Inspection on 21/12/09 for Paternoster House

This is the latest available inspection report for this service, carried out on 21st December 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Paternoster House 28/01/08

Paternoster House 11/01/07

Paternoster House 16/01/06

Paternoster House 01/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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 28/03/2010.

Key inspection report Care homes for older people Name: Address: Paternoster House Watermoor Road Cirencester Glos GL7 1JR     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: Sharon Hayward-Wright     Date: 2 2 1 2 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 32 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 32 Information about the care home Name of care home: Address: Paternoster House Watermoor Road Cirencester Glos GL7 1JR 01285653699 01285644630 manager.paternoster@osjctglos.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: The Orders of St John Care Trust care home 40 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 Paternoster House is a purpose built care home providing nursing and personal care for 40 older people. It is situated near to Cirencester town centre, and is managed by The Orders of St John Care Trust. The accommodation is purpose built, and is provided on two floors. A staircase and a shaft lift provide access to the first floor. Residents private accommodation is provided in single rooms on both floors, two of which have an en-suite facility. All rooms have a wash hand basin. Spacious and easily accessible toilets and bathrooms are conveniently situated around the home. Hoisting equipment and assisted bathing and showering facilities are provided, and throughout the home there is level access, grab rails and a resident call system. The home provides two spacious sitting rooms, a large lounge and dining area, and a small sitting room on the first floor also. Information about the home is available in the Service User Guide, called the Residents Handbook, which is issued to prospective residents, and a copy of the most recent inspection report is available in the home for anyone to read. The weekly fees for this home range from 445 pounds to 816.41 pounds depending on the Care Homes for Older People Page 4 of 32 Over 65 40 0 Brief description of the care home needs of the person. Information about how the home manages the Funded Nursing Care Contribution (FNC) is avaliable. Care Homes for Older People Page 5 of 32 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: This inspection was carried out by two inspectors over a two day period in December 2009. One of the inspectors was a Pharmacist and his role was to look at the arrangements the home has in place for the management of peoples medication. We did not request an Annual Quality Assurance Assessment (AQAA) prior to this key inspection as the home had completed one in October 2009. We have used some the the information from this in the report. We looked at other information we have received from or about the service from other stakeholders. We also looked at notifications where the home has told us about an incidents that have taken place. During the inspection we spoke to a number of people who use the service, visitors to the home and staff. We also observed staff interacting with people who use the service. We have used the information we gathered in the report. Care Homes for Older People Page 6 of 32 This key inspection was brought forward due to concerns we had about the management of safeguarding referrals and how the home manages people who are at risk of developing pressure sores. We looked at a number of systems the service has in place to include care records, activities, medication, food provision, complaints, safeguarding, staff recruitment, training and supervision. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: Care plans need to be more person centered and not about the task. Care plans should include peoples choices. We found that one person who had been admitted only a few days prior to this inspection had a number of care plans devised which is good. But they had omitted to undertake a moving and handling assessment and this person needed to be moved using a hoist and no details were available about the the size of sling or type of hoist. Since the last key inspection we have raised concerns with the Registered Provider about the management of people who are at risk of developing pressure areas and number of people who had developed pressure sores. Following this training was provided for the qualified staff and at this inspection only one person had a pressure sore but they were admitted to the home with this and it has nearly healed at the time of the inspection. Improvements are needed to the medication systems the home has in place. For example it is not acceptable for the home to run out of peoples medication especially pain relief. We issued an immediate requirement for the home to address a number of issues urgently and they responded to say they had addressed them. The home must make sure that if a safeguarding allegation is made that the correct procedure is followed especially in relation to reporting of this. Following a specific issue which, the Registered Provider investigated, an action plan has been devised to make sure all staff undertake more training in this area and are aware of the reporting procedures. Care Homes for Older People Page 8 of 32 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 32 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 32 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people have an assessment of their needs undertaken prior to admission to the home. Evidence: We examined the pre admission assessments of two people who were