Inspection on 27/01/10 for Rowans Care Homes Ltd TA Bridge, Burton & Trent Courts

This is the latest available inspection report for this service, carried out on 27th January 2010.

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

Rowans Care Homes Ltd TA Bridge,... 03/06/08

Rowans Care Homes Ltd TA Bridge,... 27/11/06

Rowans Care Homes Ltd TA Bridge,... 28/11/05

Rowans Care Homes Ltd TA Bridge,... 21/06/05

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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: Rowans Care Homes Ltd TA Bridge, Burton & Trent Courts Burton on Trent 17, 18 & 19 Ashby Road Staffordshire DE15 0LB     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: Rachel Davis     Date: 2 7 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 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 40 Information about the care home Name of care home: Address: Rowans Care Homes Ltd TA Bridge, Burton & Trent Courts Burton on Trent 17, 18 & 19 Ashby Road Staffordshire DE15 0LB 01283512915 01283509330 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Rowans Care Home Limited care home 99 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 99 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability (PD) 99 Old age, not falling within any other category (OP) 99 Mental disorder, excluding learning disability or dementia (MD) 29 Dementia (DE) 99 Date of last inspection Brief description of the care home The Rowans care complex provides nursing and personal care to a maximum of 99 people. The premises, consisting of Bridge Court, Burton Court and Trent Court, are Care Homes for Older People Page 4 of 40 Over 65 0 0 99 0 99 29 0 99 Brief description of the care home situated on the Ashby Road near to Burton upon Trent. The home, originally three large Victorian family houses, is set in grounds with adequate car parking. Services and facilities including laundry, catering and hotel services are good, with adequate staffing levels. All three buildings are served with a shaft lift, and access to all parts of the buildings is good. Bridge Court is a general nursing home with broad categories of registration, including terminal care. Burton Court provides care for people with dementia related conditions, and Trent Court provides nursing care for people with mental health and other dementia related conditions. The home also contracts for two intermediate care beds with the local National Health Service NHS trust. to receive information regarding the costs and fees for services contact the registered manager Peter Sturgess. Care Homes for Older People Page 5 of 40 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: Two inspectors visited the home for eight hours on 27th January 2010 and one inspector visited on 9th February 2010. This visit was to check compliance with the two immediate requirements made during the inspection. The people who live there and the staff did not know we were coming. We use the National Minimum Standards for Older Persons as the basis for the inspection. The last key inspection was held in February 2009 and we undertook a random inspection in June 2009. This random inspection was because we received concerns about the home and the food people were receiving. We left four requirements following that visit. Before this visit took place we sent out an Annual Quality Assurance Assessment (AQAA), this is a self assessment document that all services must complete. The AQAA gives us important information about the way the home is meeting National Minimum Standards in care and the improvements planned to create better outcomes for the people who live there. Care Homes for Older People Page 6 of 40 We look at any notifications they have sent to us about events that affect the well being of the people who live there. There were questionnaires sent to people who use the service, professionals and staff members. Two were returned from staff and six from people who live at The Rowans. We case tracked three people who live in the home. Case tracking includes meeting people and talking about the care they receive or watching staff supporting them, looking at their care records and medicines and the way that they are helped to make choices and decisions. This assists us to understand the experiences of people who live in the home. Time was spent talking to the staff team on duty during our visit and observing the way they interact with the people they care for. We spoke to eight people about their experiences of living in the home. We looked around the buildings to make sure there are clean, warm and comfortable. We looked at approximately seven bedrooms, the lounge areas, the dining room, and bathing facilities on all floors. We inspected the storage system and medication procedures and we looked at records of staff training and recruitment, health and safety records and the food people are offered. We left two immediate requirements during our visit on 27th January 2010. This means that there were urgent matters that needed to be addressed quickly to protect people who live in the home. We revisited on 9th February 2010 to check the immediate requirements had been dealt with. We can confirm the home complied and therefore both immediate requirements were met. This means all urgent matters have been dealt with. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? There were no requirements made at the last key inspection in February 2009 but four were made at the random inspection held in June 2009. All four requirements were checked during this inspection and have been met. They were as follows: The home needed to ensure they had effective arrangements for recording and monitoring when staff have given drinks and food to people who are unwell, being cared for in bed and/or known to be at risk due to dehydration or poor nutrition. This is to help ensure that the correct care is given and that people are given enough to eat and drink. We checked a number of people in bed and who required nutritional support, fluid charts and the necessary recordings were in place. We noted specialist support had been initiated where required. The second requirement was to ensure the staff offered support in a way that respects the dignity of people who use the service. During the random