Inspection on 21/01/10 for The Grange

This is the latest available inspection report for this service, carried out on 21st January 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grange 07/02/08

The Grange 10/09/07

The Grange 23/01/06

The Grange 10/08/05

The Grange 15/02/05

The Grange 14/09/04

The Grange 01/03/04

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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 25/04/2010.

Key inspection report Care homes for older people Name: Address: The Grange Grange Road Northway Tewkesbury Glos GL20 8HQ     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: 0 5 0 2 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 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: The Grange Grange Road Northway Tewkesbury Glos GL20 8HQ 01684850111 01684290221 alison@ctch.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): CTCH Ltd Name of registered manager (if applicable) Mrs Samantha Jane Williams Type of registration: Number of places registered: care home 69 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 69 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home The Grange is a purpose built care home that has been extended over the years to provide residential and nursing care for sixty-nine older people. It is owned and managed by the C.T.C.H Ltd group of homes and is situated in the residential area of Northway, in Tewkesbury. There is a small shopping precinct nearby and a public house. The home has car parking spaces to the front and rear of the building, with a Care Homes for Older People Page 4 of 34 Over 65 69 0 0 5 0 3 2 0 0 9 Brief description of the care home small-enclosed garden running alongside the home and a courtyard garden. The accommodation is set out on three floors, which are accessed by stairs or a shaft lift. Bedrooms are single with en-suite facilities, but there are a few rooms that can be used as double bedrooms if couples wish to be accommodated. Assisted bathing and showering facilities are provided, and there are several lounges, dining areas and other quiet sitting areas. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The weekly charges for The Grange range from 381.20 pounds to 667.30 pounds, depending on the level of residential or nursing need. The home also provides care at the local authority contract rates. Informaiton about how the home manages the Funded Nursing Care Contribution (FNC) is avaliable in their contract. Optical services, chiropody, hairdressing, newspapers, and toiletries are charged at individual extra costs. Care Homes for Older People Page 5 of 34 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 3 days in January 2010. Before we visited the home we sent surveys to the home in order to get the views from people who use the service. The results of these have been used in the report. We request an Annual Quality Assurance Assessment (AQAA). This was received on time and provided information about what the service feels they do well and the areas they are looking to improve on. The AQAA also contained numerical information called Dataset. We also looked at other information we have received from or about this service from other stakeholders. This includes notifications from the home regarding incidents that effect the well being of those who use the service. We looked at a number of systems the service has in place to include care records, activities, complaints, food provision, ongoing maintenance of the home and staff training, supervision and recruitment. Care Homes for Older People Page 6 of 34 We issued an immediate requirement at this inspection in relation to slings used for hoisting people. The home complied with this in the timescale we gave them. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: The home needs to work on consistency of care plans between people who receive nursing care and those who receive personal care. All care plans must detail the care people require to meet their needs and care plans should include peoples own choices. Once these are in place the home needs to look at linking care plans and risk assessments together and make sure they are not contradicting each other. Some improvements are still needed with their medications systems especially in relation to the procedure for staff to follow and the recording of prescribed creams but the home has improved on this area. The home needs to look at improving their fire risk assessment with the inclusion of evacuation procedures for some people detailing the assistance they will need to leave the home should a fire break out. The home needs to look at updating all their policies and procedures as some are very outdated, for example, the policy for the use of restraint is dated 1999. Care Homes for Older People Page 8 of 34 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 34 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 34 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. People who may use the service are provided with the information needed to make a choice about whether this home can meet their needs. Evidence: The home provides information in their contract of residency about how they manage the Funded Nursing Care Contribution (FNC) for people who are able to receive this. The home also has booklets available about this from the Department of Health. A person admitted to the home in October 2009 said they had settled in really well and were lucky to be living at the home. The home had completed a pre-admission assessment which provided a holistic assessment of their needs. This was supported by an assessment of need and care plan from the placing authority. The family of the person had completed an admission form. There was also evidence that discharge information had been supplied