Inspection on 16/11/09 for Ashley House Nursing Home

This is the latest available inspection report for this service, carried out on 16th November 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashley House Nursing Home 26/01/06

Ashley House Nursing Home 09/06/05

Ashley House Nursing Home 14/01/05

Ashley House Nursing Home 15/07/04

Ashley House Nursing Home 09/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for older people Name: Address: Ashley House Nursing Home 118 Trafalgar Road Cirencester Glos GL7 2EN     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: Janice Patrick1     Date: 1 6 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Ashley House Nursing Home 118 Trafalgar Road Cirencester Glos GL7 2EN 01285650671 01285650672 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.bupa.com BUPA Care Homes (BNH) Ltd care home 47 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Temporary variation to client categories DE(E) for 1 (one) named service user. The home will revert to the original client category when this service user no longer resides at the home. Date of last inspection Brief description of the care home Ashley House is situated on the outskirts of Cirencester Town and is within walking distance of a main bus route and some areas of the town. There is also a public house and church nearby. The home predominantly provides nursing care to those over the age of 65 years of age but can provide personal care to the same age group. The Home is staffed with qualified nurses, 24 hours of the day. Private accommodation is provided in single bedrooms, all with ensuite facilities, some larger bedrooms are available for those who wish to share or have more space. Extensive communal areas are also available including an interior courtyard garden. The Home is predominantly private fee paying, but will consider potential residents Care Homes for Older People Page 4 of 37 Over 65 47 0 Brief description of the care home who require some form of funding, on an individual basis. The current range of fees can be obtained from the service. The home makes available in the reception area the previous inspection report provided by the Commission. Care Homes for Older People Page 5 of 37 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 looked at all the information that we have received, or asked for since the last key inspection or annual service review. This included the most recent Annual Quality Assurance Assessment, AQAA that was sent to us by the service. The AQAA is a self assessment completed annually by the service and forwarded to the Commission. It tells how well the service feels it is meeting peoples needs. It also tells us of improvements made to the quality of the services provided and the plans the service has for the next twelve months. It also gives us some numerical information about the service. We looked at any information that tells us how the service has managed any complaints, staff investigations. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. We looked at the previous key inspection report and the results of any other visits that Care Homes for Older People Page 6 of 37 we have made to the service in the last 12 months. This included any outstanding requirements and how the service has told us how these have been met. We have considered any relevant information from other organisations. Prior to our site visit we forwarded fifteen service user pre inspection questionnaires and fifteen staff questionnaires. We received fourteen service user questionnaires back and eleven staff questionnaires back. We also forwarded three professional health care questionnaires for external professionals who visit the service to tells us what they think about the service and had none returned. We then visited the service on one day between the hours of 09:55am and 21:20pm where we looked in detail at the care of three people and observed interactions between several others and staff. We inspected care records, staff personnel files relating to their recruitment, supervision and training. We also inspected other records related to the smooth running of the service and health and safety. We looked at the arrangements for safeguarding people from abuse and how the service manages complaints and concerns. We looked at the current arrangement for the management of the service, how the service measures the standards of its service provision and how it aims to improve this. We walked around the building, spoke to several service users, members of staff and spoke to one relative over the telephone. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: Care planning and additional assessments need to be kept up to date at all times and they need to cross reference with each other to avoid conflicting guidance being given to staff. Peoples individual care needs must be given more thought so that they are truly met in a holistic and person centred way. In doing this staff need to listen to what people are saying to them and consider their preferences and wishes. More attention is needed to areas of care such as mouth care and nail care. Care needs should always be addressed by taking into account peoples dignity. Special attention needs to be given to people who require more support at mealtimes. The service must endeavor to address the issues thoroughly that have been the route of so much dissatisfaction. The service must ensure that meeting the individual needs of service users is paramount when staffing levels are reviewed whenever there is a drop in occupancy levels. Staff supervision must be maintained to ensure a good quality of care delivery and so that staff adhere to the companys policies and procedures. Care Homes for Older People Page 8 of 37 The service along with the Registered Provider must reassure itself that its systems for quality review are satisfactory The company must then manage the service in a way that ensures good outcomes for people using the service. 