inspection we saw staff standing up at the table to support people with eating. On this key inspection all staff seen were sitting down at the table with the people who required assistance. We asked the home to ensure food was provided in adequate quantities and that it was wholesome and nutritious. We were unhappy with the content and quality of the food during the random inspection and a number of people told us they did not like the meals. On this visit positive comments were made by people using the service and their families. We have not received any complaints about the food since June 2009. The final requirement made was regarding an admission, during the random inspection saw records to show that a person had been admitted to the home under a learning disability category, this was recorded on initial assessments. This service is not Care Homes for Older People Page 8 of 40 registered for people with a learning disability and therefore they had admitted out of category. Although we would not wish to restrict admissions the service has not followed the correct procedures. We saw no evidence of inappropriate admissions during this inspection. What they could do better: We left two immediate requirements following this inspection; this means there are serious concerns for peoples health, safety and/or welfare. We asked the home to deal with the following within 24 hours. The registered manager must ensure the different tablets given covertly and taken together do not adversely affect each other. We have also made a requirement stating that clear records must be in place regarding the management of covert medication if this is to be continued. We noted in Bridge Court that the safety of people using bed rails is compromised. We randomly selected two beds with bed rails. One had rails on both sides which would only go into the up position with force. These rails had no fixings and had movement. This means they are unsafe. On further inspection the rails fell apart, again they need to be secure to be safe. We can confirm the immediate requirements had been addressed by our second visit on 9th February 2010. As well as the two immediate requirements we consider the following areas should also be improved upon: Mealtime regimes need to be improved upon to ensure the experience for people is as pleasurable and stimulating as possible. More evidence is required to confirm a stimulating and active life is offered to everyone living at The Rowans. All comments, grumbles, niggles and compliments should be recorded to support the home with their internal quality assurance systems and help the management team evaluate any patterns or trends. The home should ensure all training and refresher training is current and up to date. This means the home can demonstrate the staff have the skills and knowledge needed to provide safe and effective support. Information within the home should be tailored to meet the needs of the people who live there. We recommend the home promotes pictorial and easy read literature when assessed as appropriate. Environmental issues need to be addressed to improve the outcomes for the people living there. The principles of respect, dignity and privacy are put into practice by the staff but there is room for improvement. The home needs to make sure they can evidence that people who use the service have been given the opportunity to contribute to their plan of care. This demonstrates the Care Homes for Older People Page 9 of 40 care provided has been agreed with the person or their significant other directly. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 40 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Up to date and clearer information is needed to ensure that people who use, or may use the service can make an informed choice about the home. People have an assessment carried out before they are admitted to the home but they may not have been fully completed. Evidence: The service has a Statement Of Purpose and Service User Guide, these set out the aims and objectives of the home, and include information about the service. They both need to be reviewed and the Service User Guide should include the fees payable and also contain information referring to the two intermediate care beds available. The management structure has changed and should be updated as should reference to the Care Quality Commission (CQC) including the address. Presently documentation refers to the Commission for Social Care Inspection (CSCI) which changed to CQC in April 2009. Care Homes for Older People Page 12 of 40 Evidence: We received an e-mail from the registered manager on 30th January 2010, it read; The service user document was an old one, the new ones in their folders does include the price lists for each home and these will be amended with the care quality commission address. It is recommended that the documents are made available in a format appropriate to the people who use the service, their family, individual capacity and language. This has been recommended since October 2008 and has still not included within the Service User Guide. We checked admission records for two people who had moved into the home, one being the most recent admission. It was clear an assessment had been completed but not fully. For example, aids brought in, not complete, medication not complete, baseline observations not complete and religion, previous occupation and language incomplete. This means initially the staff may not have all the information necessary to confirm they can meet peoples needs. We evidenced on the assessment of activities 10 sections of 14 had been completed. We saw that other professionals (specifically relating to intermediate care beds) were involved with supporting people for example, wound care specialists and information on managing risk was in place. Suitable and sufficient information was available to ensure appropriate care is in place to support these people. All of the admissions to the intermediate care beds are emergency admissions. People are assessed by the community nursing critical intervention team and once people are admitted to the home they are supported by the enablement team. Both intermediate care beds were in use at the time of this inspection. Care Homes for Older People Page 13 of 40 