by the hospital. A letter confirming that the home could meet their needs was on their file. A placement review had been held to verify that Care Homes for Older People Page 11 of 34 Evidence: the person would be remaining in the home and an annual review scheduled for next year. A copy of the statement of terms and conditions with the home was on their file. We also examined a further two pre admission assessments of people who had recently been admitted to the home. One person was an emergency admission. A senior member of staff had undertaken these two assessments and for the planned admission they had also obtained information from the funding authority. In the case of the emergency admission the member of staff had spoken to other people involved in this persons care to help with determing if they could meet their needs. We discussed the admission of another person who has a diagnosis of vascular dementia with the Registered Manager. The Registered Manager said this was not the persons primary care needs and they are certain they can meet this persons needs. The Registered Manager needs to be mindful of their registration category when assessing new people to move into the home. Care Homes for Older People Page 12 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The majority of peoples care records reflect the care they receive and they are based on peoples individual needs. The principles of respect, dignity and privacy are put into practice by all staff. Evidence: We examined the care of 5 people who use the service and this included examining care records, speaking to the person if able and staff and observing interactions between the person and staff. This is called case tracking. Two of these people were receiving nursing care. We also examined a number of other peoples care plans. The two people who were receiving nursing care had ongoing assessments of their needs in place and these are mostly reviewed monthly. From this assessment care plans are devised to meet peoples needs. We found that on the whole the majority of the care plans examined for people who are receiving nursing care were not personalised enough and tended to be based on the task and not the persons individual need. We found that some care plans were based on outdated practice and these will need to be reviewed urgently for example the care plans that relate to people who have a catheter. We also found that one person who is of low body weight did not have a care Care Homes for Older People Page 13 of 34 Evidence: plan in place. However the clinical lead nurse has just put into place a system to monitor peoples weight. We also found that some care plans contradicted others for example, one person is having pain relief frequently and in one care plan it mentions every 6 hours and in another every 4 hours. We did find a very detailed care plan in place for one person who is a diabetic that gave very clear directions on how to manage this. The clinical lead nurse said that this is an area that they are looking to improve and she is planning to attend training in care planning. Daily records are in place. We looked at the documentation in place for people who have pressure sores or wounds. The clinical lead nurse has implemented a new system. Photographs are taken weekly (with the persons consent) to monitor the progress of the wound and records are also maintained and this includes the dressing to be used. The home works closely with the Tissue Viability Nurse and she was at the home reviewing people during the inspection. A system is in place to make sure dressings are renewed as per the persons care plan and this is monitored by the clinical lead nurse. We felt this was a very effective method that the home has in place especially the use of photographs in the ongoing monitoring of the progression of peoples wounds/pressure sores. The clinical lead nurse has very recently introduced a system to monitor peoples weight both for people who are losing weight and those who are gaining weight. This includes informing the cook when people who are nutritionally at risk and the cook confirmed this. A nutritional risk assessment is in place for people. We examined risk assessments in place for moving and handling, pressure sores and falls. We saw reviews in place for risk assessments and care plans. We observed records were in place for people who have accessed external health care professionals and for one person who was assessed by an Occupational Therapist. The home had taken a photograph to demonstrate to staff the correct sitting position for this person, which is good practice. We case tracked 3 people receiving personal care only and spoke to staff about the care they were receiving. Each person had an assessment of daily living from which a number of individual care plans were developed. These provided an overview of how their physical, cultural, spiritual, psychological and social needs and preferences were to be met. The plans were clear and succinct providing the reader with sufficient information about how they wished to be supported. Personal care plans did not indicate peoples preferences about the gender of staff providing their personal care. A complaint from a relative indicated that their parent had refused care one morning because it was offered by a male member of staff. Identifying whether people have a Care Homes for Older People Page 14 of 34 Evidence: preference would have prevented this from happening. Peoples care plans indicated when they needed to be monitored for issues such as tissue viability and fluid or nutrition intake. Care plans and risk assessments clearly identified the support they needed and we observed monitoring records in their rooms confirming that staff were providing this support. For people with concerns