Inspection on 15/09/09 for Trowbridge Oaks Nursing Home

This is the latest available inspection report for this service, carried out on 15th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trowbridge Oaks Nursing Home 19/01/07

Trowbridge Oaks Nursing Home 07/12/05

Trowbridge Oaks Nursing Home 24/05/05

Trowbridge Oaks Nursing Home 02/12/04

Trowbridge Oaks Nursing Home 20/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Trowbridge Oaks Nursing Home West Ashton Road Trowbridge Wiltshire BA14 6DW     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 2 2 0 9 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 33 Information about the care home Name of care home: Address: Trowbridge Oaks Nursing Home West Ashton Road Trowbridge Wiltshire BA14 6DW 01225-774492 01225776965 Telephone number: Fax number: Email address: Provider web address: www.bupa.co.uk Name of registered provider(s): BUPA Care Homes (CFC Homes) Ltd care home 60 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: No more than 5 service users with a terminal illness may be accommodated at any one time The staffing levels set out in the Notice of Decision dated 16 June 2003 must be met at all times Date of last inspection Brief description of the care home Trowbridge Oaks is registered to provide nursing and personal care for 60 people. The home admits persons who are frail and many of them have complex nursing and care needs. The home is owned by BUPA, a national provider of care homes. The managers Care Homes for Older People Page 4 of 33 Over 65 60 0 5 0 8 5 Brief description of the care home post is currently vacant and a person has been appointed into the role. The prospective manager is supported by a deputy, registered nurses, care assistants, administrator, activities coordinators and ancillary staff. The home was purpose built, providing single and double rooms with en-suite facilities and a variety of different sitting and dining areas, on two floors. There is a passenger lift between the floors. At the front of the building, there is a large patio area, which is easily accessible for residents. Car parking is available on site. There is a bus stop close to the entrance. The centre of the Wiltshire market town of Trowbridge is a short ride away. Trowbridge has a railway station and the M4 can be reached in about 30 minutes. The fee range is 650 pounds to 950 pounds per week. Items not included in the fees are hairdressing, chiropody, newspapers and telephones. Copies of the service users guide are available in the front entrance area and all residents are also given their own copy in their room. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent 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: As part of the inspection, 40 questionnaires were sent out and 10 were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the homes last inspection considered. We also received an Annual Quality Assurance Assessment (AQAA) from the home. This was their own assessment of how they are performing. It also gave us information about what has happened since the last inspection. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home. This enabled us to decide what to focus on during the inspection. As the Trowbridge Oaks is a larger registration, the site visits were performed over two days. The first site visit took place on Tuesday 15th September 2009 between 9:25am and 2:30pm. The second site visit took place on Tuesday 22nd September 2009 Care Homes for Older People Page 6 of 33 between 9:50am and 2:00pm. Both visits were unannounced. While one inspector performed both site visits, this person is referred to as we, as the report is made on behalf of the Care Quality Commission (CQC). The prospective manager was on duty for both the site visits and was available for feedback at the end of the site visits. During the site visits, we met with ten residents and five relatives. We also observed care for eight residents who had difficulty in communicating. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for six residents, one of whom had been newly admitted and looked at specific areas for an additional three residents. As well as meeting with residents, we met with the deputy manager, four registered nurses, six carers, an activities coordinator, the chef, a catering assistant, a laundress, the administrator and the maintenance man. We observed lunchtime meals in both dining rooms and two activities sessions. We reviewed systems for storage of medicines and observed two medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records, accident records and complaints records. What the care home does well: What has improved since the last inspection? What they could do better: The home needs to improve systems for care planning when a person who is assessed as being at risk of pressure ulceration spends much of their day sitting out, to ensure that their position is changed regularly, to reduce risks. The home should continue to support staff in using measurable, precise language in care plans. The home should further develop systems for prevention of spread of infection by Care Homes for Older People Page 8 of 33 ensuring that hoist slings are not used communally. Glove dispensers should be provided in all areas where personal care is carried out and staff should use disposable gloves when handling used linen. The home should further develop in areas relating to accidents and fire safety by ensuring that all oxygen cylinders are secured. They should remove oxygen warning signage from rooms where oxygen is not longer in use. They would also benefit from developing individual fire evacuation plans for residents. Quality assurance systems would be improved by regular audits of the print-out of response time to call bells. As a large corporate, the provider should consider developing supervision systems for specialist staff such as the activities coordinators and the chef. 