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. Health and personal care needs are met. However, peoples safety is compromised by some poor medication practices and unsafe bed rails. This means vulnerable people are at risk. These issues were adressed and evidenced on the 9th February 2010, this means the risk was minimized and people are now supported safely. Evidence: We are confident that everyone living at The Rowans Care Homes has an assessment of their needs from which a plan of care is developed. We found that overall plans of care and care records are clear, informative and reviewed. We have recommended plans of care need to evidence a more person centred approach. This means the plans of care look at people in a very individualised way and offer evidence of peoples involvement and development of the plans. They should also include life histories so staff are able to tailor the way in which care is delivered to meet their specific need. The management team has confirmed this is on their agenda and will be addressed. Care Homes for Older People Page 14 of 40 Evidence: Overall plans of care are well documented and there are clear day to day records to confirm how people wish to live. It was pleasing to note key workers also add to the monthly report. The key worker system enables staff to establish special relationships and work with people on a one to one basis. We spoke with a number of staff who told us they really liked working at the home and felt well supported. Staff considered support has improved over recent months and that relationships between the nursing and care staff was good. We noted that behavioral management plans are in place, this means there are clear instructions for staff to follow and ensures consistent and appropriate care management is provided to the people who use the service. We are satisfied that other professional support is requested when necessary e.g. from the district nurse or tissue viability nurse as records verified this. We can also confirm plans of care are reviewed as required. We checked to ensure paperwork such as fluid and turn charts were in place and completed as required, they were. Some areas within plans of care could be improved and these were discussed with the manager. An example of this is that plans for people being cared for in bed did not offer clear information regarding how often to attend to the person, or what tasks to complete. However, there was clear evidence in the individuals bedrooms to show that care had been offered on a two hourly basis, but there was nothing to indicate if this is what should be occurring, i.e. the person may require support hourly. People who we spoke with or completed questionnaires told us: I would like to say that the staff are brilliant, work really hard and always with a smile. The staff are all marvelous and look after us so well, nothing is too much trouble. Staff are good and helpful. We observed two nurses administering medication at lunchtime; both nurses were sometimes secondary dispensing medications into an unlabeled pot and then taking the pot to the person. On one occasion the person refused so the pot was taken back to the trolley to be given at a later time. There is a potential for errors to occur with this procedure. One nurse stated they would not take the trolley to the person when giving the medications incase they were called away and the trolley was left in the communal area. How best to manage this situation must be considered. Care Homes for Older People Page 15 of 40 Evidence: We saw insulin that was in use stored in the fridge, contrary to manufacturers instructions and recent research. We advised the nurse to check instructions and to act accordingly. External medications, creams, ointments are kept in bedrooms, they are not dated upon opening therefore staff are unable to determine if they were still suitable to use. We recommend the home dates all items on opening and discards within the recommended timescale. We saw an assessment dated 02/09/08 by the community psychiatric nurse (CPN) which records, lacks capacity, staff to assess on daily basis if he will take oral medication (non compliant with medication and care.) The nurse told us that medication is given covertly each day and tablets are crushed together and given in tea or coffee. The nurse is unsure whether the person using the service actually takes the medication this way as the cup is always washed out when returned. We have made an immediate requirement and asked the registered manager to ensure the tablets taken together do not adversely affect each other. We have also made a requirement stating that clear records must be in place regarding the management of covert medication if this is to be continued. The home does not have a policy regarding covert medication. We did not see in the persons plan of care any consent to medication being given by staff and no multi agency agreement for covert medication administration. This was discussed with the manager and needs to be explored in line with the best interests of the person and under the Guidelines of the Mental Capacity Act. As and when required medication (PRN) is prescribed to a number of people, there are no protocols or guidance in place. The nurse stated it is the nurses responsibility to assess the situation to justify the administration of all PRN medication, written guidance is needed. We checked the records and storage for controlled drugs. These were accurate and well managed the home has the appropriate controlled drugs register to comply with the safe handling and recording of medication. We asked the nurse to rectify the page numbers for one person however as these were incorrect. This was done immediately. There were not any gaps on the medication administration records (MAR charts) and medication records checked randomly tallied. Care Homes for Older People Page 16 of 40 Evidence: The deputy manager confirmed the staff were spot checked at random during medication administration to ensure everyone remained competent. We noted in Bridge Court that the safety of people using bed rails is compromised. We randomly selected two beds with bed rails. One had rails on both sides which would only go into the up position with force. These rails had no fixings and had