recently admitted to the home. Both people were having their care funded by Community and Adult Care Directorate (CACD). The homes AQAA states that all people are assessed prior to admission by the manager or one of the nurses. However we were unable to find evidence that both people had been assessed prior to admission as the pre assessment formats for both people had been completed from written information provided by the local hospital and for one person it was dated on the day they were admitted to the home. The manager was able to find brief written information that she visited one person but could not find the written record of her assessment for the second person. The manager wrote on the second persons care records during the inspection that she did visit this person in hospital. We were informed by a Care Homes for Older People Page 11 of 32 Evidence: Representative from the Registered Provider that their pre admission format must be completed when the person is visited by a member of staff from the home. The assessment that was dated as being undertaken on the day of admission for one person was completed with help from the person and their family which is good practice. We spoke to a relative of one of these people and they said they knew about the home as they live locally and they are happy with the level of care their relative is receiving. Intermediate care is not provided by Paternoster House. Care Homes for Older People Page 12 of 32 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. Peoples care records do not reflect their individual care needs however staff were able to demonstrate a good understanding of peoples needs. The principles of respect, dignity and privacy are not always put into practice. Conclusion about medication. There were generally suitable arrangements in place for managing medicines but we found some weaknesses in the way medicines were obtained so that some improvement was needed to make sure people were not at risk because the medicines and prescribed feeds they need were not available to administer. Evidence: The care of two people was examined in detail. This involves examining care records, speaking to the person if able and any relatives and speaking to the staff. Several other peoples care plans were examined. Both people had recently been admitted to the home and one person had only been at the home three days. Care plans had been devised from information obtained from the pre admission assessments. Care plans had been devised for the person that had only been at the home for three day which is good practice. However examining these and other care plans it was found that they Care Homes for Older People Page 13 of 32 Evidence: are not personalised but based more on the task. We also found that people had the same thing written in their care plans again indicating that care plans are about the task and not the person, for example in one persons care plan for personal care it stated clean and trim nails, shave and comb hair attend to teeth and dentures. Staff to give am and pm wash to face, hands, under breasts, under arms and genitals. This person is a female and they do not have any teeth therefore indicting that this was written to address the task and not about what this person would like or what they can do for themselves. Some care plans appeared to be a set format that were altered for the person, however one makes reference to a male but the care plan is for a female. The terminology in the care plans needs to be reviewed as words like adequate fluid intake and regularly checking of their catheter should not be used as care staff need clear directions to follow. Also in one persons pre admission assessment it mentions they use incontinence pads but this was not in their care plan. Care staff spoken with also confirmed this. The person that had been at the home for only 3 days had the majority of care plans as mentioned in place however, there were care plans that we would have been expected to be in place due to their care needs. For example this person was immobile and was at high risk of developing pressure sore and was also on pressure relieving equipment but no care plan in place. Also they were requiring frequent pain relief and again the care plan had not been started. A care plan was in place for moving and handling but it referred to the moving and handling assessment but this had not been completed and no details about the hoist or sling required was recorded. Risk assessments were in place for nutrition, pressure sores, falls and moving and handling except for the person mentioned above. The manager said the moving and handling assessments are undertaken by the moving and handling trainer and they would complete the person assessment as a matter of urgency. Care staff spoken with were able to discuss with great detail the care of the two people, however this also highlighted that some of the care plans for both people were not up to date with the actual care being given. Care staff said they have input into peoples care plans and they also write some care plans for people whos are not receiving nursing care. Since the last inspection the home had a period of time where a number of people developed pressure sores. This was investigated by the Registered Provider and actions put in place to address the situation. At this inspection one person had a pressure sore and they were admitted to the home with it from hospital. The manager said it has now nearly healed. The documentation and care plans were examined, the care plan stated that daily dressing were needed, however, the recorded changes of dressing indicated that they were taking place every 4 days. In the evaluation of this care plan it mentioned that an area on their foot was red but this was not recorded in