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 set out 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 33 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will have their needs assessed, so that they can be assured that the home can meet their individual needs Evidence: In their AQAA, the home reported that prospective residents who are unsure about admission are given the option of a trial in the home and that they actively encourage enquirers to look at other homes so an informed decision can be made. During the inspection, we met with some people who had been recently admitted. One person reported that they came and saw the home, including their room before admission. They also reported that staff had been helpful in explaining what they were doing when they were being admitted. Another person reported that they had met with the manager before their admission. Other people reported that they had not been well enough to visit the home before their admission but a member of their family had done this on their behalf. Care Homes for Older People Page 11 of 33 Evidence: The prospective manager reported that they met with each prospective resident prior to admission. They nearly always had a second member of staff with them to support them in the assessment process and if the person had dementia care needs, they would always ask the registered mental health nurse on their team to accompany them on the assessment. Staff reported that they were always informed about prospective new admissions, both in writing and verbally. The chef reported that they always went to meet any person who was newly admitted, soon after their admission. The activities coordinator reported that the registered nurses in charge of each floor were very good at informing them about newly admitted residents. Staff reported that some people were admitted on occasion in an emergency and that when this was the case, it was important to make a prompt assessment of their needs. We looked at assessment documentation. The home uses BUPAs standard admission assessment record. This record is set out so that all relevant areas relating to the resident are assessed, using a scoring system and directs where care plans need to be developed following assessment. All the assessments had been completed in accordance with the homes procedures and included full details relating to the individual residents needs. Assessments were regularly reviewed after a persons admission. Care Homes for Older People Page 12 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by the homes systems to ensure that their health and personal care needs are met. Evidence: In their AQAA, the home stated that all residents have comprehensive personal plans produced, which are reviewed monthly and updated as necessary. They also reported that resident care is focused on being person-centred. Quality of care is reviewed during monthly audits by the regional manager, when they assess many aspects of care. We observed that all personal care was provided behind closed doors. Staff consistently knocked on residents doors before going into their room. Care and nursing staff always called people by their own preferred name. Records showed that residents were asked about if they would prefer a carer of the same sex when providing personal care. During the inspection we met with several people who were confused. All of them were nicely turned out. We did not meet anyone who showed overt signs of distress. One person we met with was having difficulty in expressing Care Homes for Older People Page 13 of 33 Evidence: themselves, while they were aware of this difficulty, they were also relaxed and happy that staff would support them when needed. The persons fingernails and glasses were clean and they looked neat and tidy and were dressed in their own clothes. We discussed with staff about how they found out about residents needs. Staff reported that they were told at report and that as residents records were kept in their rooms, they had ready access to assessments and care plans, if they were not sure. Carers and registered nurses showed a detailed knowledge of individual residents needs. The activities coordinator reported that registered nurses always listened to them if they reported that a residents condition had changed. During our inspection we met with a range of different residents and their visitors. We also discussed residents needs with different staff and reviewed residents records. All residents had assessments of their needs, these included risk of falls, dietary needs, manual handling and risks of pressure ulceration. All risk assessments were completed in full and related to the individual. Where a need or a risk was identified, a care plan was drawn up to direct staff on how the persons needs were to be met and risk reduced. These care plans were very individual in tone and reflected what we observed and what people told us about. For example one person had a very clear continence assessment and a care plan had been put in place to direct staff on how these needs were to be met, ensuring their privacy and dignity. Another persons records showed that they had a visual deficit, they had a very clear care plan about how their needs were to be met in the light of this. Another person had a detailed care plan about how their needs were to be met during the night. Where a person had additional dementia care needs, there were clear care plans drawn up about how these needs were to be met. The wording of there care plans was clear and written in a non-judgemental style. Where peoples care needs changed, care plans were revised. One persons records showed that they were slowly loosing weight. Their care plan has been reviewed and revised in the light of this. Another persons records showed that were now usually choosing not to use their hearing aid or glasses. Their care plan relating to communication had been revised, advising staff on how they needed to communicate with the person in the light of this. Where a person had a short-term need, a care plan was put in place. For example one residents records showed that they had recently