movement. This means they are unsafe. On further inspection the rails fell apart, again they need to be secure to be safe. The second bed seen had a mattress on top of which sat an air flow mattress. Due to the use of two mattresses on the bed base the three bar bed rail was not at sufficient height to stop the person rolling out. We were advised by the nurse in charge that the carers fix bed rails but dont receive training , they also told us checks were visual (not recorded) and there were no monthly safety checks. We left an immediate requirement to ensure that the safety of people using bed rails was assessed and made safe where necessary. We received an e mail from the manager on 30th January 2010 it read; Bed rail check sheets were present in all bedrooms and completed, the service user whose rooms they were not in was because the sheets were in the lounges with them. We have asked the provider to ensure all bed rails are safe and they must reply to us regarding the immediate requirements by February 10th 2010. We revisited on 9th February as part of this key inspection to ensure the immediate requirements had been complied with, these are our findings. We met with the deputy manager who was able to provide us with adequate and ample records confirming professional advise regarding administrating medication covertly had been sought. We noted that agreements have been reached with the necessary professionals and a full review is taking place very shortly. We are satisfied the home has complied with this immediate requirement. We visited all rooms where bed rails are, or were, being used. A number have been removed completely, consent has been obtained where necessary, and alternative methods have also been introduced. The home has also purchased profiling beds and has some more on order. This now means the people who use the service are Care Homes for Older People Page 17 of 40 Evidence: appropriately supported , sufficient documentation was also in place and suitably completed. We can confirm this immediate requirement was also dealt with and the home has complied. This means people are safe. During the inspection we observed people sitting in one of the lounges , two of the five men were not wearing shoes or slippers. One lady had no socks on just slippers , the nurse asked for this to be addressed. Staff popped in and out but did not always engage with people. One lady asked for a coffee, the care worker said; the trolley is coming soon. This was at 10:00am, the tea trolley arrived at 11:35. The same person asked another carer ten minutes later, this carer made a coffee. When the drinks arrived no one was asked what they would like, everyone who needed support to enjoy their tea or coffee was offered assistance. Peoples state of dress was variable, some people were in stained clothes, some people spilt drinks but were not changed, and some looked smart and well groomed. There are some shared bedrooms, only one looked at had privacy curtains and these were mobile on wheels. The other rooms did not have any privacy curtains between the beds or at the wash basins. If not using privacy curtains is at peoples request it should be noted on the plan of care. Care Homes for Older People Page 18 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples social needs are met but improvements regarding mealtimes is needed. People who use the service are supported to maintain relationships with friends and family. Evidence: The home has two full time activity coordinators therefore there is a structured activity programme with some evidence of what activities are provided. The evidence is only available in personal records; there is no information within the home of what is taking place. The staff told us they do not know when the activities coordinators will be attending. The staff said, they are not allocated specific times on the units but is rather ad hoc and come whenever. The Service User Guide states that; the activities organiser will complete a biographical assessment on each service user in order to form a social care plan. Activities will be provided both on an individual and group basis. Individual participation must be recorded in the care plan. Biographical assessments are not available in Burton Court or Bridge Court. This was discussed and will be completed for people as Life Histories. These have commenced in Trent Court. Care Homes for Older People Page 19 of 40 Evidence: From the six questionnaires returned from people using the service three people said the home always arranges activities I can take part in, and two said the home did sometimes. There is also no information available about external entertainment although again this does occur. We recommend more information is made available, so people can refer to notice boards etc to see what will be taking place and when. We spoke with the activity coordinator and discussed how to ensure people are clear and know what is happening. The activity coordinator was enthusiastic and wished to make improvements where possible. She confirmed external entertainers do visit the home and that the vicar visits monthly. She also advised us that people went out for lunch and in the better weather trips are arranged. One person said (Trent Court); We have a small church service arranged at Easter and Christmas I would like it more often if it could be arranged. At Trent Court there was lots of activity during the morning in the ground floor area. Staff were sitting with people in the dining room playing dominoes, scrabble, and monopoly. We observed plenty of interactions and conversations. Visitors and made welcome and people were seen coming and going throughout the day, one visitor said : The staff do a good job under sometimes difficult conditions, there is always something (activity wise) when I visit. One questionnaire stated: The home could be more visitor friendly. Staff appeared to be very attentive to peoples needs, varying standards of dress were again seen, some people were well dressed others with stained and soiled clothes. One gentleman was walking around without shoes or slippers. The staff said that his feet are swollen so his slippers do not fit, they are waiting for the family to bring him some however, the staff member was unsure how long he had been