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 9 of 37 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 10 of 37 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides very good opportunities for people to receive all the information they require to make an informed decision about their future care and about the service and their finances following admission. Evidence: We received fourteen pre inspection questionnaires from people using the service; all but one confirmed that they had received enough information about the service at the point of needing to make a decision about their future care. One questionnaire did not reply to this question. During our visit we saw a large amount of information which is available to people already using the service and visitors. This also included guidance on paying fees. There is also specific literature about the service in each bedroom. The receptionist can also help with peoples enquiries and is in the home from 8am until 2pm and then 5pm until 8pm, including some hours over each weekend. During the week days an administrator is present and can help with more specific Care Homes for Older People Page 11 of 37 Evidence: financial and billing enquiries. All but one person confirmed receipt of a contract following admission. The Manager confirmed that everyone, irrespective of how their fees are being paid, receive a residency contract. The service provides a monthly invoice which breaks down the service charges. Information is also provided on a monthly basis in relation to the Free Nursing Care, FNC contribution showing the exact figures in relation to this. This means that the service has complied with a requirement made at a previous inspection to provide people with clear information about their FNC contribution. Care Homes for Older People Page 12 of 37 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. Some peoples care needs have not been adequately met and are still not being consistently met to a standard that enhances their quality of life and meets their individual needs. However, the service is well aware of where the shortfalls are and have started to address them in a robust manner. Evidence: During our visit we spoke to staff about peoples needs, observed staff delivering various types of support and spoke to the people who were receiving this. We inspected a selection of care records and discussed these with the nurses. We have also considered all of the information given to us, in relation to this outcome, from the fourteen pre inspection questionnaires and by talking with one relative during the visit. We have also noted information given to us by the service in the returned AQAA. Several questionnaires expressed specific concerns about how long it took staff to answer the call bell system. In the section that asks what could the home do better, one service user had commented answer the call bell, it can seem along time before anyone comes. There were several other comments relating to call bells not being Care Homes for Older People Page 13 of 37 Evidence: answered quickly enough; we therefore discussed this with the Manager and Deputy Manager who have been aware of peoples dissatisfaction in this area. They told us that they have begun to address this by auditing the call and response times and by making alterations to the organisation of each shift. They were able to demonstrate that call response times were generally improving but said there was still room for improvement. We looked at some of the response times, which were occurring approximately a month before this inspection and some of these were still at an unacceptable length of time; fifteen minutes, nineteen minutes and up to twenty six minutes for one person. This was on an evening when some people were waiting to go to a resident and relative meeting but not everyone was ringing for this reason. We can also report however that three questionnaires said staff were always available when they needed them, nine said they were usually available and two said sometimes. One said they felt the call bell response times were beginning to improve. There were many more specific comments about there not being enough staff available. One staff questionnaire said of the staffing extremely stressful over the summer months. There wasnt enough time to do care plans as so short staffed. Issues relating to staffing have been reported on within the Staffing outcome of this report. All the questionnaires confirmed that people felt they always or usually received adequate medical attention and most people felt that staff always or usually listened to them, although three felt this to only be sometimes. During our visit we were aware of three people being visited by their Doctor and care records demonstrated that other external health care professionals are involved in some peoples ongoing care. Comments about the staff included some carers and nurses are excellent and nice atmosphere, kind and helpful staff. We observed one nurse giving one person dedicated time in their bedroom to manicure their nails and to talk. This nurse could speak the persons first language and was therefore also able to translate for us. However, a couple of questionnaires made comment about service users having problems understanding staff when English is not the staff members first language. Over the last six months the home has received various complaints and concerns about the standard of care and services being provided. The Commission has been contacted by one person within the last six months who was unhappy about the standard of their relatives care. They contacted the Commission as they remained dissatisfied with BUPAs investigation findings. The overall arrangements for managing Care Homes for Older People Page 14 of 37 Evidence: complaints is discussed in the Complaints and Protection outcome of this report. BUPA and the current Manager of the service are very aware that the overall standard of care has not been up to the previous standard that gave the home its excellent rating in 2006. The main reason for this seems to be a lack of consistent strong leadership, certainly over the last year. However, the service now has a permanent Manager and a very competent Deputy Manager who are aware of what improvements need to take place and who have started to address these. Quality assurance arrangements have been addressed in more detail in the Administration and Management outcome of this report. We did witness some practices that would not necessarily put people at risk but which would have a bearing on