about tissue viability who were receiving residential care the District Nurse provided treatment and monitoring. Their individual care records were kept in the nurses office. People were provided with specialist equipment where needed and this was evidently being kept under review. Records confirmed that a new mattress had been supplied for one person case tracked. Staff confirmed this was being done in a timely fashion. Health care records were in place indicating that people had access to other health and social care professionals such as their General Practitioner, Optician, Care Manager and Chiropodist. People were also supported to attend out patient appointments at hospital. Food and fluid and turn charts were in place for some people who were assessed as needing them and on the whole these were completed. However especially for the food and fluid charts the home needs to demonstrate that a senior member of staff is reviewing these and monitoring what is being recorded. We found that there is some inconsistent practice with care plans and risk assessments between people who are receiving nursing care and those who receive personal care. This will need to be addressed. The homes AQAA states that they are looking to implement core care plans, however they will need to make sure that they are amended to reflect the persons individual needs and not just about the task. In the surveys we sent to the home for people who use the service we asked them, do you receive the care and support you need, 5 people said always and 2 people said usually. We also asked them does the home make sure you get the medical care you need all 7 people said always. The comments we received include, the home looks after me well, staff are friendly and show compassion and kindness and the care I receive is excellent. We examined the system the home has in place for managing peoples, medication. We did not look at the arrangements at this inspection for people who are assessed as being able to self medicate. Since the last inspection the medication room has been refurbished and new flooring added. The room was very tidy and well organised. Each person has there own storage container where there stock medication is stored and Care Homes for Older People Page 15 of 34 Evidence: this is audited. The clinical lead nurse said that the home is working their way through a large stock of medication that was in place when she started at the home. The medication round is split between 3 trolleys and 3 staff due to the number of people in the home. A qualified nurse administers medication to all people who are in receipt of nursing care and 2 team leaders administer the medication to other people. We were told that staff under go training in medication and have competency assessments. We observed as part of the inspection staff administering medication and from our observations a safe system is in place. We examined a number of Medication Administration Records (MAR) and they were completed in full. However we did find one handwritten entry that had not been signed by the member of staff who had completed this and it had not be checked and signed by a second member of staff. The recording of prescribed creams are done on a chart in people,s rooms however we found that they were not always completed. Daily temperature checks on the medication fridge are taking place and records are maintained of this. They are waiting for a thermometer for the medication room so they are able to make sure the room is at the correct temperature for storing medication. Records were in place for medication received into the home from the pharmacy they use and for administering of medications except for some creams as previously mentioned. Records were also in place for medication that are returned to the pharmacy when no longer required or refused by the person . A specialist contract is in place for all returned medication. We looked at the arrangements for controlled medication and we checked the medication with the records and all was correct. Auditing of this takes place daily. We randomly selected a number of peoples medication to audit and this includes, checking the amount of medication in the blister pack or box against the MAR. All were correct except for one where there was only 1 tablet remaining and there should have been 2. This needs to be investigated. We found dates of opening on boxed medication, eye drops and creams we examined. The home is looking to implement homely remedies once they have the consent of all GPs. The clinical lead nurse has implemented a number of audits to include stock checking, controlled medication, weekly checking of the blood glucose machine and syringes and wound dressings. She has plans to audit the MAR and prn or as required pain relief medication. As part of the case tracking exercise we examined one persons care plan for the use of prn pain relief and this provided staff with the information required however, it did contradicted another care plan when mentioning the times it was due. We did not examine any other care plans for prn or as required medication. Two medication errors have taken place and these were reported to us and investigated by the home. One did not involve a person and the other one was dealt with appropriately by the home. Staff were observed treating people with dignity, respect and sensitivity. People were spoken to using their preferred form of address and staff were observed knocking on Care Homes for Older People Page 16 of 34 Evidence: doors prior to opening. A visitor stated staff were very attentive and responsive to their parents needs. Care Homes for Older People Page 17 of 34 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 to help meet their recreational expectations. People are offered