without suitable footwear. We observed two care staff helping a person to get out of a rather low chair to stand. The care staff used the underarm method and pulled them up, this is not good practice, the staff did however tell the person what they were going to do before they started. Care Homes for Older People Page 20 of 40 Evidence: The meals are served in the dining room and the delivery of the mid-day meal was observed. There is little information regarding what is for lunch except small laminated four week menus, as people are not aware of which week it is they cannot determine what is for lunch. People we asked did not know. (Burton Court) Pureed meals were served to those who required a soft diet and it was pleasing to note all foods were pureed separately. Meals are prepared in the main kitchen and then placed in a heated trolley and sent to each unit. The meals are then plated by the catering staff and served to people. The choice was sausage and onion pie with vegetables or chicken curry and rice. Staff confirmed they ask people what they want prior to the meal; this is recorded on the daily menu document (Trent Court.) At Trent Court the dining room was not prepared; all people had a blue plastic apron on, sat at the table and were given a plate of their chosen meal. Cutlery is given with the meal. No one was asked if they wanted any salt or pepper, there were not any drinks. The meal time was very mundane, not a social or pleasing experience. People with dementia would not necessarily know that it was time to eat as they had no participation in the preparation. Meals to the people on the first floor are sent, plated in an unheated, uncovered trolley. The trolley was rusty and the paint chipped. We observed one lady asking for cutlery after she had been served the plated meal and had to wait for staff to go downstairs to get cutlery. Everyone had a blue plastic apron on, no serviettes; one lady asked for something to wipe her hands on and had to wait a considerable time for a piece of kitchen roll given to her. One questionnaire returned recorded: I visit in the afternoon there is an excellent choice of sandwiches and cake. We observed staff sitting with people who needed help with the meal, people were not rushed. (Burton and Trent Court) At Burton Court meals are in three sittings, again tables have no tablecloths, place Care Homes for Older People Page 21 of 40 Evidence: mats, condiments, menu or jugs for juice and meals were served plated up. No one we saw was asked if they would like salt or pepper, everyone received a drink in a plastic cup. Blue plastic aprons were used rather than serviettes or discreet aprons. Staff told us people were asked the day before what they would like to eat, they stated for those with dementia related conditions the staff chose. (Burton Court) There are no visual aids or prompts to support people in making choices. Changes to the menus, managing choice and table settings, along better visual prompts to assist with understanding will ensure an improved outcome in this area for the people who use the service. People who use the service should be involved with these changes. Care Homes for Older People Page 22 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are given information to make a complaint, where any concern is identified people are confident this will be acted upon. Staff are trained on how to protect people to ensure they are safe. Evidence: The AQAA tells us: All service users are able to access the complaints and procedure policy, which is clear and simple and is located in the main office and in the service user guides for all to see. Our aim is to resolve any small problem before it becomes a complaint. Therefore the moment we hear of a grumble we try to resolve it before it gets to a more serious stage. Our philosophy is to sort any problems amicably. Very occasionally we do have a complaint and then it is documented and resolved, again amicably. All complaints are responded to within 28 days. The home keeps a record of all complaints and they are acted upon immediately, so that problems are dealt with before becoming a major issue. All staff have received training in recognising abuse and this is covered during induction. Staff are trained to recognise that the capacity of service users vary from day to day and make allowances for the change in capacity from day to day in their capability to make choices and decisions. Staff receives Safeguarding training and are aware of their responsilbilities to protect the service users. The home operates a policy of non violent crisis intervention. The advocacy service is available to service users. We encourage service users to remain independent. Procedures are in place to deal with suspicions of abuse. Care Homes for Older People Page 23 of 40 Evidence: We can verify the home has a complaints procedure, which is made available to people and their relatives when they move in. All returned questionnaires confirmed that people knew how to complain and were aware they could discuss any issues or concerns informally. The manager verified the service acts on all complaints and concerns identified. The complaints book identified one complaint since the last inspection, this had been dealt with and concluded. Through discussion it was evident other issues, grumbles or concerns had been raised but not recorded. We recommend all comments are evident to support the service with identifying how changes are made to improve the services for the people who live there. We also recommend a complaints/suggestions box where people can offer their views anonymously if they so choose. Safeguarding Adults is a process of identifying and reporting suspected or potential abuse to vulnerable people and provides a framework of consistency to protect those individuals who are at risk. During our inspection we check to ensure vulnerable people are suitably protected. The home has policies and procedures for safeguarding people in the home and staff have received training for recognizing signs of abuse and reporting possible abuse. The manager is ensuring the staff are aware of The Mental Capacity Act Deprivation of Liberty Safeguards. All staff must be aware of their responsibilities and ensure there are no other less restrictive ways