them, although other records and discussions with staff indicated that they were following the most recent instructions, regardless of what was written on the administration record. One person was prescribed a medicine in patch form; the dose of this was unclear from the records that the home had. The doctor was contacted during the inspection to visit and review their patients medicines. Many people in the home chose to apply their own creams and lotions and these were kept in their rooms. The medication administration records did not reflect this practice and the care plans we saw did not show who was applying the creams or what checks or records should be made. We saw records of medicines received into the home and returned for disposal. The day before the inspection the supply of medicines for the succeeding month had been delivered. The items requiring refrigeration had been removed and stored appropriately, however the controlled drugs had not been locked in the controlled drug cupboard or entered in the register which meant that they had not been stored securely, in the required legal manner, overnight. Care Homes for Older People Page 17 of 33 Daily life and social activities
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 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. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to exercise choice over daily routines and from a range of activities offered, including availability of religious services. People keep in contact with family and friends and visitors are welcomed. An extensive menu is offered and people choose where to take their meals. Evidence: The activities co-ordinator showed us that the range and delivery of activity provision was much as it was at our previous visit, when we rated it as good. The co-ordinator has completed a course on activities in the home. She has taken responsibility for creating an activities and social needs care plan for each person, as we recommended at the previous inspection. These gave a good picture of peoples preferences and represented a basis on which to build, in particular by adding detail as it becomes known. For example, recognised interests in books, music or television need to be expanded to be more specific, so that on evaluation, it can be determined to what extent people have been supported to enjoy the things they most like doing. As with physical care plans, there was scope for more direct input and agreement on the part of people in the home. We also identified that religious preferences were as yet insufficiently ascertained. It may be appropriate to consider a bespoke format for the activities and social needs care plan, so it is not shoehorned into a form primarily
Care Homes for Older People Page 18 of 33 Evidence: designed for other uses. Activities planned for the week were written up on a notice board by the dining room. They included Scrabble in two different formats, holy communion, board games, armchair bingo, movie time and one-to-one manicures and foot massages. We saw that these were delivered at the publicised times and resulted in a wide spread of involvement by people. A person told us they considered there to be sufficient organised activity, given the extent to which many people enjoyed television or music in their rooms, and family contacts. They spoke of special events such as Halloween being used to do different things, and enjoyed music events when these were arranged. The co-ordinator was aware that many people would like more opportunities for community access. One person told us they would like occasional experience of going to shops. There was now a new minibus available, with a wheelchair lift, and the activities co-ordinator hoped to arrange occasional trips for those who did not have such opportunities with family visitors. The overall profile and awareness of activities in the home could be promoted by a notice board or photo album in a prominent place. This would show people and their visitors what was going on, and emphasise social engagement as a core part of what the home offers. The menu for lunch and tea was displayed near the dining room. People in the dining room at lunch time told us they found the room conducive to an enjoyable meal. There was a consensus that a good range of choice was available and people said they usually enjoyed their meals. Other people we spoke to during the visit were also complimentary about the food. One person said, I regard myself as fussy but Im generally well pleased. Another person said good choices, theres always something I like. We saw that meals were well presented and served. Some people preferred to receive tray service in their rooms, which was on a par with the dining room service. One person had received dental treatment during the morning. We saw how staff engaged with them about what they could eat and how the meal would be best presented for them. In the servery there was a list of individual likes, dislikes and allergies, so staff could ensure these were taken account of in the meals they served. People were aware they could request alternatives to the menu choices and we saw a person do so. One person had been supported to make individual arrangements for the preparation of their meals. This was a creative approach to enhancing the persons independence and respecting preferences. Visitors were welcome to share meals in the dining room or individual rooms. We saw that people received visitors throughout the day, and there was an easy relationship between visitors and the staff. Care Homes for Older People Page 19 of 33 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. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe, although they are in need of training about mental capacity and deprivation of liberty safeguards. Evidence: There was good availability of information regarding how to make a complaint. The record of complaints received showed each was given a reference number, and it was possible to track how matters were received and responded to. With regard to a matter of complaint of which we were previously aware, there was a record of a meeting with a persons family members, during which an apology had been given about ineffective responses to complaints they had made in the past when the complaints procedure was undeveloped. Another complaint investigation we looked at showed an investigation had revealed a staff competence issue, leading to an action plan for improvement and an apology to the complainant. Lesser verbal complaints and comments and their outcomes were also recorded. The record supported Sarah Robinsons expressed view that complaints were valued as an indicator of shortfalls and how to correct them. Several written compliments had been received since the previous inspection. All staff had received training in abuse awareness and safeguarding procedures within the previous two years. Staff were given copies of the No Secrets guidance to the
Care Homes for Older People Page 20 of 33 Evidence: local inter-agency safeguarding procedures, and further copies were readily available. There was an urgent need for staff, including the manager, to receive training in their responsibilities under the Mental Capacity Act 2005, including deprivation of liberties safeguards. Care Homes for Older People Page 21 of 33 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, 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. 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. The home is safe and well-maintained and most parts are homely. Standards of hygiene in some parts of the home need greater attention to detail. Evidence: At our inspection in June 2009 we found a major shortfall in environmental standards in the servery area, where meals are received from the central site kitchen and served to the dining room. This was followed up by a visit in August 2009 by an environmental health officer [EHO], who was able to confirm that a re-fit of the servery was then nearing completion, with new cleanable surfaces and replacement of some items. There was no concern about food safety. The EHO also visited the central kitchen, where they reported mostly excellent standards. We confirmed at this inspection that our requirement for assessing fitness for purpose of the equipment, furniture and fittings in the servery and communal areas, followed by replacement and making good, was met. However, we noted some build-up of dirt and grease in some areas, including skirting boards, cupboard hinges and tiles. The interior of the microwave oven was dirty. A wooden serving trolley that was badly degraded at the previous inspection had been replaced by a catering standard stainless steel trolley, but this had a build-up of dirt around the wheels. There were also shortfalls in detailed cleaning in the bathrooms. We noted that cleaning standards had been subject of concern and discussion at management level. Housekeepers and night staff signed to indicate they had completed their cleaning schedules but there remained a need for
Care Homes for Older People Page 22 of 33 Evidence: greater vigilance over the actual outcome of their efforts. These staff might benefit as much as care staff from training in the promotion of peoples dignity, since that is undermined by cutting corners on cleanliness. People and their visitors told us personal rooms and en suites received plenty of attention from the housekeepers, and we saw good standards of cleaning there. People were able to configure their rooms as they wished and many rooms were highly personalised. By contrast, bathrooms presented as tired and functional, with few features to make them homely. In some bathrooms and toilets there was a need to re-seal the flooring to the skirting, in order to avoid dirt traps. The home was completely free of any unpleasant odours. The conservatory lounge had received some upgrading since our previous visit and it presented well. The door to the outside terrace was open and people made spontaneous choices about use of the room and the terrace. We drew attention to the fact that the sluice room was unlocked and therefore could be inappropriately accessed by people living in the home. Sarah Robinson said staff would be reminded of the existing policy that this door should be kept locked. We saw clean laundry being distributed to peoples rooms. There was a central laundry serving Hillcrest House and other establishments on the site. People told us it provided an efficient service with few problems. We heard how a lost item had been successfully tracked down. Care Homes for Older People Page 23 of 33 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 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 to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers provide for peoples assessed needs and allow for engagement between staff and people living in the home. People are protected by safe recruitment procedures, and staff receive appropriate training and qualifications. Evidence: Staffing rotas confirmed the basic provision was for three care staff throughout the day, each working a 12-hour shift, 8 a.m. to 8 p.m. As much as possible, the three staff on duty included a senior carer. Since our previous inspection the staff team had been augmented by a head of care. This person may be the senior member of the care shift, but also has off rota