Inspection on 09/03/10 for Winterbourne Care Centre

This is the latest available inspection report for this service, carried out on 9th March 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Winterbourne Care Centre 16/06/09

Winterbourne Care Centre 05/05/09

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Key inspection report Care homes for older people Name: Address: Winterbourne Care Centre London Road Salisbury Wiltshire SP1 3YU     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: Susie Stratton     Date: 0 9 0 3 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 46 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 46 Information about the care home Name of care home: Address: Winterbourne Care Centre London Road Salisbury Wiltshire SP1 3YU 01722428210 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Caring Homes Healthcare Group Limited Name of registered manager (if applicable) Mrs Claire Lousteau Type of registration: Number of places registered: care home 80 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Service users whose primary care needs on admission to the home relate to their dementia may only be accommodated to receive personal care and not nursing care. The maximum number of services users who can be accommodated in 80. The registered person may provider 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 categories Old age, not falling within any other category (Code OP) - maximum of 80 places Dementia (Code DE) maximum of 41 places Date of last inspection 0 9 1 0 2 0 0 9 0 0 Over 65 41 80 Care Homes for Older People Page 4 of 46 Brief description of the care home The Winterbourne Care Centre is registered to provide nursing and personal care for up to 80 people. It was purpose-built and first registered on 5th February 2009. Accommodation is provided over three floors. The home is divided into six units. At the time of this inspection, four units were opened. One unit on the ground floor to the right of the entrance area provided personal care to elderly people, the unit above this on the first floor provided nursing care to people who were medically frail. The two units to the left of the entrance area on the ground and first floor provided dementia care. The home is owned by Caring Homes Healthcare, a national provider of care. The registered managers post has recently been filled. The new managers name is Claire Lousteau. Mrs Lousteau leads a team of registered nurses, carers and anciliary staff. The home is on the London Road, leading into the city of Salisbury. There is ample car parking on site, a bus stop close by and a train station about 10 minutes away by bus or car. Care Homes for Older People Page 5 of 46 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: As part of the inspection, 40 surveys were sent out and 10 were returned. Comments made by people in the surveys and to us during the inspection process have been included when drawing up the report. The homes file was reviewed and information obtained since the previous inspection considered. We performed a random inspection on 9th October 2009, this was because of a range of matters brought up by external people. Mrs Lousteau, the current manager was not in post at the time of the random inspection. At that inspection, we identified a range of requirements and recommendations, some of which had not been addressed since the previous key inspection on 30th June 2009. An Annual Quality Assessment Audit (AQAA) was submitted to us to us before the inspection. This was not received until the day before the inspection, so it was not considered as part of our inspection planning process but it was reviewed after the inspection. An AQAA is the homes assessment of the quality of their service provision. It also provides numerical information on services provided. We looked at the surveys and reviewed all the other information that we have received Care Homes for Older People Page 6 of 46 about the home since the last inspection. This helped us to decide what areas we should focus on when doing the inspection. The site visit was performed by two inspectors and a pharmacist inspector. These people are is referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The site visit took place on Tuesday 9th March 2010, between 9:10am and 5:35pm. The visit was unannounced. The manager was in charge of the home throughout the inspection. The manager and her line manager were available for a brief feedback at the end of the inspection. During the site visit, we met with a range of residents in all parts of the home and also observed their care. 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 five residents, including a resident who had recently been admitted to the home and looked at specific records relating to a further two residents. As well as meeting with residents, we met with the assistant manager, three registered nurses, six carers, a domestic, the maintenance man and the laundry person. We observed a lunchtime meal. 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, complaints records and maintenance records. Care Homes for Older People Page 7 of 46 What the care home does well: What has improved since the last inspection? What they could do better: The home needs to make some improvements in its pre-admission processes and documentation, making it more detailed. Some care plans need more development, to include all factors for the resident and make them clearer. All care plans need to be Care Homes for Older People Page 8 of 46 regularly evaluated so that they are up-to-date. There needs to be written evidence that staff are following care plans, this includes nursing as well as general care, particularly in relation to the prevention of pressure ulceration and management of urinary catheters. The home needs to further consider how they provide information to all staff about residents individual needs. This includes agency staff as well as permanent staff. The introduction of a full key worker system would support continuity of care. Further developments are