the actual care plan. This person also had a care plan in place for sore groins, but this Care Homes for Older People Page 14 of 32 Evidence: appeared to be a standardised care plan that had been amended for this person. This care plan was devised on the 2nd December 2009 but no other entry had been made. The documentation for wound care must be improved. We saw in one person daily records that a member of their family had requested that they are not resuscitated but we could not find any other information about this. As this person has capacity to make their own decisions as there was not records to indicate otherwise, then a best interests meeting should be arrange and the appropriate professionals invited and a full records and plan made about this. We spoke to a number of people and visitors to the home who were relatives and they all said they are happy with the standard of care provided by the home. We saw evidence in peoples care records that they have access to external health and social care professionals. These include GPs, Chiropodist, Social Workers and Speech and Language Therapists. We observed staff speaking to people in a respectful manner and the majority of time staff knocked on peoples doors prior to entering, we did witness one incident where a member of staff did not knock on the door before entering the room. Whilst staff were assisting a person into a wheelchair we observed them at first speaking to the person but then they continued to have a conversation between themselves. This is not good practice as this person was able to join in conversations. We observed a mealtime and found that the vast majority of people were wearing an apron and those who required assistance with feeding were all fed with a spoon. We asked the manager about this and she said that the staff know who likes to wear an apron and people are asked by the staff. In relation to people being fed with a spoon the manager said that a Speech and Language Therapist had advised this for one person but she was not sure about other people. We asked one member of staff whey they use a spoon and they said they have always done this. During this mealtime we also observed a member of staff check one persons blood glucose level at the dining table, this is not good practice both from an infection control and dignity perspective. Following the inspection the manager said the member of staff who undertook this procedure did this because the person became unwell unexpectedly and that they normally would not do a procedure like this in the dining room. People who use the service that were spoken with felt the staff respect their privacy and dignity. Pharmacist inspectors report about arrangements for the handling of medicines. As a part of this key inspection one of our (the Care Quality Commission) pharmacist Care Homes for Older People Page 15 of 32 Evidence: inspectors specifically examined some of the arrangements for the handling of medicines. We looked at some stocks and storage arrangements for medicines and various records about medicines. We spoke to the manager designate and two registered nurses. We visited some bedrooms and at lunchtime saw nurses giving some medicines to people who lived in the home. We gave feedback following the inspection to the manager designate. The inspection took place during a five hour period on a Monday. Registered nurses were responsible for administering and managing the arrangements for medicines. The manager designate told us that all their own permanent nurses also have to undertake a computer based training programme about the safe handling of medicines that the Trust has introduced. There was also a system to check the competence with medicines of their own nursing staff. At the time of the inspection nobody living in this home was assessed as able to self administer their medicines so people were therefore totally dependent on the staff for this part of their care. The medicine policy indicated people living in the home could self administer their medicines if a risk assessment showed this would be safe for everyone. One of the nurses we spoke to also told us about this. We looked at the records for one person recently admitted to the home but we could not find any information about what this persons choices or preferences were for their medicines and why they were not self administering or if this had been considered. We saw at lunch time when nurses administered medicines that some people were in the dining room eating their lunch. It would be good practice to include in the care plans if people had particular preferences about this to make sure that their privacy and dignity is respected. There were arrangements for keeping records about medicines received, administered and leaving the home or disposed of (as no longer needed) for each person. The pharmacy that dispensed the medicines for people living in the home provided printed medicine administration charts each month to help with keeping the detailed medicines records needed. Accurate, clear and complete records about medicines are very important in a care home so that people are not at risk from mistakes with their medicines because of poor records and so that there is a full account of the medicines the home is responsible for on behalf of the people living here. We looked through a sample of the medicine records in use and found that these were generally up to date. Since the last key inspection some different records have been brought into use for creams, ointments and other prescribed treatments applied to the skin. Some handwritten medicine charts did not have a start date included so it was difficult to tell just from the numbers on the date column when medicines were given. We spoke to Care Homes for Older People Page 16 of 32 Evidence: the manager designate about reviewing the time of administration for a medicine for one person where the medicine chart indicated doses were often missed because (s)he was asleep. We were very concerned that some medicines and a food supplement prescribed for people living in this home were out of stock. Some records we looked at also showed that this had been the case for another medicine in the recent past. This had resulted in a number of missed doses and was a risk to the health and wellbeing to people living in the home. On 21st December 2009 we left an immediate requirement form with the manager designate to make the necessary arrangements within 48 hours to obtain stock of all medicines and prescribed food supplements for people living in the home so that these may be administered in accordance with the doctors directions. On 24th December 2009 we received confirmation that this action was completed within this timescale. We discussed with the manager designate about reviewing how prescriptions and medicines were ordered and ways to avoid this situation happening again. Ordering medicines for people living in the home involves careful coordination between the home, the doctors surgeries and the pharmacy. The manager designate would have much more control of this process if she was responsible for obtaining any new prescriptions and that the pharmacy collected these directly from the home rather than the current arrangements. In this way the nurses in the home would be aware if a prescription had been issued without delay and if the pharmacy had collected it promptly. They would then know where any delay was occurring and be able to take definite actions to make sure the medicines are always available. The nurses in the home will always be in the best position to know what medicines they need for each person. We discussed with the manager designate that not administering a medicine as prescribed for what ever reason was still an error with medicines and an incident that should be recorded and reported to us as an event which adversely affects the well-being or safety of any person living in the home. We looked at the arrangements for dealing with anticoagulant medicines where there is specific national guidance to follow. We found that care records were in place but doses were taken by phone message and not confirmed in writing by the doctor as required in the national guidance. There was the standard yellow anticoagulant record book in use but this was not always kept up to date and some standard information had not been completed. The care plan did not indicate the reason for treatment and target levels and the nurse asked was not able to tell us. There were often protocol forms containing information to guide staff about the use of medicines with a direction to use when required but we did see examples where we could not find any guidance. In other cases more specific information was needed such Care Homes for Older People Page 17 of 32 Evidence: as the dose to use, frequency of use or interval between repeat doses and maximum dose each day. We also looked in care plans and found that sometimes information was included about these medicines but not in all cases or not in a person centered way with the specific needs of the person described. This was included in other plans we saw. It is important in order to meet each persons needs in a consistent way that there is clear guidance for nurses about the use of medicines particularly where the use is when required. The requirements of the Mental Capacity Act 2005 must also be taken into account in these care plans particularly where people may lack capacity to consent to treatment or express their need of the medicines. For example one person prescribed a sleeping tablet when required had received a dose every night since 30.11.09 despite also receiving another sedative medicine at night. A doctor stopped this medicine on the day of the inspection as there were concerns that this person was very sleepy. It was not clear why this medicine had been given regularly and there was little definite guidance in the care plan and no protocol in place. There were suitable arrangements to store medicines safely and at the right temperature. The insulin injections on the medicine trolleys must have an opening date written on the packs as these can only be stored for a limited period at room temperature. As there were three different insulin injections in use the name of the person needing these must be transferred to the syringe or vial that is in use on the trolley. Containers of some creams and ointments that were in use were kept in peoples bedrooms. It is important to always check that this would be safe for everybody in the home. The right arrangements were in place for managing controlled drugs. Two staff check these medicines when doses are given and record twice daily checks of the stock and record book. There was a monthly system of auditing the medicine arrangements and the manager designate told us this had been done recently. The way this is carried out needs to be looked at to make sure that the sort of issues we identified are also picked up and action taken particularly when there are not enough medicines in stock. The Trusts standard medicine policy and procedures were available so that all staff should be aware of how the Trust expected medicines to be handled in a safe way. Care Homes for Older People Page 18 of 32 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 who use the service are able to make choices about their daily lives and have access to an activities programme that meets their expectations and choices. Evidence: The home has an activities coordinator that arranges the activities for people who use the service. She works 15 hours per week and the home