a varied and wholesome range of food based on their preferences. Evidence: We observed people during our visits and joined them for lunch on the second day. People were offered the choice of breakfast in their rooms or in the dining room. Most chose to have breakfast in their rooms. Staff had a list of each persons individual choice of breakfast, some choosing a hot meal, porridge, toast or cereals. Staff confirmed that some people liked to have a different breakfast each day and they were provided with this choice. The start to the day was observed to be relaxed and unhurried. The home had received a complaint about one person being left in bed until late morning but they said this had been due to the circumstances on that day and would not be repeated. During the morning people were observed either spending time in their rooms, in the area outside of the dining room listening to music or in the lounge with the television on. Some people had visitors and were taken out for lunch or to a chapel coffee morning. Visitors were observed arriving throughout the day and meeting with Care Homes for Older People Page 18 of 34 Evidence: relatives in the lounges or in their rooms. Some people expressed concerns that a lounge had been converted into an additional dining room reducing their access to communal areas to meet and greet friends. The Registered Manager said that plans for this year included redecorating the smoking lounge used by a few people to provide an additional communal area at the front of the house. Staff said that no one had lead responsibility for arranging activities and a visitor commented, more activities would be good but she wouldnt go out if we didnt take her. Staff said that the home no longer had access to a mini bus and people rarely went out with staff. Some activities were arranged such as a quiz, music and dance/keep fit sessions on a monthly basis. Staff said a monthly magazine was produced giving people information about what was on and each person was given a copy of this. We did not see a copy of this. We spoke to a number of people about activities and the majority of them felt there was not enough and one person said they are bored just sat in their room with nothing to to. We observed in one of the small lounges that staff had put on a DVD for people to watch, however they were all asleep and the staff were not in the room as they were seeing to other tasks. People were able to take part in a monthly communion held at the home. Information about advocacy was displayed in the office, but to make it more accessible to people consideration should be given to putting it, for example in the entrance area by the smoking room. In the surveys we sent to the home for people who use the service, we asked, does the home arrange activities that you can take part in if you want, 1 person said always, 2 people said usually, 2 people said sometimes and 2 people said they choose not to take part. People had personalised their rooms with their fixtures, fittings and possessions. Copies of inventories were on their files. Peoples personal information was kept securely in offices or in draws in their rooms. Lunch was served to people in their rooms if they wished or one of two dining rooms on the ground floor. Additional dining areas were available on other floors. People had a choice of main meal and they all said the food was excellent. Visitors also commented that food was very good and that if a person had not eaten their lunch then staff would prepare something for them later. Some people commented that they had tea at 5.45 pm and then did not have breakfast until 8.45 am. We noted that fresh fruit was not available around the home although staff said they had access to fruit in the kitchen if people wanted it. We also noticed that other snacks are not rfeely available for people to help themselves, however the cook said people can ask and she will make a snack for them. There was no information around the home about the menus and no menu board in the dining room. Two choices are offered each day Care Homes for Older People Page 19 of 34 Evidence: except when they have a roast meal but alternatives are always provided. At the evening meal people have a choice of a hot or cold option. When we spoke with the cook she also told us about wide choice of food on offer for people at breakfast time, however there is no records to support this. We would suggest that the home looks at providing information about the food provision for people in the home. Food records held in the kitchen need more detail for example the flavour of soup needs to be recorded as well as what people have for breakfast. The cook said people can request a cooked breakfast. We did not examine the kitchen or health and safety records as the cook said the home had recently had a visit from Environmental Health Department and they were going to be awarded 4 stars. The cook confirmed that she is aware of people who are assessed as being nutritionally at risk and is planning to undertake a training course in nutrition for the elderly in the near future. As previously mentioned we joined people for lunch on the second day of the inspection and sampled the food. The food was very tasty, well cooked and we enjoyed our meal. We asked people in the surveys we sent them, do you like the meals at the home, all 7 people said always. Care Homes for Older People Page 20 of 34 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 able to express their concerns and have access to a complaints procedure. Systems are in place to help safeguard people from possible risk of harm or abuse, however policies and procedures for this need to be updated to meet current legislation. Evidence: The home has a complaints procedure which is displayed around the home in