needed to fully document the administration of medicines to residents. All documentation relating to nursing and care needs to be dated and signed by the person drawing up the document. Service provision at mealtimes needs to be fully reviewed, to ensure that nutritious, appetising meals are served in a timely manner, with enough staff being available to support residents at this time. Improvements are needed in practice in relation to the management and handling of infected and potentially infected items and all staff need to be trained in their responsibilities in this area. Staff need to follow the homes procedures on the individualisation of hoist slings. Practice in the cleanliness of nebulisers used for people with breathing still needs improvement. Sluice rooms need to be secured, to prevent risk to people with dementia. The provider needs to perform a further review of staffing levels, to ensure that there are sufficient numbers of staff to meet residents needs and ensure their safety. The home would benefit from development of training plans to meet residents nursing and care needs. The provider must ensure that it meets requirements set by us during inspections, or inform us of why they are not able to do so within timescales. They must also inform us of how they are planning to meet requirements from the fire authority. 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 46 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 46 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by improved systems put in by the new manager to ensure that their individual needs can be fully assessed prior to admission. The home needs to ensure that it can demonstrate that they can meet all of a persons needs in certain areas in the admissions process. Evidence: In their AQAA, the home report that all prospective residents are assessed prior to admission by completion of a pre-admission form. They report that the form has been updated this year to ensure that comprehensive information is collected. New residents are admitted only after a full care management assessment has been made by the registered manager or deputy of their care needs and it is clear the home can meet those needs. They report that following this, a plan is collated with the resident for daily living and the home can begin longer term outcomes based on the assessment. During the past twelve months they state that the home has become more organised when admitting new residents. Care Homes for Older People Page 11 of 46 Evidence: During the past year, the Winterbourne has undergone a range of changes at senior management level. We are aware that issues had been identified relating to residents being admitted who needed nursing care, who were being provided with residential care. This related to a previous manager, not the current manager. The current manager has ensured that all residents have been re-assessed by relevant health care professionals, to ensure that their needs for nursing or residential care are clarified. As part of this process, the provider has identified issues relating to their contracts and at the time of the inspection, the provider reported they were reviewing all contracts across their group of homes, to ensure that contracts relating to nursing and residential care were clear. Once new contracts have been approved in accordance with their processes, residents will be re-issued with contracts of residence. This will benefit residents as half of the people who responded in surveys about contracts reported that they did not know if they had received a contract and one person reported that they had not received a contract. We met with two people who had recently been admitted to the home. One person reported that they were all right here and that they were gradually getting better. Another person reported that the home was all right and that the service was very good. We discussed with staff how they found out about new residents and their needs and received a range of comments. Some staff reported that there had been issues in relation to clear reports about residents conditions, particularly if they had not been on duty for a few days but that this was now improving under the new manager. However more junior staff reported that the system of senior carers informing junior carers of residents needs was variable and senior staff felt that while junior staff did receive reports from senior staff at times, this did not always consistently occur. Staff did report that they could read residents records to inform them of new residents needs but, due to pressure of work, they did not always have time to do so. We met with several residents who had been admitted during the last six months. We reviewed pre-admission assessments and post-admission assessments. We observed a variability. A range of matters were documented in detail. For example there were clear details about the care and management of a newly admitted persons wound. This person also had complex needs relating to their bowel management and there were clear details of how their needs in this respect were to be managed. We observed that the person had been noted to have visible bruising on admission and there were clear records relating to this, including a body map. We noted other issues which needed addressing. A persons pre-admission assessment Care Homes for Older People Page 12 of 46 Evidence: was not dated, so it was complex to assess if their assessment had been completed prior to admission. Their records stated that they wore glasses, without stating what they wore them for, it also stated that they experienced occasional pain, without describing the persons experience any further, including details of where the person experienced pain. The pre-admission assessment had a section relating to the persons sleep habit which was not completed, although the person was able to describe their sleeping habit to us. A person reported to us that they had no formal next of kin to support them. There was no reference made to this in their