time for assisting the manager with care planning and reviews, and other administrative roles. The activities co-ordinator hours were always additional to the basic shift provision. There was a plan shortly to increase the staff team by a further senior carer, to enable more off-rota time for the head of care, and also to make the team more self-sufficient in covering for staff absence on sick leave or training. It was rare to deploy agency staff to cover absence, as it was usually possible to bring in care staff from other parts of the care village site. Sarah Robinson also liked to cover some shifts as a means of keeping in touch with care issues at the point of delivery. At night there were two care staff on duty. They had some housekeeping duties, although meeting peoples care needs took priority. We spoke with the care staff on duty. They experienced staffing levels as mainly
Care Homes for Older People Page 24 of 33 Evidence: sufficient. One person in the home currently needed the assistance of two staff for their morning routines and, as this was the busiest time of day, other people requesting assistance at the same time could be kept waiting. A significant part of the senior carers duties revolved around administration of medicines, when they could not be disturbed. The staff also said some training sessions were missed because staff absence could not always be covered. However, the regularity of provision of mandatory training meant this was not a great problem, and they considered the management did everything possible to cover any absence. The AQAA acknowledged that covering training needs could be problematic. It also pointed out that as the manager had been promoted from within the staff team, there had been some delay in returning the complement to full strength. People that lived in the home reflected the staff view of essential sufficiency of staff, with experience of some delays in answering call bells at the busiest times. Both residents and staff said there was time during the day to have plentiful interaction, particularly in the afternoons. One person living in the home told us lots of the staff make a point of coming in for a chat. We noted that staff frequently called on people who chose to remain in their rooms to see if any assistance was required. A person said that staff are sufficient and do find time for a chat, though it tends to be short. Care staff were able to give some support to the activities co-ordinator. A visitor who called in several times a week at different times said they observed a lot of one-to-one interaction between staff and the people living in the home. They were very pleased with this aspect of care as far as their relative was concerned. Out of a care staff team of twelve, all but two had achieved NVQ [National Vocational Qualification] to at least level 2. For repeated mandatory training there was a twelvemonth schedule of provision for the whole Care Village site. This cross-referred to training needs matrices for the homes staff groups [care, nights, and housekeeping] on the office wall, which Sarah Robinson kept up to date. The rolling programme of core training provided on site, but using some external trainers, included safeguarding, infection control, health and safety, dementia awareness, moving and handling, emergency aid and food hygiene. Wiltshire Council quality team were to provide some training in record keeping and dignity awareness. We found staff to be very positive about their work, and well motivated. This was also the experience of the member of the quality team who had spent time with the care shifts. Staff felt they had good opportunities for training and that management were in touch with the daily realities of their work. They confirmed their moving and handling training supported them in use of hoists. Care Homes for Older People Page 25 of 33 Evidence: Two people had been recruited to the care team since the previous inspection. Recruitment records showed the outcome of vetting checks was awaited before confirming appointment. Interview notes showed this was a thorough process. On appointment, new staff signed for receipt of the code of conduct for care workers, the guidance to safeguarding procedures, and safety information. There was evidence of an efficient induction for new staff. We saw an example of a persons probationary period being extended as their performance was not considered satisfactory. Care Homes for Older People Page 26 of 33 Management and administration
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 led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate 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. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. 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 of the home has been stabilised, leading to progress on prioritising areas for development. People living in the home, and the staff, have good access to management. People control their own money, or their supporters do, without intervention from the home. Staff performance is appraised, but staff do not experience regular individual supervision. A range of measures provides for peoples health and safety. Evidence: Sarah Robinson has made application for registration as the homes manager, having been acting into the role since June 2009. She has been supported by Lisa Beeson, formerly responsible individual for the service, and by Shaun Kelly, who has taken over that role. Records showed that there was an interchange of information between the different tiers of management, especially through monthly monitoring visits, which included gaining the views of people living in the home, and staff at all levels. These records showed how Sarah Robinson had brought some of the issues raised in this inspection to attention and secured support for working towards change. For example,