how some people would perceive the care in the home to be. Some would certainly impact on the persons quality of life and their dignity in a negative way and others were satisfactory. The shortfalls were mainly related to staff not particularly thinking about their actions and what impact these may have on the person. It was also in the way people were sometimes addressed. All of these are resolvable with the right arrangements in place. During the handover meeting from day staff to night staff we witnessed staff discussing many health and personal care needs which had either been considered or addressed during that day. However, based on what we observed and the feedback we have received, some people have not had good care experiences and some are still not having their needs appropriately met in a consistent and person centred manner. On the day of the inspection shortfalls were observed in how two peoples toilet needs were addressed, in the support given to two people at mealtimes, some staff interactions, in the attention given to two peoples finger nails and two peoples mouth care. These were consistent with comments made by relatives such as being upset when finding their relative with food down their front, not wanting to interfere in their relatives care but deciding to cut and clean their relatives finger nails themselves as staff did not seem to realise they needed doing; one comment referred to watching people ask for the toilet and staff saying they would have to wait. One relative questionnaire commented on very simple things that make a difference to someones quality of life but which they felt were not being considered. This relative felt that some things were improving but still felt they needed to visit on a regular basis to ensure the little but important things were getting done. There was one comment about people not being dressed on their bottom half but just covered with a blanket because it was easier for staff to then help them with their toilet needs. There were a couple of people who are totally dependent on two staff and the use of a sling and Care Homes for Older People Page 15 of 37 Evidence: hoist for their toilet needs so we asked the Manager to be aware of this comment and to ensure these practices were not taking place. The Deputy Manager explained that she spent alot of her time checking on areas of care and felt confident that this was not happening. One questionnaire commented the care needs to be holistic, another said staff need to be more aware of peoples individual needs and another said for the considerable amount we are paying the care does not reflect the amount that we have to pay. We looked in detail at the care records of three people. BUPA have devised a very comprehensive system for assessing and planning peoples care. However, individual assessments do contain several pages of information and although the care plans are designed to be person centred and assessments and care plans should cross reference; at times, actually finding the persons current needs and the guidance on how the needs should be met was quite time consuming and laboured. After meeting one particular person we wanted to find out what the persons current mobility capabilities were and what guidance was being given to staff on how to move the person safely. This persons abilities had altered several times over the last few months so it was important for the guidance to staff to keep pace with the persons changing needs. After reading the moving and handling assessment, the persons falls risk assessment and the associated care plan, which had a lengthy preliminary text we remained unclear as to this persons current ability and what support they actually needed. This care file was one that had previously been updated but the Deputy Manager agreed that parts of the documentation pertaining to the persons safe moving and handling had not been consistently updated. We also discussed how wordy and lengthy the information was and how the facts and guidance ended up getting lost. This seemed to be a theme in several care plans and has been identified by staff who recognise there is a need to get back to clear and succinct care planning. We were informed that several care records had fallen behind. One staff questionnaire describes the problems they were having in relation to staffing extremely stressful over the summer months. There wasnt enough time to do care plans as so short staffed. We were informed at the time of this visit that many care files have now been reviewed and updated and that Registered Nurses have been allocated specific, protected time to do this. After meeting one particular person we wanted to find out what the persons current mobility capabilities were and what guidance was being given to staff on how to move the person safely. This persons abilities had altered several times over the last few months so it was important for the guidance to staff to keep pace with the persons changing needs. After reading the moving and handling assessment, the persons falls risk assessment and the associated care plan, which Care Homes for Older People Page 16 of 37 Evidence: had a lengthy preliminary text we remained unclear as to this persons current ability and what support they actually needed. This care file was one that had been updated but the Deputy Manager agreed that parts of the documentation pertaining to the persons safe moving and handling had not been consistently updated. We discussed how wordy and lengthy the information was and how the facts and guidance sometimes get lost in the text. This seemed to be a theme in several care plans and has been identified by staff who recognise there is a need to get back to clear and succinct care planning. Although BUPA have obviously agreed recently to nurses having protected time to review care records; this is a legal requirement of Registered Nurses and should be accounted for when the original staffing is worked out for the home. By letting care plans and other assessments slip it means there is a risk that staff do not have access to the correct guidance. One of BUPAs specialised teams are currently providing support to the nurses with respect to care planning. The same persons care file contained appropriate assessments for the