addition to a suggestions box which is accessible in the main hall. People spoken with said they would complain to the Registered Manager if they had a concern. The Registered Manager said that house meetings had been scheduled to provide an additional forum in which people could express their concerns. The AQAA indicated that the home had received 14 complaints in the last twelve months. We inspected some of these. Each contained a copy of the complaint accompanied by the investigation, the outcome of the complaint and the response to the complainant. The AQAA indicated that all staff had completed training in the protection of adults and those spoken with had a good understanding of this and felt the Registered Manager would challenge poor practice. There was information in the home about the local adult protection procedures. We asked people in the survey we sent to the home for them. is there someone you can speak to informally if you are not happy all 7 people said yes. We also asked Care Homes for Older People Page 21 of 34 Evidence: them do you know how to make a formal complaint 5 people said yes and 2 people said no. We examined the policies and procedures that the home has in place for safeguarding and these include dealing with abusive incidents, whistle blowing, managing aggressive outbursts and restraint. We found that all these need to be updated with the latest legislation and our contact details. The restraint policy was dated 1999, therefore it is over 10 years old and is very outdated. The homes AQAA stated that staff have received training in the Mental Capacity Act 2005 and an overview of Deprivations of Liberty. The home has a number of people who have bed rails in place and we saw risk assessments in place and the Registered Manager said the home always make sure that bed rails are used with bumpers to reduce the risk of entrapment. Checks are taking place to make bed rails are safe and this is discussed further in Management and Administration. We did see a record in one persons care plan about the use of a wheelchair belt but no risk assessment was in place for this, however the clinical lead nurse said that it is no longer used. Bed rails and wheelchair belts must have risk assessments in place and consent forms as they can be viewed as a form of restraint. Care Homes for Older People Page 22 of 34 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. Improvements are needed to the environment to make it a pleasant and comfortable place for people to live. Evidence: We toured the environment and viewed a number of rooms belonging to people with their consent. The home is set over 3 floors and a shaft lift provides access. The Registered Manager informed us that the home is due for refurbishment this year and this includes the main entrance area and the smoking room. The home is also looking to review the communal areas and change some of the usage round of some rooms. We found that the decor in the home is very tired looking and that in the door ways the paint work has been damaged due to wheelchairs and hoists when they are pushed through. The doors to peoples rooms and toilets are a dark wood stain which makes the corridors look very dark. We were told that when a room becomes available it is redecorated prior to a new person moving in. In Woodpecker lounge the wicker furniture is stained in places and needs to be cleaned. We found that a number of bathrooms/shower rooms were cluttered with trolleys and bags, boxes of gloves, aprons for staff to use and bars of soap (which need to be disposed of if they do not know who they belong to as they are an infection control risk if they are shared). Some of the shower curtains need to be replaced as they are stained. We found that some of the tiles in these rooms were dirty and this was also the case for the staff toilet on the ground floor. We observed that some fire doors are wedged open and the Care Homes for Older People Page 23 of 34 Evidence: Registered Manager said this is in their fire risk assessment. This needs to be discussed with the local Fire Service and whether doorguards should be used instead. People who were spoken with said they were happy with their rooms and the cleanliness. We observed that staff have access to protective clothing to include gloves and aprons. We examined the laundry area. The room was very cluttered in places with old machinery and linen. Each person has their own laundry box but some of these were damaged and could pose a risk to the member of staff. We asked about how they manage soiled linen and we were told they have red bags that are placed straight into the washing machine, however we were told that when these run out they use black bin liners. This is poor infection control practice as this means soiled linen needs to be taken out of the black bin liner and then put into the machine. One washing machine was leaking from the door on to the floor and staining to the floor had occurred and this needs to be repaired. We were told that the washing machines have a sluicing cycle. The lock on the laundry door was missing on the back of the door which would mean it cannot be secured when it is unoccupied; this needs to be addressed as a matter of safety. The laundry assistant said she has not had training in infection control and this needs to be provided. During the tour of the home we observed that one of the domestics trolleys was left unattended in Chaffinch lounge and chemical used for cleaning were left on their. This is unsafe practice as any chemicals needs to be stored securely at all times. We asked people in the surveys we sent them, is the home fresh and clean, 5 people said always and 2 people said sometimes. Care Homes for Older People Page 24 of 34 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. Peoples