developed a chest infection and a care plan had been drawn up to direct staff on how the person was to be supported until they became improved. Many of the residents found communication complex and for these people, there were clear records that the home consulted with their advocates, generally close family Care Homes for Older People Page 14 of 33 Evidence: members, about how their needs were to be met. Relatives also told us that they were informed if their relative became unwell. One person reported that the home DO act if [my relative] was not well, another any scratch or bruise, they tell us. Where people were very frail and unable to move themselves or give themselves drinks or food, the home maintains monitoring records, so that staff can see when the person was last moved and what they have been able to eat or drink. These records were observed to be completed in full at the time care was given. We also observed that all staff, including carers wrote in the daily record as and when they gave care, signing and dating every record. While the home has systems for ensuring that residents are protected from risks of pressure ulceration when in bed, they do not have clear records of how risks of pressure ulceration are to be reduced when the person was sitting in their chair. Three of the residents we considered in detail were observed to sit out during the day, this was supported by records. All of them were assessed as being at risk of pressure ulceration, but their care plans did not state how their risks were to be reduced for them when they were sitting out. They also did not have any records on their monitoring charts to show that their positions had been changed, whilst sitting out. Risk of pressure ulceration does not reduce whilst someone is sitting out of bed, so this is needed. Most records were very clear and written in measurable language, however a few needed some attention, for example one persons turn chart stated repositioned without documenting what position they had been placed in, another persons records stated that they wore their glasses at times without giving more detail of what this meant. Where a person had a complex need such as a wound, the wound was assessed and clear care plans put in place as to how the wound was to be cared for. Regular assessments were completed of the wounds response to treatments. We met with one person who reported that they had had a pressure ulcer in the past, they were able to tell us how the home had treated it and that it had now healed but that they spent much of their time in bed to prevent they from becoming sore again. Where a resident had a catheter, the clinical reason for the need for the catheter was documented and there were clear records relating to changes of catheter, the day-to-day care of the catheter and associated equipment. Where a resident had complex swallowing difficulties there were clear institutions as to how thick their fluids needed to be, to ensure that they could swallow safely. Care Homes for Older People Page 15 of 33 Evidence: Records provided evidence that peoples GPs were called in when needed. One person reported that they had been poorly a week ago and that staff had kept a close eye on me, as well as calling in their GP. There was also evidence that other health care professionals were consulted when needed. The tissue viability nurse was visiting the home during the inspection advising them about the management of a residents wound. One persons records showed that a physiotherapist had seen them to advise on how their mobility could be improved. We observed two medicines administration rounds during the inspection. Both rounds were completed in accordance with guidelines from the Nursing and Midwifery Council. Registered nurses wore a red tabbard during the round, so that people were aware and they could concentrate on safe administration of medicines. We observed that they consistently locked the medicines trolley when they were away from the trolly with a resident giving them their medication. They always signed for a medicine only after the person had taken it. Records were clear and maintained in full. Where a resident was prescribed one or two tablets, the number given was always documented. If a medicines instruction had had to be changed by hand, this was always dated and signed. Where a person was prescribed a medication on an intermittent basis, for example one a week, there were clear systems to ensure that this was taking place. If a resident was prescribed Warfarin, instructions on changes of dose were in writing from the residents GP. Records relating to administration of insulin were clear, with evidence of rotation of injection suites and safe systems for disposal of needles. All drugs were securely stored, including Controlled Drugs. There were full and accurate records of Controlled Drugs. All medicines which required cold storage were kept in a medicines fridge, which was locked. Limited life medicines were dated on opening. All residents had clear care plans about their medication, this included known allergies. If a person was prescribed a drug on an as required basis, there were clear care plans relating to this, so that the resident could receive their medication as they needed it, in a consistent manner from staff. Where a person was prescribed a medication which could affect their daily life such as a painkiller or mood altering drug, medication care plans were regularly evaluated, so that the affect of the drug for the person was reviewed. Care Homes for Older People Page 16 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by the home in living their life as they choose. Evidence: In their AQAA, the home reported on their dedicated activities coordinator and their structured activities programme. One person commented in their questionnaire particularly on how the home did activities well. We asked people about activities when we were in the home. One person commented on how they only rarely left their room but always went down to the