safe use of bed rails. This person had experienced falls from the bed but also had a tendency of attempting to get out of bed alone so bed rails had been assessed as not being appropriate. Instead a specific bed and other specialised equipment was in use. All care files seen had a bed rail assessment describing their safe use or a decision not to use them for similar reasons as above. Another persons care plan for eating and drinking demonstrated that their weight was being monitored and had increased in the last month. The care plan was very specific about what the person liked and disliked and described a preference to eat in their bedroom. Although this person sometimes sits in their armchair to eat, we had a specific conversation with them about how they sometimes now eat in bed. This person described sliding down the bed at times and when the food is placed on the bed table in front of them and neither their position or the bed table height is adjusted the food ends up too high for them to manage comfortably. This persons care plan for washing and dressing was very specific and described the persons preferences well. However, the person explained that this is not always completed this way and at times staff are rushed and they are left feeling damp. Another person who is totally dependent on staff for all care and daily activities was at risk of their skin being compromised due to immobility and incontinence. The care plans described in detail the persons cleanliness needs and toilet needs. They also gave detail about the pressure relief in place for when the person was in bed but not for when they are sitting in their chair, which is most days. Care Homes for Older People Page 17 of 37 Evidence: We noted that the section in the care records for relatives expectations was often not completed and yet the home had had quite a few interactions with some relatives about their expectations and concerns about care. The Managers said that they had noticed this and that staff had not been sure how to use this section but that this has now been explained. Also, the section that asks if the person living in the home wants their relative to be involved with and aware of their care planning was often not completed. This is now particularly relevant in relation to considering peoples mental capacity and their rights to confidentiality. We inspected medication administration records, MARs and other relevant records. All MARs were preceded by a photograph of the person to aid correct identification. As the new medication order had just arrived and therefore the current MARs did not give much information, we asked to see the previous months MARs for several people. We did not see any signature gaps, there were a couple o recorded without an explanation of what this meant but not many. Some handwritten orders only had one signature but it was explained that as the new order had just come in they were waiting for a second nurse to double check the contents of the prescription and then these would be signed. Ideally this should obviously be done before staff start administering and using the current MAR. The process of checking the MAR and new stock against the photocopied prescription is good practice. One person was prescribed a well know medicine for anxiety, on an as required basis. This medicine slows the person down and is therefore open to being used inconsistently or not in the persons best interest. There was an associated care plan for this medication in this persons care file pointing out this was prescribed to be given as required. We were concerned to see that a member of staff had highlighted a specific time during the day for this to be administered. The Deputy Manager explained that this was probably because the person usually required this at this time of the day. This however increases the chances of misuse as staff could automatically give this medicine regularly, at this time purely because the time is highlighted. If it is required regularly at this time it should be prescribed as such or a specific time should not be stated. We inspected the records for controlled medicines. One persons records showed an entry which had been crossed out, which initially caused us confusion when balancing the stock. The stock balance was correct but an explanation for the original written mistake may help to explain such anomalies to someone in the future. The controlled medicine stock for two other people corresponded with the records being kept and there were associated care plans for the use of pain control medicines. Arrangements are in place for people to self medicate if they wish to and are capable Care Homes for Older People Page 18 of 37 Evidence: of doing so safely. The records of one person demonstrated that fresh stock is given each month after collecting from the person, any medicines left over from the previous month. Records demonstrated how many of each medicine had been issued and there was a record of any medicines that had not been used, that were going back to the Pharmacy. We asked how the nurses determined each month if the person was capable to self medicate. Although we were given a description of what is considered each month, this process was not recorded. The service have reported quite a few medication errors to us since the last inspection. The incidents have involved most Registered Nurses at various times and have therefore highlighted that basic systems and protocols have not been followed. The MARs and other areas of the medication system have always been audited monthly but since these incidents extra checks have been put in place. The nurses concerned have been provided with extra supervision and are to attend additional medicine training. The Manager explained that the home wishes to be part of the national drive to improve end of life care and she plans to explore the Liverpool Care Pathway. Care Homes for Older People Page 19 of 37 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 generally provided with opportunities to take part in activities and to socialise. They are provided with a balanced and appropriate diet that also incorporates a choice. More attention to peoples individual needs and requests will help staff deliver care in a way that will further improve peoples