of keeping people safe and well if liberty is compromised. Decisions must always be in the persons best interests and assessments and questions must be satisfactorily answered. We are aware the home has made applications where necessary to the local authority. The home has initiated policies and procedures as required, these now need following up and documentation should be available on peoples plans of care to confirm this has been considered where people lack capacity. Care Homes for Older People Page 24 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in need of some improvements to improve the outcomes for people who live there. Evidence: In Bridge Court there are three well furnished lounges plus a dining area, it is warm, comfortable and homely. Two questionnaires recorded: It is a clean and fresh smelling home. The home is always spotless, warm and friendly. The dining tables had linen clothes, condiments and flowers. The nurse in charge stated that there is one person who takes the cutlery off the tables if they are prepared too early but says they get round this by finishing setting the tables just before the meal is served. In Trent and Burton Court this is not the case - see Outcome 3. Some of the shared bedrooms seemed very small and as stated earlier in the report did not have any screening for privacy. Care Homes for Older People Page 25 of 40 Evidence: One bedroom selected randomly had a very hot radiator. All uncovered radiators within the home must be assessed for the risk they present to the people who use the service and action taken to minimize the risk. This is to ensure people who use the service are free from possible scalds or burns. Some people have a commode for night time use. Commodes seen had the rubber protectors at the bottom of the legs missing. The commodes are metal framed and as such there is a potential of injury. The third floor (Bridge Court) had a detectable odour. In all units all bedrooms on ground floor are locked and all doors have baffle locks. This restricts people from going to their rooms for privacy, quiet time or if they are tired. A number of people would not be able to ask staff to assist them to the bedroom. We recommend the home seriously consider ways to improve the outcomes for people and evidence that restrictions are not imposed. All toilets and bathrooms seen had suitable equipment and infection control measures such as liquid soap, gloves, aprons and paper towel dispensers, although a number did not have signage. All bedroom flooring in Burton Court and Trent Court is laminated, people should be offered a carpet in their bedroom and we recommend evidence is available in plans of care to show choice is offered. We saw that some bedrooms have been personalised and were individualised to the people who use the service. No one has a key to their bedroom we have asked the manager to ensure they can evidence people have had the choice, this should also be addressed regarding lockable storage in bedrooms. The lounge areas in Burton Court were very stark, chairs around the walls of the room, no settees, and no clock in one lounge. There were no items on the walls to stimulate people, no personal effects, or items of interest. A number of people who live at The Rowans care homes have dementia related conditions. We recommend the home should look at providing information to support people with orientation. This may include some notice boards in key areas offering the date, staff information, symbols and pictures regarding meals and activities for example. Photographs for toilet and bedroom doors should also be considered. Care Homes for Older People Page 26 of 40 Evidence: People can not use the garden area without support as it is not secure and people could be placed at risk if left alone. We recommend the home ensures the garden area is made safe so people can use the outdoor space safely and independently meaning they could come and go as they pleased. One person told us; I would like to go outside for a breath of fresh air. We did not inspect the laundry area on this visit. Care Homes for Older People Page 27 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are suitably recruited and overall have the skills to support the people who use the service. Evidence: The AQAA tells us: There is a skill mix of qualified nurses both RGN and RMN, to ensure the best possible care is given to the service users. The majority of our care staff are trained to NVQ 2 and higher. We have overseas nurses who work as carers so the skill base is considerably higher. The commitment of the staff is second to none, they really care for the service users which shows in the rapport they have with them, and the pleasant atmosphere around the homes. Some staff have completed NVQ 4. Staff are well supported by the company, and have regular team building exercises, bonus schemes and have attended customer service training. They are supported in the home with regular staff meetings and training sessions. The company uses external providers to deliver mandatory training sessions and other health related training. We carry out induction training and ensure staff are aware of new legislation such as the mental capacity act and deprivation of liberties. Recruitment is carried out both locally, nationally and internationally. The international recruitment follows guidelines as laid down by the Home Office. We use a Human Resources company to assist with all personnel aspects. When we recruit staff we ensure that we seek references CRB checks and their employment history. The company supports and sources any required training by the staff to improve the quality of care delivered to Care Homes for Older People Page 28 of 40 Evidence: the service users. The company has a commitment to its staff and service users and this training is vital to ensure high standards of care are delivered. We encourage our staff to promote independance in our service users and to make them feel safe and secure. The homes has a four week rota which shows which staff are on duty at any one time. During this visit three staff files were sampled all files contained proof of identity, two references, a completed application form and evidence of enhanced Criminal Record Bureau (CRB) checks. The home are shredding CRB