also has several volunteers that would also help out with activities. At other times care staff undertake activities. People are able to have one to one and group sessions. The group activities include quizzes, bingo and crafts. Outings are also arranged for people. A number of activities have and were due to take place to celebrate Christmas. People spoken with said they are able to chose if they take part in activities. Several people said they prefer not to. One person said that the home does not provide enough activities that they enjoy. The activities person said that people are asked at their meetings what activities they would like. An activities list is displayed each week detailing the activities planned which also include outside entertainers. The homes news letter also includes information about activities. We spoke to a number of visitors to the home who all said that visiting is not restricted and the home makes them feel welcome when visit. Care Homes for Older People Page 19 of 32 Evidence: During the tour of the home we observed that in a number of peoples rooms their own personal belongings where on display to include pictures and photographs of family and friends. People said they are able to make choices about how they spend their time each day and this includes where they eat their meals and the choice of food. We did not discuss with people who manages their finances at this inspection. The kitchen had recently been inspected by the local Environmental Health Department and it was rated as 5 stars which is excellent. We therefore did not examine the kitchen area or the health and safety checks. The Cook said he has an NVQ 2 in professional cookery. We were told that people have an input into the menus and that they are due to be renewed in January. A list of peoples likes and dislikes is available and this would also list any special or therapeutic diets. People are offered two choices at lunchtime and a hot and cold option at the evening meal. Alternatives are also provided if people request them. Specialist cutlery is available for people if needed and liquidised meals have each course liquidised separately. We observed a lunchtime meal and found that staff were very attentive towards people and it appeared to be social event with staff and people enjoying the time talking together. We tasted the meal on the second day of the inspection and we had fish pie and winter tart for pudding the food was very tasty, well cooked and we enjoyed the meal. All the people we spoke with and relatives said the food is very good at Paternoster. Care Homes for Older People Page 20 of 32 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. People who use the service are able to express their views and have access to an effective complaints procedure. The systems the home has in place to protect people from possible risk of harm or abuse are not robust enough and because of this people have been placed at unnecessary risk. Evidence: Information about how people and their relatives/representatives can make a complaint are on display in the home. People we spoke with said they did not have any concerns about the home and they would speak to staff if they were unhappy about anything. The homes AQAA stated they have received 5 complaints in the last 12 months. On examining the information the home had in place we found 4 complaints and 2 incidents. All complaints were responded to within the recommended timescale and letters sent to complainants were in place. However the manager has not maintained records of the investigations she undertook and also of a meeting with one complainant. The manager said she takes all complaints very seriously and looks to address any shortfalls, however record keeping needs to improve. Auditing of any complaints received takes place on a monthly basis by the manager. We looked at how the home safeguards people who use the service from possible risk of harm or abuse. Policies and procedures are in place for staff to follow, however we did not examine these in detail. Training is provided in house by a member of staff who is qualified to provide this. As part of this training a DVD is used. The manager Care Homes for Older People Page 21 of 32 Evidence: said that updates for all staff have started since November 2009. Prior to this inspection an allegation of possible abuse was made, however a systematic failure by all staff involved in this allegation meant that the appropriate agencies were not notified immediately and actions that should have been taken did not take place. We wrote to the Responsible Individual about our concerns about how this allegation was managed by the home. They responded to us with actions they have taken and plans for increased training for all staff. Training for the manager is planned with the local County Council in Enhanced safeguarding and we would recommend that the Deputy manager also attends this training. Training for senior staff is planned in the Alerters guide which is provided by the local County Council and we we would strongly recommend that all staff attend this training and not a cascaded version. This was discussed with a Representative from the Registered Provider. The manager said she has undertaken training in The Mental Capacity Act and Deprivation of Liberty and that the home has plans for 4 senior care staff to attend this training. We would strongly recommend that all care staff attend this training. Care Homes for Older People Page 22 of 32 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well maintained and comfortable environment. Evidence: A tour of the environment took place with a number of rooms belonging to people seen with their consent. The standard of cleanliness was very high and no unpleasant odours were found. People spoken with