preadmission assessment or how they were to be supported in the light of this. A person was noted to have bruising on their body on admission, however there was no assessment of the risk of pressure ulceration for them on file. The manager did contact us after the inspection to inform us of the persons risk assessment score. This indicated that the person was at high risk of pressure ulceration. The National Institute for healthcare and Clinical Excellence (NICE) guidelines state that in clinical settings, assessment for risk of pressure ulceration needs to be made within a short period of admission and an appropriate plan put in place if risk is identified. This had not happened in this persons case. Care Homes for Older People Page 13 of 46 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will have improved supports from the systems put in by the new manager, however the quality of verbal and written information and issues relating to continuity of care means that some residents may be at risk of not having some of their nursing and care needs met. Evidence: In their AQAA, the home reported that all residents have a detailed care file, which contains details of needs, problems, strengths and risk assessments from which the care plans are generated. They report that these are reviewed monthly or as changes occur. They report that residents are assessed regarding pressure ulcer and nutritional risk and that they can evidence the interventions carried out. They report that during the past year, they have among other areas, improved medication administration procedures, ensured that all residents on fluid charts are monitored closely, with 24 hour totalling of charts and any discrepancies highlighted on the 24 hour report and passed to registered nurse and home manager for action, that where a person is unable to move/change position there are monitoring records in place and all those assessed as being at risk of pressure area damage are nursed on appropriate pressure Care Homes for Older People Page 14 of 46 Evidence: relieving equipment in bed and when sitting out in chairs. This inspection showed that these statements were not accurate in all cases. People commented to us about care and support in surveys, with all people responding that they always or usually received the care and support that they needed. However people were less sure about staff listening to them and acting on what they said, with people reporting that staff either usually or sometimes, did this. Most people reported that they always got the medical care that they needed, however two people felt that this only usually happened. One person reported all round I think they cope well no doubt improvements are possible but I am satisfied, another person reported that the home looks after us all!!! and another that the home was about average, all OK. A member of staff commented residents care are excellent as some of our residents came in with pressure sore but now all healed. A resident commented to us during the inspection that staff were very respectful of their privacy and dignity, with all staff explaining carefully what they are doing at the time. Another person reported that the home was an easy home to work with. A resident reported that they got their tablets when they needed them and had no pain. They also reported that the home had been good at getting the doctors in, saying that they had had a terrible cough and were very poorly one night and that the home got someone in right away. We talked to staff about how they found out about residents nursing and care needs. Staff reported that the registered nurses and senior carers received a handover and that senior staff then handed on about peoples needs to more junior staff. Staff felt that improvements had been made in this area since the new manager came in post, including the introduction of a written handover sheet, however they felt that more improvements were needed. A carer commented that they felt that more should be written down to make sure that staff knew priorities. An agency registered nurse felt that while they were given a hand-over it was not in depth to enable them to have full knowledge about residents needs, particularly if they had not worked in the home for a few days. They reported that information was available in residents records but due to pressure of work, they did not often have time to read residents records in detail. One junior carer reported that they felt that they were always informed about residents needs, however another reported that they were mainly told and another that they found out about residents needs by asking them, as only senior staff received handover. Many of the residents had dementia care needs and so would not be able to inform people about their current needs. The new manager reported that they wished to break down the old ways and so, while certain senior staff always held responsibility for certain areas, more junior staff were Care Homes for Older People Page 15 of 46 Evidence: expected to work across all the home on a shift-by shift basis. The home does not appear to have a functional key worker system and none of the residents we spoke to were aware if they had a key worker. One persons key worker documented in their information folder was out of date, as the member of staff now worked elsewhere in the home. One person did describe their good continuity of care but on further discussion it became apparent that this related to the cleaning, not nursing and care staff. As many of the residents had dementia care needs and others were very frail, systems should be developed to ensure more continuity of care to residents, including a full key worker system. At the time of the inspection, four of the wings of the home were open, this included two wings for dementia care and two for nursing or residential care. As noted above residents are currently being assessed for needs for nursing or residential care. As assessments were completed, a colour-coding system was being used to distinguish which residents needed