checks after six months , thsi does not comply with legislation, the home should keep CRB records until they receive an inspection from the Care Quality Commission (CQC). The staff files and training matrix also contained evidence of training that has been completed, this included mandatory training and additional training to support the needs of the service. m From reading the training matrix not all training is up to date, the home needs to ensure this will be rectified in a timely way, the company are able to provide all the necessary courses. Questionnaires returned to us by staff and discussions revealed the following: We offer good care and support residents when needed. Lots of training and opportunities for training, supervision with senior staff received regularly, lots of overtime at the moment as short of staff. Its a good place to work, no two days are the same. Lots of training and support from the senior staff. Staff member on induction, they wouldnt let me work before they had received the checks. We all work as a team and support one another. The management and senior staff are helpful and supportive. Things are getting better than they were. We are satisfied the service provides a good skill mix which means people who use the service can be confident the staff understand their role. Care Homes for Older People Page 29 of 40 Evidence: Duty rotas were not checked on this visit but we saw enough staff on duty in the morning to meet the needs of people who use the service and we can confirm the home has a consistent staff group. People who use the service told us: I read most of the day but I like to do that, the staff are all marvellous and look after us so well, nothing is too much trouble. Its ok here I go out to the day centre each week and enjoy it. I play Bingo, sometimes I go shopping. Its ok. I would like to go home. Staff are thoughtful. Staff are good and helpful. Care Homes for Older People Page 30 of 40 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 ensure the home is run in the best interests of the people who live there. Evidence: There is now one registered manager, Peter Sturgess managing the home since the departure of the other registered manager in October 2009. We saw and heard evidence to validate the manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The manager is aware changes need to be made to improve overall outcomes for people. One visitor stated: Peter has been brilliant; I cannot speak highly enough of him. Of the home, one person recorded; The support and care from the home was excellent and went above and beyond normal expectations. Care Homes for Older People Page 31 of 40 Evidence: There are two deputy managers both qualified nurses. The deputy managers do not get any additional hours to complete paperwork or manage and supervise staff. We recommend time should be offered to the deputy managers to enable them to complete their management role as effectively as practicable. The managers area manager visits the home regularly and conducts their own audit of the home monthly. The insurance certificat was seen and is in date until August 2010. The AQAA was completed within the timescale offered and provided us with useful information, thi sis an overview of what the home considers they do well: Rowans Care Homes provide a warm and welcoming atmosphere. It strives to supply and maintain a very relaxed atmosphere where the service users can lead the lives they want to. They are all individuals with different likes and dislikes and wants and needs, the home tries to cater for all of these. As a result the service users are happy and contented. Family and friends are free to join the service users as any time of day or to join them for a meal. The home provides a safe environment for all and encourages services users to lead as full a life as possible maintaining independance. Care staff take pride in their roles, they show the service users dignity and respect and choice at all times. All staff are inducted and receive on going training and supervision, many staff are trained to NVQ levels 2 and 3. The homes domestic staff are always efficient in their work ensuring the homes remain clean and fresh at all times. The kitchen provides nourishing and nutritionally balanced meals. The nurses are well trained providing a good skill mix for the varying service users accross the homes. All documentation is recorded in a thorough manner according to legislation. Care plans are evaluated on a monthly basis or more if required, and audited by the manager and senior manager. Our home is well supported by the company, we support the staff to make them feel valued, this helps boost morale and keeps staff motivated The home responds immediately to concerns or complaints, which are dealt with in a professional and fair manner. The home has an open door policy encouraging individuals to voice their concerns for improvement of the serivce. The home has a secure garden where service users are free to walk and spend time. People reading this report can compare the AQAA statement with our report findings. Quality assurance is completed by the home but outcomes are not made available for people to read, this needs to be implemented. We randomly checked the personal allowances held for people who use the service by the home. All records tallied and Care Homes for Older People Page 32 of 40 Evidence: appropriate records are held. Supervision of staff is undertaken but some timescales have slipped the manager is aware of this and will prioritize supervision sessions. The manager confirmed fire risk assessments for people who use the service are not in place, we have asked him to contact the fire officer to seek clarity on this matter. Care Homes for Older People Page 33 of 40 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 34 of 40 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 1 9 13 Regulation 13(2) 28/01/2010 The manager needs to ensure the three medications mixed together in fluid do not have an adverse reaction or contra-indicate each other. This is to ensure the medication administered is safe and effective in this state. 2 38 12 Regulation 12( 1) (a) 28/01/2010 Where people are using bed rails staff must assess if they are safe for the person to use. All 21 bed rails need to be assessed and made safe. This will make sure people are kept safe. 