quality of life. Evidence: All the people that returned a questionnaire said that there are always or usually activities provided that they feel they can join in with. One comment said I would like to go out for short walks but there is usually no one to take me and another said that it would be nice to have more informal visits from the staff. The AQAA tells us that a newsletter is distributed telling people about the various activities taking place. Comments within the questionnaires were very complimentary about the activities coordinator saying how patient and kind she is. We received a couple of comments about the need for a carer to be available when activities are taking place to help those who may need to use the toilet, rather than the activity coordinator having to interrupt the activity. Recent audits carried out by the service did highlight the lounge area as an area where the response time for answering the call bell required improvement. Care Homes for Older People Page 20 of 37 Evidence: The activities coordinator was on leave during our visit but we were informed that a carer is now allocated to specifically cover the lounge area when service users are present and is allocated to be available when activities are taking place. When we visited the lounge about 4pm, with the Manager, there were eight people sitting in there and no staff nearby. None of the people present could tell us whether they had just taken part in an activity or not; all seemed fairly dependent people. After exploring what had happened the Manager explained that the member of staff who had originally been allocated to provide an activity had gone off sick, another carer had been given the task and had carried a quiz, but had left the lounge area to help elsewhere in the home and had not told anyone she was leaving the area. The Manager agreed that the importance of staff be present or at lease being available close by when service users are present would be reiterated to staff. We did ask if the home had enough staff to maintain this and were told that it did. See Staffing outcome in this report for further details on staffing issues. We saw several people sitting around the windows that look out onto a large courtyard style garden. Several people told us they enjoy looking out and enjoy the sun light. There was a music centre in an area opposite reception where people also sat but we noted there was no music playing during out visit. We also noted that several people prefer to remain in there own bedrooms for most of the day. Family and friends were seen visiting and we saw some being greeted by the receptionist. There is a receptionists presence in the home seven days a week. Information about Advocacy; through Age Concern can be found in the reception area. People told us that they usually like the food. One person said that its sometimes what they like. We have been told that there is a choice of food and that this is done by completing a menu card the day before. On the day we visited lunch was a chicken dish or baked fish. Two people we asked could not remember what they had ordered. One person commented that they felt the suppers were sometimes not suitable for older people. The AQAA tells us that menus are devised following consultation with people who use the service. Food is available at anytime of the day and the service are trying to improve peoples awareness of the Nite Bite service, which enables certain foods to be provided at anytime of the night. There are two sittings for lunch; the first is for people who require a degree of supervision or assistance. During this sitting we saw five people being assisted by staff and one person being helped by a relative. When staff needed to feed someone, this was done in a quiet and dignified way; staff sat alongside the person and did not rush. We were surprised at how the soup was served to some people in this sitting. This did not seem to meet with the Care Homes for Older People Page 21 of 37 Evidence: high standards the home set for peoples dining experience and related to one of the comments from a relative, albeit did not involve the same service user, where they felt more trouble could be taken to avoid spillages down peoples clothes by simply offering a napkin. One service user was provided with their soup in a tea cup. This was not placed on a saucer or mat and had a dessert spoon standing up in it. The person was sitting in a wheelchair that could not get as close as needed to the table, so as the person leant forward to reach the cup the spoon swung around and soup spilled down the persons front. A napkin was on the table but not offered to or placed on the persons chest. This persons eating and drinking care plans specifically said they need support and supervision to successfully eat and drink. We saw an attractive sweet trolley containing several choices. There has clearly been a period of time where peoples choices and preferences have been compromised. They indicate within the questionnaires that this has been mainly due to a lack of staff. We are also aware that the current Managers of the service are currently encouraging and developing a culture within the staff team that enables the service to run in a manner that best suits the service users. Care Homes for Older People Page 22 of 37 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual concerns and complaints are listened to and responded to within the correct period of time, but the core issues which caused the original concerns and which effect the outcomes for people were not addressed quickly enough. These are however now being managed and there are good arrangements in place to help protect people from abuse. Evidence: Fourteen questionnaires were returned to us; six indicated that the person knew how to make a complaint, seven indicated that they did not know and one made no comment. The service does have a Concerns and Complaints Policy, which the AQAA tells us was last reviewed in December 2006. The procedure on how to make a complaint is within the information that each person or representative gets when they first use the service and it can be found in the reception area. We recommended that it maybe helpful to remind people of this in the next relative and resident meeting due