BINGO, which they enjoyed. Another resident reported on a card game that they enjoyed playing and that they had taught another two residents the game and that they played together at times. One person reported that they liked the quizzes. One person reported I make my own activities. The home employs two activities coordinators and also has support from several volunteers. The activities coordinator we met with was very enthusiastic in their role. discussions with them showed that they had a detailed knowledge of all of the residents in the home and how they chose to spend their time. During the morning, we observed this person making visits to people in their own rooms on a 1:1 basis. They reported that they always made sure they met with every resident on a daily basis. They reported that they aimed to do two trips out a year but would also do Care Homes for Older People Page 17 of 33 Evidence: individual trips out, for example to the local supermarket. They tried to put on a show every couple of months and also had evening events, such as a recent cheese and wine party. They had developed close working links with the local community including local schools and the towns mayor. They reported on the supports from the local churches and was aware of the importance of practice of religion to residents for whom faith was important. All residents have a map of life drawn up showing their family relationships and events important to them. All residents have care plans relating to how they wish to live their lives and recreational activities important to them. These were regularly reviewed. The activities person reported that all staff contributed to these care plans to ensure that they were up-to-date and reflected what the individual wanted. Care plans were very clear, reflecting what we were told. Records also provided evidence of contacts with families and visitors. Discussions with staff showed that they felt getting to know family members was a part of their role, so that they could fully support the resident. One relative commented on the family atmosphere in the home. Care plans showed that residents were supported in making choices. One resident reported that they appreciated being able to remain in their room and were pleased that staff respected this. One relative reported that they always phoned the home before they came and appreciated how the home then made sure that their relative was assisted to come downstairs, so that they could meet them in the sitting room. We observed a resident asking if they could go downstairs after their meal and a carer promptly assisted them to do so. The activities coordinator reported that when he told staff that certain residents had opted to attend certain activities, that staff ensured that the resident was ready and able to attend. One resident liked to clean their teeth after the main meal and we observed that staff respected this and provided them with relevant supports so that they could do this. In their AQAA, the home reported that we encourage the involvement of residents and staff in the development of the menus and that the menu master helps ensure every menu within the home is customer led and nutritionally balanced. We met with the chef, who reported that they develop menus following meetings with residents, individual comments made and observations of what residents enjoy at mealtimes. The chef reported that they meet with each resident, soon after admission, then about two weeks after admission and then regularly thereafter, depending on what each resident needed. The chef was observed to be very actively involved at lunchtime, plating up meals, discussing what residents thought of meals with residents, their visitors and staff. The chef showed a very individual knowledge of residents in the home, what they liked to eat. They also showed a detailed knowledge of the principals Care Homes for Older People Page 18 of 33 Evidence: of health eating for older people. People commented on the meals. As would be expected in a large home, comments varied from awful through reasonable, some meals are quite nice, lovely, excellent, Im very satisfied with the food, its really good. A relative commented the food? - well just look at how well [my relative] has eaten!. Everyone we met with who commented on the meals commented favourably on the choice of meals. One person reported we get a menu every day and can choose and another I can choose and get something different if I want. On the first day of the inspection, we observed that one resident had asked for a salad and had been given one, at least two of the residents changed their mind about what they would like to have at the meal time and were given the different option. Meals were observed to be attractively presented. This was echoed by a resident who reported that they had a small appetite and that the presentation of the meal helped them to eat. All meals were cooked from raw ingredients. The chef makes all the soups, sauces and gravies. One resident commented yes I do like the soups and its always nice and hot. Many of the residents were very frail and unable to feed themselves. We observed that where residents needed assistance, that staff sat with them, trying to support the resident in making the meal a social occasion. Where a resident had swallowing difficulties, the member of staff was observed also to ensure that the person was swallowing safely and was not rushed. Where a resident could not open their mouth wide, staff used teaspoons. We observed that a carer remained with one such resident throughout the mealtime, slowly supporting them in eating a full meal. As well as carers, registered nurses and the manager supported residents in eating meals. Despite there being a high number of residents who needed assistance with their meal, there was no atmosphere of rush at the mealtime, this meant that residents who needed support could relax and enjoy their meal. Care Homes for Older People Page 19 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be fully