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 9 13 Regulation 13(2) Policies and guidance need to be available to staff with regard to as and when required medication and covert medication. 01/03/2010 Care Homes for Older People Page 35 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This means everyone is clear of the procedure to follow and consistency is maintained. 2 9 13 Regulation 13(2) Proper arrangements must be in place and recorded to confirm a multi disiplinary approach has been taken with regard to administering a persons medication covertly. This will confirm that all avenues have been explored and ultimately that this practice is in the persons best interests 3 9 13 Regulation 13(2) The home needs to ensure that insulin is stored as per manufacturers instructions. This means medication is stored and administered safely. 4 25 13 Regulation 13(4)(a) 01/03/2010 All radiators within the home must be assessed for the risk they present to the people who use the service and action taken to minimize the risk. 27/02/2010 07/02/2010 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure people who use the service are free from possible scalds or burns. 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 1 Fee information should be made available to people who use or may use the service. This has been recommended since October 2008 and has still not included within the Service User Guide. The Statement of Purpose and Service User Guide should be reviewed and contain information about the present management structure, costs and up to date information about the regulatory body the Care Quality Commission (CQC) It is recommended that information is made available to confirm that the Statement of Purpose and Service User Guide are available in a format appropriate to the people who use the service, individual capacity and language. When a needs assessment is undertaken all sections should be completed and offer the necessary information. This means people are clear of the individuals needs and wishes. Information regarding intermediate care beds should be expanded upon to ensure people who use the service have a clear understanding of the process and cost implications. Continue to improve the contents of plans of care to evidence people have been included in their making. This will confirm people who use the service agree with, and have been involved in their content. Consider ways to ensure secondary dispensing practises cease to minimise potential errors. Continue to inform and advise staff on issues pertaining to dignity and respect Page 37 of 40 2 1 3 1 4 3 5 6 6 7 7 8 9 10 Care Homes for Older People 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 9 10 The home should continue to work closely with staff to ensure privacy and dignity is maintained at all times. This is to include suitable records pertaining to screening in shared bedrooms.. All people who are sharing a bedroom should have suitable screening to ensure they have some privacy, particularly during times of personal care and attention. This recommendation was also made at the last key inspection held in February 2009 Activities and structured programme information should be made available to people who use the service. The ethos of meals and mealtimes needs to be considered to improve the experience for people using the service. The rusty food trolley should be replaced. There should be daily menus produced in appropriate formats, such as large print or pictorial, suitable for people with dementia or sensory impairments to assist their understanding and help them make realistic choices. All records should be updated to reflect the change in name of the regulatory body from the Commission for Social Care Inspection (CSCI) to the Care Quality Commission (CQC). The home could improve upon the recording of complaints, however minor they may appear, including the outcome, this will further evidence the homes openness and transparency. Comments and grumbles should be recorded to assist the manager in identifying any patterns or trends. The home should provide a suggestions, comments or complaints box which is easily accessible. This is so people may provide information anonymously if they so choose. The home should enable people to be outside independently by making the area safe. This means people can come and go as they please. The home must look at ways to safely minimize restrictions on people and enable then to live in the home freely. Orientation information should be considered to help support the people who live there. The home should ensure they have suitable information available to confirm people who use the service have been Page 38 of 40 10 10 11 12 13 14 12 15 15 15 15 16 16 16 17 16 18 19 19 20 21 19 19 19 Care Homes for Older People 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 offered a key to their room and/or a lockable facility within their room. 22 23 24 19 22 29 Appropriate signage need to be available on all bathrooms and toilets to promote privacy. Ensure commodes are in a suitable state of repair to minimize risk. This means people can use aids safely. Ensure criminal record bureau checks are stored and not shredded until after an inspection , this is to comply with CQC legislation. Any themes within complaints should be incorporated within the agencys quality assurance. This will support the agency with their quality assurance evaluation. The home should produce a report that shows the results of annual surveys and any actions they will be taking to meet issues raised as part of the quality assurance system. This recommendation was also made at the last key inspection held in February 2009 Ensure that staff receive regular supervision so that people know the staff are appropriately managed. Prioritised action must be taken to ensure essential mandatory up to date training is provided for all staff commensurate to their role. Speak with the fire officer to confirm the need for individualised fire risk assessments for the people who use the service. This means people will be suitably protected. 25 33 26 33 27 28 36 38 29 38 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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