Care Homes for Older People Page 27 of 33 Evidence: there had been agreement on simplifying care plans and making them more personcentred, and on tackling issues of cleaning standards. Following the previous inspection, staff were invited into a feedback meeting with management to share ownership of the homes improvement plan made in response. Sarah Robinson had held a further staff meeting in April 2010 in response to issues being raised by some staff, in order to strengthen shift management arrangements and to stress provision for peoples dignity as fundamental to how people worked. She did not identify a need for regular staff meetings, as she considered the small size of team and nature of working relationships as conducive to communication and every day problem solving. There were no residents or relatives meetings recorded in the past year. It was stated in the AQAA that relatives had turned down the opportunity to commence relatives meetings because they were satisfied with the open door policy in place. There was provision for carrying out annual surveys of peoples views of the home, but for the current year this was overdue. Although it was evident many people in the home, and many visitors, find it easy to have their say and influence the service they receive, this is not the same as ensuring all people have that opportunity, and using information obtained to aid systematic planning. For the staff that we spoke with, their only area of discontent was a lack of one-to-one supervision. Records showed that most staff had received individual supervision only twice in the preceding year. The actual quality of supervision appeared variable. All staff had received an annual appraisal, which was carried out to a good standard. We suggested that the head of care could be trained to take on some of the individual supervision of staff. Supervision should be regular. It should be used in part to discuss peoples work as key workers to individual people living in the home, and how they see their role as achieving good outcomes for people. A sample of risk assessments, both task-centred and environmental, suggested these were being produced to a higher standard to that seen at the previous inspection. The Fire and Rescue Service visited the home in March 2010 and identified some minor shortfalls in testing procedures, and a lack of an evacuation plan. These issues had been addressed. In fact, the home experienced a boiler room fire in April, when there was a successful and efficient evacuation to a safe area. Care Homes for Older People Page 28 of 33 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 Older People Page 29 of 33 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 3 14 People must not be admitted 31/08/2010 to the care home without evidence that their needs have been fully assessed beforehand. People admitted, and the staff of the home, need to be confident that the placement is appropriate to meet their needs. 2 9 13 Staff must follow the homes 31/08/2010 procedures and the National Patient Safety Agency advice for the recording of anticoagulant medicines. This will ensure that people receive their medicines safely. 3 9 13 Medication administration 31/08/2010 records must be clear and accurately reflect any changes to doses or variable doses that are prescribed. Care Homes for Older People Page 30 of 33 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 This will ensure that people receive their medicines safely. 4 9 13 There must be a record of the use of all creams and other external preparations, including care plan guidance where people choose to apply their own creams. This will ensure that people are receiving the correct treatment whilst being able to maintain their independence. 5 9 13 All controlled drugs must be 01/07/2010 stored in the controlled drug cupboard and entered into the controlled drug register as soon as they have been received form the supplier. This ensures that controlled drugs are secure and accounted for at all times. All staff, commencing with 30/09/2010 the manager and senior staff, must receive training about the implications of the Mental Capacity Act 2005. People in the home, and their supporters, need to know that concerns around decision making will be recognised and addressed 31/08/2010 6 18 18 Care Homes for Older People Page 31 of 33 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 on the basis of current legislation, to protect peoples best interests. 7 36 18 All care workers must receive regular individual supervision. People who live in the home will benefit from staff who have the opportunity to reflect on the impact of their work and to identify and follow up professional developmental needs. 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 01/07/2010 1 2 7 12 People should be invited to sign to show they agree the contents of their care plans. Consider how best to devise individual activities and social needs plans, and ensure religious wishes are recorded and provided for. Maintain and display a record, including photographs, of activities and social events organised in the home. Consider ways of making the bathrooms more inviting and homely, ensuring any potential dirt traps are also eliminated. Seek ways to strengthen the monitoring of cleaning standards, so that shortfalls can be identified and made good at the earliest opportunity. 3 4 12 26 5 26 Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 33 of 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