supported by the homes effective systems for complaint investigation and they will be safeguarded from risk of abuse. Evidence: In their AQAA, the home reported that the current complaints policy had agreed timescales for managing complaints and that the information that accompanies the policy is prominently displayed in the home. The policy includes a three-tier framework including the home, the regional management team and the national quality and compliance department. We observed that the complaints policy was clearly displayed in the home. We asked residents about how they raised issues of concern to them. One person reported Id tell the manageress - she WOULD listen Id make her anyway, another there is a manageress here and shed listen to you, another Id talk to [the registered nurse in charge of the floor] and theyd do something and anothertalk to anyone. All staff we met with knew how to support residents and their supporters in raising issues of concern. During the inspection we met with some people who reported that they had made complaints about service in the past. When we looked at the complaints register, we observed that these matters were all fully documented and what was documented reflected what we had been told about. We noted as good practice that the prospective manager documents all issues raised and then performs a full investigation, feeding back as necessary to all parties. Where matters are identified Care Homes for Older People Page 20 of 33 Evidence: during the investigation into the complaint, there was full evidence that actions had been taken. The prospective manager showed an open attitude towards complaints, reporting that they were a key area in quality assurance to ensure that people were satisfied with the service received and they were keen to work with people to resolve issues. In their AQAA, the home reported Bupa Care Homes has robust allegation of abuse and neglect policies, allowing staff to raise concern within the home or to senior staff outside the home. They also reported that the Pova procedures are well documented should the need arise. We looked at training records and these provided full evidence that staff at all levels are trainee din the area. When we discussed safeguarding with staff, all staff at every level in the organisation we discussed this with were very clear on their responsibilities for reporting any suspicions to people in authority within the organisation. The home has experience of working within local safeguarding procedures and have referred people who they judge may be at risk, in accordance with their procedures. They have always taken a very supportive approach to any investigations and have taken action where indicated. We noted as good practice that where residents need devices such as safety rails or lap belts, which could put them at risk if inappropriately used, that there were always risk assessments completed. These were regularly reviewed. As much as possible, residents were cared for in profiling beds which go down close to the floor, to avoid the risks associated with the use of bed rails. Care Homes for Older People Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by a home environment which meets their needs. Evidence: Trowbridge Oaks was purpose-built as a care home over ten years ago. Accommodation is provided over two floors, with a passenger lift in-between. All parts of the home we visited were well maintained and the maintenance man reported that staff promptly reported deficits to them and that they also regularly performed checks on the home, to identify any deficits. Most rooms are now for single use, all have ensuite facilities. There is a large dining room and sitting room on the ground floor and a smaller sitting room and dining room on the first floor. Outside, there is a wheelchair accessible patio garden area, which is secure, to ensure that residents who may wander are not put at risk. The home is seeking to register to admit people with dementia care needs and secure locks have been put on the doors to the first floor. The home has a range of equipment to meet residents disability needs. All of the beds are variable height and many are profiling. The prospective manager reported that more profiling beds are to be provided. There are a range of hoists to meet residents needs and all residents who were assessed as being at risk of pressure ulceration had relevant pressure relieving equipment provided, which was consistent with their assessed degree of risk. Two registered nurses reported that if they needed more equipment, they could approach the prospective manager, but that it also would be Care Homes for Older People Page 22 of 33 Evidence: useful to have more equipment available, as residents needs could change rapidly. The home has a separate laundry, which is small. However the laundresses have all worked there for many years and know how to manage their service within the restrictions presented by the area. All of the laundry was clean, including the areas behind the machines. Te laundress showed a good knowledge of risks presented by dust accumulation behind machines, both as a fire hazard and as a risk to infection control. The laundress reported that staff consistently placedlaundry in correct bags and that infected and potentially infected laundry was always managed correctly by staff. She reported that naming of clothes, as in all homes, could be an issue and the steps that the took to return un-named clothes to their owners. The receptacle for unnamed clothes was observed to contain only a very tems. We observed that all of the home was clean and smelt fresh. Difficult to reach areas such as the undersides of raised toilet seats and bath hoists were clean. During the inspection, a resident was taken for a hospital appointment by ambulance. Unfortunately the wheels of the ambulance trolley caused visible marking on the residents floor. We noted as good practice that this was promptly noted by the laundress, who was in the area, who informed one of the