to the number of people who indicated that they were not clear on the procedure. Some people clearly do know how to make a complaint and have done so. As we have previously referred to in the Health and Personal Care outcome within this report. We did also receive a copy of one persons complaint to the service as they remained unhappy following BUPAs investigation. We had also received a copy of this and although BUPA revisited some of the areas of concern, the initial investigation had been carried out thoroughly. Some areas of care practice were identified as not being Care Homes for Older People Page 23 of 37 Evidence: satisfactory and appropriate action was taken. One person said in their questionnaire that they have raised on several occasions that the home should provide higher staffing levels. This relative confirmed that they were provided an opportunity to speak to a senior manager within BUPA about their concerns at the time but did not feel that the route of the problem was addressed i.e. the lack of staff. Based on how many comments have been received from people who use the service, visitors and staff; this comment would appear to be fair summary of the situation. The AQAA tells us that the service has received ten complaints in the last 12 months and all were responded to and investigated with twenty eight days and that five were upheld. The services monthly audits within the complaints file indicate that a higher number of complaints were received between January and June of this year alone, with an increase in number predominantly occurring between the months of April and June. Overall, this is a high number for this service and confirms that there has been a period of dissatisfaction. Evidence shows that BUPA have responded to the complainants and that this has been done within the companys stated time frame. However, it would also appear that a period of time went by when complaints and general dissatisfaction just escalated. The arrangements for managing these issues and the home generally have been reported on in the Administration and Management outcome of this report. The service have arrangements and systems in place for safeguarding people from harm and abuse. The service adheres to BUPAs corporate policy on this which the AQAA tells us was last reviewed in December 2006. We know that the managers of the service are aware of the local County Councils Safeguarding Adults Team as they have liaised correctly with them when it has been necessary. We were informed that training on the Protection of Vulnerable Adults and abuse issues is provided to all staff by one of the Registered Nurses. A video on relevant abusive situations is shown and discussed and staff are given an awareness of and encouraged to feel safe using the Whistleblowing policy. The Deputy Manager confirmed that staff have used this and appear comfortable in doing so. Care Homes for Older People Page 24 of 37 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a home that is well decorated and which is clean and has arrangements in place to prevent the spread of infection. Evidence: The services interior is presented to a high standard and is spacious with wide corridors making the use of moving and handling equipment easy and allowing plenty of space for wheelchairs users. Soft furnishings are to a high standard in communal rooms and individual bedrooms. The Manager has confirmed that all en suites have been upgraded to shower rooms giving service users easier access to their own private bathing facilities. There are a number of assisted communal bathrooms with specialised equipment if people prefer to have a bath. The AQAA tells us that there has also been new furniture supplied throughout since the last inspection. Areas such as the kitchen and the heating system have also had either new fittings or been upgraded. The kitchen was last inspected by the Environmental Health Organisation, EHO in August 2009 and was awarded four stars for cleanliness and other well deployed systems. We did not therefore inspect this area. The service adheres to BUPAs corporate policies on Infection Control and there are arrangements in place to maintain a high standard of cleanliness and reduce infection spreading. We saw several bedrooms and all communal areas and corridors and they looked clean with no offensive odours. The AQAA tells us that a new segregation Care Homes for Older People Page 25 of 37 Evidence: system has been introduced in the laundry to further improve infection control in this area. One comment in a questionnaire praised the services of the laundry. We saw hand washing guidance in most areas where hand washing would take place and alcohol based hand gels were also available. We noticed that staff adhered to the protective clothing protocols when serving food or carrying out some specific care tasks. We are aware that all staff complete training in infection control practice. The Manager wants to improve how the day to day maintenance is organised and completed so alterations and improvements to this will be taking place. One comment within a questionnaire returned by a member of staff commented that there was a need for quicker repairs, particularly to toilets. This issue had previously been brought to our attention by someone who had used the service. The Manager explained that there had been difficulties getting post en suite refurbishment problems sorted out but that this has now been resolved and any problem in this area can now be quickly resolved. We found the lighting in the main lounge to be very dull at about 4pm despite the central lights being on. This is a room that gets less natural light but the manager explained that there is additional lighting apart from the central lights that staff forget to switch on. Care Homes for Older People Page 26 of 37 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is currently building a well trained team of staff to improve how peoples needs are met. People will also benefit from there being improvements in how staff are supervised, organised and monitored whilst delivering the required care. Evidence: We received many comments from people who use the service or from their representatives within the pre inspection questionnaire under what the home could do