needs are met by a competent staff team, who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. Robust recruitment and selection procedures should protect people from possible harm. Evidence: The staff rosters indicated that staffing levels were being maintained in sufficient numbers to meet peoples needs. Staff said that the quality of care delivered was good and that staffing levels were satisfactory. As mentioned the home would benefit from having a member of staff with lead responsibility for co-ordinating activities. Domestic staff were observed carrying out their duties on all floors and said there were sufficient staff on their team to maintain the standards of cleanliness. Staff have access to a National Vocational Qualification (NVQ) and training records indicated that 40 per cent of the staff team have an award in Health and Social Care. An induction programme was in place and booklets confirmed that this was equivalent to the Skills for Care Common Induction Standards. Staff working during their induction shadowed a named member of staff and this was identified on the off duty rota. Monitoring records were in place for new staff to make sure that they had completed their mandatory training. Care Homes for Older People Page 25 of 34 Evidence: Files for 4 new members of staff were examined and found to be satisfactory. Application forms requested a full employment history and where there were gaps, there was evidence that this had been explored with staff and a record kept. Two satisfactory references were being obtained prior to employment, which requested the reason for leaving any former employment in care. Some staff were working before their Criminal Records Bureau check (CRB) had been returned. There was evidence that a POVAfirst or Independent Safeguarding Authority (ISA) Adult First check was being obtained. We discussed with the Registered Manager the roles and responsibilities of staff during this period which were in line with our requirements. Rotas highlighted who new staff would be shadowing during their shift. A risk assessment should be in place to describe what new staff can and cannot do until a satisfactory CRB check is returned. New staff had completed a health questionnaire prior to employment and proof of identity including a current photograph was on their file. Robust training records were kept for the staff team as a whole, with a training matrix so that monitoring of training needs and refresher training and individual training profiles. Copies of certificates of training completed prior to working at the home were on their profiles alongside copies of training certificates for courses completed whilst working at The Grange. Staff had access to Dementia awareness training, training on Parkinsons disease, healthy eating and equality and diversity. In addition, competency audits were being completed for staff administering medication. Nurses were being supported with their professional development including stoma care, wound care, immunistation, palliative care and gastronomy training. Care Homes for Older People Page 26 of 34 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. The management of the home are working hard to make sure the home is run in the best interests of people who use the service, however some improvements are needed with health and safety to make sure people remain safe. Evidence: There have been no changes to the management of the home since the last key inspection. A clinical lead nurse was appointed in September 2009 to assist the Registered Manager as she is not a clinician. Since then the clinical lead nurse has been working at addressing some of the short falls identified at the last inspection. The Registered Manager has completed the NVQ 4 and Registered Managers Award. At the present time she is undertaking managing workplace stress and conflict. She has completed training in equality and diversity and other topics in line with other staff in the home. The Registered Manager has plans to undertake a dementia course once she has completed the one she is currently doing. Staff spoken with said the Registered Manager and clinical lead nurse are approachable but some staff felt they do not see the Registered Manager around the home enough. Care Homes for Older People Page 27 of 34 Evidence: We received the homes Annual Quality Assurance Assessment (AQAA) on time and it contained information about what the home feels they do well and what they would like to improve on. It also contained numerical information called Dataset. The Registered Manager provided us with evidence that auditing of the service is taking place and this includes care plans, medications, complaints and concerns and accidents/incidents. Questionnaires have recently been sent out and these are collated and an action plan devised. A newsletter is in place and meetings for people who use the service and the last one was in December 2009. We examined the minutes of these and some for recent staff meetings. The last documented Regulation 26 visit (this is where the Registered Person or a Representative on their behalf visits the home monthly unannounced and assesses the service) was in February 2009. The Responsible Individual said she is doing them but is not up to date writing the reports. The regulation for this is very clear and that a report has to be complied and stored in the home for future inspections. The homes policies and procedures need to be updated with the current legislations and this was documented in their AQAA as needing to be addressed. The home has a safe system in place for the management of peoples monies. The AQAA contained information about the servicing and ongoing maintenance of some of the larger equipment in the home. We were shown records of