domestics, who ensured that the carpet was promptly cleaned. We discussed hoist slings and slide sheets for manual handling with staff and on discussion it appeared that they were used communally. Tis could present a risk to cross infection and all such items needs to be named for the person and only used for them. The laundress reported that staff did send hoist lings and side sheets to be laundered very frequently. We observed that disposable aprons and gloves were available on trolleys for staff to use in personal care. Current advice is that they should also be provided in dispensers wherever people may be performing personal care. Male staff we talked to reported that the home also had supplies of larger gloves for their use. Sme staff will need more support in the management of used laundry. We observed a care assistant carrying used linen and putting it in a linen skip. They were not wearing gloves or an apron, although they were holding the linen to themselves. After had done this, we observed that they did wash their hands. The linen was not infected, however as good practice, staff need to always use disposable gloves and aprons when handling used linen. Care Homes for Older People Page 23 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by staff who have been safely recruited and are trained to perform their role. Evidence: In their AQAA, the home reported on their stable work-force and low staff turnover. This was found to be the case at the inspection, with many of the staff having worked in the home for an extended period of time. We discussed staffing with people and whilst there were, as is often observed in most care homes, residents, visitors and staff who considered that the home was short staffed, there were others who did not regard this as an issue. Comments varied from theyre short staffed, if I ring my bells, they arent quick but they come sooner or later, through if I ring my bell theyre not bad at all, that staff were fairly quick if they rang their bell, to if I ring my bell, theyre not bad at all and ring my bell - no problem. During the inspection, we observed that although Trowbridge Oaks is a home where many of the residents have complex care needs, that there was no feeling of rush by the staff and that they were able to calmly perform their roles. Observations showed that where residents needed frequent care, for example two hourly turns, that this was taking place, in accordance with their care plans. The prospective manager reported that if dependency did increase, that they were able to discuss this with BUPA and was able to give examples of where staffing had been increased in such situations in the past. Care Homes for Older People Page 24 of 33 Evidence: In their AQAA, the home reported Bupa Care Homes has comprehensive Human Resource policies and procedures to aid staff management and recruitment. We looked at the files of three recently employed people. All files included proof of identity, including a recent photograph, a full employment history, at least two satisfactory references and police checks. Where issues were identified prior to or at interview, there was evidence that this was probed. For example, one persons application form did not show a fully employment history, so further information was gained at interview, one of another persons references was very limited, so a third reference was obtained. We did find that one document relating to a person employed from abroad before the prospective manager took up post had not been retained on file. this was rectified at the time of the inspection. We advised that the prospective manager should review all staff files to ensure that all equipment documentation is on file. We looked at newly employed staffs files and saw that all staff completed an induction programme in accordance with BUPAs policies. BUPAs polices conform in full to our guidelines. Inductions were all completed in full and signed and dated by the inductee and their mentor. The prospective manager reported that newly employed staff were usually fully supernumerary for their first week but that this could be flexible, depending on the persons needs for support. In their AQAA the home reported there is a training matrix specific to the home that identifies the training requirements of staff and that all mandatory trained was up to date. We looked at the training matrix and it was clear that staff are being trained. All staff have an individual training file, this showed that care staff are supported in undertaking National Vocational Qualifications, as well as other areas. All staff we spoke with reported on the supports for staff training. A registered nurse reported on how they were currently undertaking nutrition training, the chef reported that all their staff were undertaking or had completed NVQs in catering, the activities coordinator reported that BUPA had supported them in gaining a diploma. On the day of the inspection, the tissue viability nurse was in the home, giving a training session. Staff at all levels spoken with reported that they had been given dementia training, in preparation for the new dementia care unit. One member of staff described to us how interesting they had found the dementia care training and how it had given them an insight into the area. Care Homes for Older People Page 25 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be protected by the homes management systems, which will up-hold their health, safety and welfare. Evidence: The previous registered manager has left their post since the last inspection. The provider has appointed a new manager, the person appointed was the previous deputy manager and this person is applying to us to become the registered manager for the service. A deputy manager has been appointed to support the prospective manager. People commented specifically on the prospective manager. One person reported management is no problem, communication is so good and another that the prospective manager has only been in place for a short time but look