said they were happy with their rooms but one person said they would like a larger room as they have a lot of personal belongings. People also said they felt the home is always clean and their own rooms. People had their personal belongings on display in their rooms. The outside grounds and garden area were viewed from the home due to the cold and snowy weather. Staff were observed to wearing protective clothing when required and they confirmed they have access to this whenever it is needed. The laundry area was examined and the laundry assistant informed us about the procedure for managing soiled linen. The laundry area was clean and tidy and the assistant on duty took a lot of pride in their work. People spoken with said their clothes are well manged by the laundry but one person said they have had several jumpers that have shrunk. One person said the standard of ironing is very good. Care Homes for Older People Page 23 of 32 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. The home is confident that the numbers and skill of the staff meet the needs of people who use the service. Evidence: The staffing levels were discussed with the manager and she felt they were meeting the needs of people who use the service. A qualified nurse is on duty 24 hours a day and there are two qualified nurses on the early shift. The manager felt they have sufficient ancillary staff to support the care staff. People and relatives spoken with all complimented the staff saying they work hard and they are very caring. Two relatives felt that the staff have done an excellent job with their relative as they were very poorly prior to being admitted to the home and they have improved greatly. No concerns were expressed by people who use the service about the home not having enough staff as people felt they were having their needs met. Staff spoken with said they all enjoy working at the home and they have a good staff team that support each other. The home has several volunteers that visit to assist with activities and preparing the dining room on certain days. The manager confirmed that the home exceed the recommended 50 percent of care staff with an NVQ 2 or above in Health and Social Care which is excellent. The recruitment files of the most recent staff appointed since the last inspection were Care Homes for Older People Page 24 of 32 Evidence: examined. The majority of the required checks were in place except for; a full employment history for both members of staff and one member of staff did not have two written references in place prior to starting work at the home. Both staff had a Criminal records Bureau Disclosure (CRB) in place and where required a POVAfirst check. Best practice is to wait for the return of the CRB prior to the member of staff starting work and this was the case for one member of staff. A risk assessment was in place signed by the Responsible Individual following the return of one member of staff CRB. The manager said she is aware of the changes that took place from the 12th October 2009 where the POVAfirst check ceased and an Independent Safeguarding Authority(ISA) Adult first check started. The manager was not working at this home when the two members of staff started work and therefore was not part of the recruitment process. The manager said the induction programme used for new care staff is based on the Skills for Care Common Induction Standards. We saw evidence that one member of staff had completed their induction programme. The manager explained that each new member of staff is supernumerary for first week and assigned to work with a senior carer. We checked the duty rotas for the two staff whose recruitment files were examined but we could not see this information. The manager was not at the home when these two members of staff started work, but she did explain the process she used at the home where she worked previously. We were concerned that one new member of staff according the records did not receive moving and handling training for nearly 6 weeks after starting at the home. The manager felt this member of staff would have had this as part of their induction programme. We looked at the training for all staff. The uses in house training and e-learning for some topics and staff spoken with had mixed views on e-learning. Some said they found it useful others felt they preferred it when they could ask the trainer questions. Some external training is provided by the Care Home Support team and other outside training providers. The homes computer system provides a list of staff who are due training and in what area. Training for qualified nurses is provided and this includes venepuncture and male catheterisation. Staff spoken with confirmed they have access to training. Care Homes for Older People Page 25 of 32 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. Improvements are needed to a number of areas to make sure the home is run in the best interests of people who use the service. Evidence: Since the last key inspection the Registered Manager has retired. A new manager is in post. She has been a Registered Manager at a another service owned by the Registered Provider. The manager is a qualified nurse with many years experience of working with older people. She said she undertakes training courses to keep herself up to date with current practices. People, staff and relatives spoken with said the manager is approachable and friendly. This key inspection was brought forward due to concerns about how a safeguarding incident was managed by manager and other staff and due to previously high numbers of people who developed pressure sores. Actions have been put in place to address the above concerns. At this key inspection we found a number of areas that need to be addressed and we will be requesting an improvement