better about a lack of staff. Comments included: make more staff available ? staffing levels more staffing there is a clear shortage of staffing and consequently those who are here are obliged to work long hard hours with little respite and inadequate pay. Their last pay rise was 8 pence an hour, which is insulting to hardworking and dedicated staff more staff needed, more money for carers provide higher staffing levels staff appear pressurised and personal care is secondary to the homes routines the home does not address the increasing dependency of its clients have staff available at all times care at weekends and Bank holidays is not so good as staff want breaks at the same time, a sign of the times. On the day of our visit the Manager told us that the home was over complimented with staff. Taking into account the absence of the activity coordinator and the sickness of one carer, whose hours had been covered for the afternoon shift, the service did not appear in excess of what had been described to us as the numbers they would aim Care Homes for Older People Page 27 of 37 Evidence: to have on duty on any day. A difference on the day of our visit was the skill mix, for example there were four nurses on duty instead of the usual two and therefore less care staff. We spoke to the night staff who consisted of three carers and one nurse on the date of our visit but we were informed that there are usually two nurses and two care staff. We asked staff if they considered four staff in total to be enough to meet peoples needs. Generally they agreed it was but said the evenings and particularly between 6am and 8am when the day staff come on duty, can be a rush. We were told that there have been discussions about a twilight shift (one day carer working until maybe 10pm) and of one day carer starting slightly earlier in the morning but this is not currently the case. It was confirmed that when occupancy levels dropped in the summer months, the staff numbers were dropped in response. As referred to in the Health and Personal Care outcome of this report one member of staff commented on how stressful it was completing the work that was needed in the summer months. Another staff questionnaire said ensure staff are aware of the staffing levels that are set by the CQC. The Care Homes Regulations and therefore the Care Quality Commission, CQC do not stipulate the numbers of staff to be on duty at any given time. What the regulations do require is for the service to have on duty at all times suitably qualified, competent and experienced staff working in such numbers as is appropriate to meet the health and welfare needs of the service users. In doing this the regulation also says that the size and layout of the building and the needs of the service users must taken into consideration. The personnel files of two new members of staff were inspected. We noted that each carer had been employed before a clearance was received by the Criminal Records Bureau, CRB. They were however checked against the Protection of Vulnerable Adults, POVA list before starting work in the home. Starting staff before receipt of a CRB is not best practice however, it is fairly common practice for care homes to do this if they really need to be recruiting staff. In this case the home needed to recruit new staff quickly and there were arrangements in place that demonstrated that neither staff member worked alone until their CRBs had been received. The service were in receipt of additional information such as two satisfactory references. Each application form gave an employment history and any gaps in employment had been explored with the applicant. Medical statements had been requested and a recorded and a record of the interview was seen on file. The service was therefore complying with the Care Home Regulations 2001. Both staff had been allocated to work with the qualified nurse who also delivers and coordinates all induction training and additional trainings for the service. A record was Care Homes for Older People Page 28 of 37 Evidence: seen of induction training taking place for both staff members. We also looked at the training record of one other member of staff who had been employed for a longer period of time and this demonstrated that additional, relevant trainings had been either completed or were planned. BUPA explain during the recruitment process that it is an expectation that all staff undertake the National Vocational Qualification, NVQ award in care and that this usually follows on from the induction training. The service have told us that BUPA no longer fast track staff through this training; preferring rather that each person receives a thorough and good quality training. There are currently fourteen staff who hold a NVQ award at either level 2 or 3 and four staff are due to start training. The service has recently attracted two new staff members who already hold a NVQ at a higher level 3. The service would like to develop and utilise more thoroughly the skills of the more experienced and highly trained carer and start a lead carer system. This would add a tier to the staffing structure where some care staff will hold more responsibility in the supervision, organising and monitoring of the personal and social care being delivered. Care Homes for Older People Page 29 of 37 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. People are now living in a home that is being managed and where shortfalls are being addressed. Through effective use of quality reviews and improvement plans the outcomes for people should improve. Evidence: Since the end of 2008 the home has lacked strong and consistent leadership. There is now a new Manager in post who has previously been a long-standing Manager for BUPA so she has a good understanding of BUPAs processes. A quality review audit, carried out by BUPA when the new Manager began, has highlighted areas of shortfall and the areas that require improvement. An action plan has been devised to help the new management team address these. The new Manager is therefore very aware of what has to be achieved. She is supported by the Deputy Manager who already had an understanding of staff members individual abilities and the needs of the people who use the service. We could see during our visit that alot