at the difference [the prospective manager] has made. The manager runs regular meetings for residents and their supporters and staff at all levels. These are all minuted. Additional meetings have been held to inform people about the proposed dementia care unit and also to hear their comments. Relatives and Care Homes for Older People Page 26 of 33 Evidence: staff spoken with were all aware of the plans and felt that they had been able to contribute to the change process. BUPA has standard systems for reviewing quality of service provision. Regular surveys are sent out and results collated centrally. Where matters are identified, the manager has to develop an action plan to report on how matters are to be addressed. The home also has monthly visits by a senior manager, who completes a report. The home reports on a range of matters to the provider, including incidences of pressure ulceration, accidents and infection. Again where matters are identified, the manager is directed to develop an action plan. The manager also regularly reviews staff performance and records relating to provision of care. We noted as good practice that they had observed that a registered nurse in charge of the floor had not ensured that a particular resident had been turned by staff at the frequency directed in their care plan and that there was written evidence that this had been taken up with the person. The home has a print-out system for when call bells are used. A random review of print-outs did not show any issues. However as some people feel that staff can take time to answer call bells, it would be advisable as part of quality audits for the manager to perform a written review of their random audits of print outs for times when call bells are used, to ensure that they can evidence that staff are responding promptly when call bells are used. The home uses the standard systems from BUPA for management of residents moneys. This includes a full audit trail and retention of receipts for all transactions. Records showed and staff confirmed that they were regularly supervised. Supervisions used a variety of approaches, including 1:1, small group and larger group supervisions. Some supervisions were planned, others spontaneous because circumstances indicated they were needed to support staff. Supervisions also included direct supervision of practice in providing care. Heads of departments such as the chef and housekeeper supervise their own staff. Heads of department all reported that they felt supported in their role by the prospective manager. Where staff have specific expertise, such as activities provision or catering, it would be advisable for a large company by BUPA to develop supervision systems, so that such specialist staff can be fully supported in their roles. The home has full systems in place so that staff can be trained in all areas relating to health and safety, and full records were maintained. BUPA has clear systems for ensuring that equipment and services are serviced in accordance with instructions and guidelines. Full records are maintained. We observed that two oxygen cylinders had not been secured. Oxygen cylinders need to be secured as they can present a risk of Care Homes for Older People Page 27 of 33 Evidence: injury and explosion if they topple. Rooms where oxygen cylinders were in use had warning signage on them, however other rooms where oxygen was no longer in use had not had signage removed and this should take place, to prevent unnecessary delay to fire officers in the event of a fire. The fire log book is fully maintained in accordance with local guidelines. The home does have evacuation policies, including a traffic lights approach. It would be advisable to develop this further, to include individual fire evacuation plans for each resident. Care Homes for Older People Page 28 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 Where a person is at risk of pressure ulceration and spends much of their day out of bed, their care plan must state how risks are to be reduced when they are not in bed. There must be full records to show that pressure has been relieved to the person when they are out of bed. Peoples risk of pressure ulceration does not reduce when sitting out of bed. Therefore plans need to state how risk is to be reduced and records provide evidence that staff are complying with care plans. 30/10/2009 2 26 13 All residents who need to be moved using a hoist sling or a sliding sheet must have their own equipment which is only used for them. 31/12/2009 Care Homes for Older People Page 30 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Communal use of such equipment can present a risk to cross infection. 3 38 13 Oxygen cylinders must be secured at all times. Oxygen cylinders by their shape can topple easily if they are not secured. If they do topple over, they can present a risk of injury and explosion. 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 12/10/2009 1 2 3 4 5 7 26 26 29 33 Staff should ensure that only clear, measurable language is used in nursing and care documentation. Glove dispensers should be provided in all areas where personal care is carried out. Staff should use disposable gloves and aprons when handling used linen. All staff employment records should be reviewed, to ensure that all contain all required information. A written audit of periodic checks on response times to call bells should be included in the homes quality audit systems. The provider should develop supervision systems for specialist staff, such as the activities staff or chef so that they are fully supported in the specialist parts of their role. The home should develop individual fire evacuation plans for residents Oxygen cyliner warning signs should be removed from all Page 31 of 33 6 36 7 8 38 38 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 rooms where oygen is no longer in use. Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 33 of 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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