plan from the Care Homes for Older People Page 26 of 32 Evidence: Registered Provider. The Registered Provider have a number of audits that are carried out by the home and others by a Representative. Despite this auditing the issues with care plans and medication for example had not been identified prior to our visit. We saw evidence of these audits to include Regulation 26 visits that take place monthly. A monthly news letter is given to people who use the service and minutes of residents and relatives meetings were seen. Staff meetings take place and we also saw minutes of these. We did not request an AQAA prior to this key inspection as they are requested yearly and the home had completed one in October 2009. The home has a safe system in place to manage peoples monies. We examined the system the home has in place for staff supervision. The manager said that staff who are supervisors all have had training. We randomly selected 6 staff files and we found that there is not a consistent approach as some staff have had more sessions than others. For example a night carer had 1 session in 2008 and only 1 so far in 2009, where as one qualified nurses has had 4 sessions plus an annual review in 2009. This area needs to be reviewed by the manager. Mandatory training to include fire, infection control, food hygiene and first aid is provided for staff. As mentioned previously the homes computer system produces a list of what staff require what training and when it is due. The AQAA provide in October gave us information regarding servicing of some equipment to include hoists, the lift and heatings systems. The maintenance person was able to provide us with evidence that weekly fire equipment checks are taking place and when fire drills happen. The fire alarm was activated during the inspection and the manager confirmed that all staff followed the correct procedure. The homes fire risk assessment was not examined at this inspection. Checks regarding the prevention of Legionella are undertaken by a specialist company. Weekly checks of window restrictors have now started. Care Homes for Older People Page 27 of 32 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 28 of 32 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 The Registered Person must 31/03/2010 make sure that people have care plans in place that reflect the care provided and are personlised. This will help to make sure that staff have access to up to information so they can meet peoples needs. 2 8 12 The Registered Persons must make sure that a system is in place for the management of peoples wounds. This must include up to date care plans. This will help to make sure that staff have access to up to date information and the progress of peoples wound. 12/03/2010 3 9 13 Review medicine records and care plans for people living in the home to make sure that for any medicines prescribed with a direction when required or with a 26/02/2010 Care Homes for Older People Page 29 of 32 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 variable dose there is clear, up to date and detailed written guidance for nurses on how to reach decisions to administer the medicine and at a particular dose, also taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure people living in the home receive the correct amounts of their medicines to meet their needs in a consistent way in line with planned actions. 4 29 19 The Registered Persons 31/03/2010 must make sure that all the required recruitment checks take place prior to the member of staff starting work at the home. This includes obtaining a full employment history and two written references. This will help to make sure that any unnecessary risks to people who use the service are minimised. Care Homes for Older People Page 30 of 32 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 1 2 7 9 Care plans should not be task orientated, they should reflect peoples choices and their individual needs. Make arrangements for dates on any medicine charts to be clear and complete so that at any time the day, month and year of medicine administration can be clearly seen. Review the arrangements for managing treatment with oral anticoagulant medicines so that guidance detailed in Patient Safety Alert 18 from the National Patient Safety Agency is followed and dose changes are confirmed in writing by the prescriber. Make sure the date of opening and residents name is always written on the insulin injections when these are first used and stored at room temperature. This is so that there is a system to know who the injection belongs to and that it is only kept in use for the period the manufacturer specifies. Review the system for ordering prescriptions from the various surgeries and sending these to the pharmacy and put in place arrangements by which the nurses have more control and can make sure the risks of running out of stock of medicines is substantially reduced. Care plans should reflect what choices people who live in the home were given when they were admitted and have made about how their medicines are managed and administered and their consent to the way in which staff administer their medicines. All care staff should attend the Alerters guide training provided by the local County Council rather than another staff cascade this training. All care staff should attend training in The Mental Capacity Act and Deprivation of Liberty that is also provided by the local County Council. The home needs to look at ways of providing evidence that new staff are supervised and have an allocated mentor. The home should look at staff accessing more external training. 3 9 4 9 5 9 6 9 7 18 8 18 9 10 30 30 Care Homes for Older People Page 31 of 32 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - 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!