of work has already started in addressing some of the services problems. We are also aware that the comments received in the pre inspection questionnaires are a summary of peoples views and Care Homes for Older People Page 30 of 37 Evidence: experiences that span over a period of time before our visit. What the increase in complaints and peoples comments tell us is that despite BUPAs quality assurance systems, which include an Early Warning Audit Tool, EWAT; shortfalls within the service continued over a period of time and were allowed to have a negative impact on the quality of life and outcomes for people who use the service. The feedback also tells us that professional boundaries between staff and people that use the service and visit it were compromised. Staff have clearly discussed their dissatisfaction over staffing and pay with those using the service, which will definitely have caused added stress and anxiety for those who need to both rely on the service and who are paying for the service. There were however some positive comments. One staff questionnaire said: the Manager is taking the reins after a period of disruption resulting in better morale amongest the staff. Another said: the Deputy is greatly improving standards of care. One questionnaire from a service users representative said: there have been recent improvements in the answering of call bells. The AQAA was well completed and implies that many areas of the service are running smoothly. This clearly has not been the case and the service needs to demonstrate a period of consistency to be able to truly demonstrate some of the statements made in the AQAA. The AQAA also informed us of its plans and aims for the next 12 months. The new Manager is bringing structure back to the home and improving communication by holding appropriate staff meetings. Through these she has told us that her expectations are made clear to all departments. A resident and relative meeting will be held soon but the Manager also tells us that she employs an open door policy. Staff confirmed to us during our visit that both Managers are visible within the home and approachable, but that the Deputy Manager in particular takes a lead on supervising and monitoring the care delivery. We did not inspect individuals personal allowance accounts during this visit. We are aware that BUPA carried out a full financial audit when the new Manager started and there were no issues raised after this. There have been no changes in how peoples personal monies are kept safe, how individual amounts of interest are added and the same very organised administrator is in post as was during our last inspection. People confirmed during this inspection that they have access to their monies when they want it. There are still locked facilities in each bedroom for people to keep small amounts of money and valuables safe. We have not received any information since the last inspection that would make us feel that the regulation relating to the safe keeping of peoples personal monies was not being complied with. The AQAA tells us that all aspects of Health and Safety within the home are adhered Care Homes for Older People Page 31 of 37 Evidence: to. We know that all BUPA services record various Health and Safety checks and this service complies with this. The AQAA tells us that all relevant policies and procedures are up to date and it has been confirmed that all staff are up to date with relevant trainings. These include fire training, safe moving and handling, food hygiene, infection control, first aid. For those who have not completed all of the above trainings or updates there are specific reasons for this and the service are aware that these need to be completed and have made arrangements. Training is to be organised for staff in the Deprivation of Liberty Safeguards, DOLs which is affiliated to the Mental Capacity Act 205 which most staff have received training on. The Commission receives, under regulation 37 of the Care Homes Regulations 2001 notifications of events, accidents and deaths. Care Homes for Older People Page 32 of 37 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 33 of 37 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 7 15 Care plans and associated 22/02/2010 assessments must give staff clear and concise guidance about how a persons specific needs are to be met. This guidance must be kept current and relevant to the individuals needs. This so that staff can reference the information they need easily. So that they know exactly how to manage someones specific need. This will help the care to be delivered in a safe and consistent manner and in a way that takes into account peoples wishes and preferences. 2 8 8 Peoples oral hygiene needs 22/02/2010 must be met. This is so that oral infections can be avoided. So that the person has a fresh and clean feeling Page 34 of 37 Care Homes for Older People 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 mouth. So that their dignity is maintained. 3 10 12 Peoples basic care needs must identified and support given when it is required. This is so that when people require the toilet, or require support to eat or have dirty nails situations do not then lead onto their dignity being compromised. 4 27 19 The Registered Person must 22/02/2010 make sure the care home is sufficiently and appropriately staffed at all times. This is so that the health, personal care, social and welfare needs of those who live in the home are met at all times. 5 31 10 The Registered Persons shall, having regard to the size of the home, the statement of purpose, the number of service users and their needs carry on and manage the home with sufficient care and competence. This is so that people who live in the home are well cared for and that any 22/02/2010 22/02/2010 Care Homes for Older People Page 35 of 37 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 dissatisfaction with the service being provided is acknowledged or identified and timely and appropriate action taken to rectify any shortfalls. 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 Care Homes for Older People Page 36 of 37 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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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