checks undertaken in relation to fire equipment and drills etc. A fire risk assessment is in place but it does not contain information about evacuation of each person. We had a discussion with the Responsible Individual who felt that they would not need to do this as the staff knew all the people in the home. We therefore contacted the local Fire Service for advice. They visited the home and advised that each person who is nonambulant and people who have dementia or short term memory problems should have a personal emergency evacuation plan (PEEP) in place. We issued an Immediate Requirement in relation to slings used for hoisting. We found that a high number of slings had a build up of fluff in the velcro which could potentially stop the sling from fastening tightly. The Registered Manager ordered new slings immediately and some were delivered that same day and more were due the next day. The Registered Manager said that they are going to introduce a checking system on all slings and review how they are laundered. The maintenance person told us and provided a record sheet of the most recent checks he has made on peoples bed rails to make sure they are safe. The record sheet we saw stated that 13 beds with bed rails had failed these safety checks and Care Homes for Older People Page 28 of 34 Evidence: only 4 had passed. This needs to be addressed as a matter of urgency to make sure people are not being placed at risk or the home needs to look at reassessing people to see if bed rails are required. Following the inspection the Responsible Individual said that the Registered Manager has started to rectify the faults. Nine beds that were provided by the local Primary Care Trust have been referred back to them and the 4 remaining beds which are owned by the home have been referred back to the supplier for advice. At the last key inspection we issued a requirement in relation to how they were reducing the risk of Legionella. We did not follow this up as the Health and Safety Executive (HSE) were also at the home on one of our inspection days and they were following this up. We were informed that they felt the home has satisfactory measures in place. Care Homes for Older People Page 29 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 9 13 Review and update the 31/05/2009 medicine policy and local procedures (including homely remedies) and make sure this is read, understood and implemented by all staff. This is so that all staff have precise direction about the way medicines are safely managed and handled in this home. 2 9 13 When any medication is 18/05/2009 administered to people who live in the home it must always be clearly and accurately recorded. (This particularly relates to records for prescribed treatments applied to the skin). This is to help to make sure people receive their prescribed medication correctly and to help reduce risks of mistakes. Care Homes for Older People Page 30 of 34 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 make sure that if people are assessed as needing fluid and food charts. Then they must be completed and evidence put in place that a member of staff has taken notice of what is recorded. This will help to make sure that the health and welfare of people is being monitored. 02/04/2010 2 7 15 The Registered Person must make sure that care plans accurately reflect peoples needs and that these are kept under review and updated as required. This is so that staff have access to the relevant information to meet peoples needs. 14/05/2010 3 9 13 The Registered Person must make sure that they review and update the medicine 14/05/2010 Care Homes for Older People Page 31 of 34 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 policy and local procedure (including homely remedies) and make sure this is read, understood and implemented by the staff. This is so that staff have precise direction about the way medicines are safely managed and handled in this home. 4 33 26 The Registered Person must make sure that unannounced visits as described in this Regulation take place and a report is compiled and held at the home. This will help to make sure that the Registered Provider is monitoring the service and that it is run in the best interests of people who use the service. 5 38 13 The Registered Person must 09/04/2010 make sure that where beds with bed rails have failed the safety checks that this is addressed as a matter of urgency. This will help to make sure any risks to people are minimised. 15/04/2010 Care Homes for Older People Page 32 of 34 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 7 The inconsistencies between the care plans for people who receive nursing care and people who receive personal care needs to be addressed. Peoples care plans should indicate their preferences for the gender of staff providing personal care. A member of staff should have responsibility for arranging activities. Activities co-ordinator training is available locally. The home needs to look at providing snacks for people around the home so that they are able to help themselves. The home should provide people with accessible information about the provision of food and this should include menus on display. The home should update all their safeguarding polices and procedures as a matter of urgency. A risk assessment should be in place to describe what new staff without a CRB and working with an ISA Adult First check can and cannot do until a satisfactory CRB is received. Evacuation procedures for some people as detailed in the text should be in place to inform staff what assistance is needed if a fire was to break out. 2 3 4 5 10 12 15 15 6 7 18 29 8 38 Care Homes for Older People Page 33 of 34 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. 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