which form of care. A senior carer we spoke with was very aware of which people needed which type of care in the wing they were managing. This carer was aware that for people who needed residential care, they needed to refer nursing issues to the district nurse and they felt able to do this. We met with a range of residents on different units, discussed their needs with them, reviewed their records and discussed their needs with staff on duty and some of their relatives. The home have put much effort into the development of care plans since the last inspection. For example one person who was reluctant to eat and found difficulty in feeding themselves, had a detailed care plan about their preference for fingerfoods, so that they could continue to feed themselves, this included a detailed description of the finger foods that they liked to eat. Another person had a detailed care plan about personal cleanliness in the light of their need for a urinary catheter, this plan would clearly direct any person on actions needed to support the resident. Another resident was documented as having had a blister on their hip, clear records were made of this occurrence and a body map drawn up. However some care plans had only been partially drawn up. One person had a care plan relating to their breathing needs and use of oxygen via a nasal cannula, their care plan stated that their breathing was to be kept within acceptable levels, with no more details of what the acceptable levels were. The care plan stated that the persons nose was to be checked for soreness and stated the regularity of change of the filter in the nebuliser, but there was no mention of cleanliness of the nasal cannulae or how often they were to be changed and there were no records that the cannulae or tubing had been changed. As at the last inspection, two people who were assessed as being at high risk of pressure ulceration had air mattresses on their bed Care Homes for Older People Page 16 of 46 Evidence: but a chair cushion relating to a medium risk of pressure ulceration on their chair, with no documentation in their records as to why this was in their best interests. Risk of pressure ulceration does not reduce when a person sits out of bed. The home uses standard care plans in certain areas, particularly for ensuring a persons privacy and dignity, where there are a set of standard phrases in the document and the persons name is written on the document. Such a format does not ensure individualised care planning, as all the people we met with had different needs in this respect. Care plans relating to dementia care needs would benefit from development. One resident had a care plan which stated they had cognitive impairment and were chargeable in mood, without documenting how these observations presented for the person. Improvements are needed documentation. Several people had additional information available in their rooms about such matters as specific instructions about their manual handling needs or their daily regime. These were not dated or signed, and need to be to enable regular review and up-dating. Whilst some fluid charts were totalled every 24 hours, others were not. Information relating to fluid intake by residents at risk of dehydration was not consistently reviewed in the daily records. This was recommended at the random last inspection and the homes AQAA stated that it had been addressed. Three of the residents we met with were assessed as being at high risk of pressure ulceration; staff reported that none of them were reliably able to change their own positions without assistance. None of them had a turn chart to enable staff to review when the person last had their position changed. A requirement relating to the need for turn charts was identified during the random inspection of 5th May 2009, by the key inspection of 30th June 2009, turn charts were in place but issues relating to accuracy of recording were identified at that inspection and the random inspection of 9th October 2009. This inspection shows that the home have lapsed to the situation prior to their last key inspection. The homes AQAA stated that monitoring charts were in place. People who are at risk of pressure ulceration need to have their positions changed on a regular basis, to ensure that risk of pressure ulcers are reduced. Pressure ulcers can take an extended time to heal, are painful and may present a risk of infection, therefore the emphasis must always be on prevention. A resident had a urinary catheter in place. Their care plan about changing their catheter was not clear, implying the catheter needed changing six weekly, however generally the type of urinary catheter used needs changing every three months. The persons records showed that neither time period had been followed and the had not had their catheter changed for a period of over six months. This could have put the person at risk of infection. Another person was documented as having a medical Care Homes for Older People Page 17 of 46 Evidence: device in place. The care plan was clear and documented actions to be taken if the persons bowels were not opened. It was dated as last evaluated in May 2009. We discussed the care plan with a senior carer who was able to provide us with more information about the device; this had not been documented. There was no written evidence in the persons records that they had opened their bowels, so it was not possible to assess if the care plan was being followed. Our Pharmacist Inspector looked at the arrangements for the handling of medicines in the home. Medicines were stored securely and appropriately on both floors. We watched the nurses giving medicines on both floors and saw that it was done correctly and with consideration to peoples individual needs. At the time of the inspection there was no senior carer on duty on the ground floor who was trained to give medicines, so the nurse gave them, all which took some time. For part of the round they were obliged to carry the phone which could lead to distractions. The home has a clear procedure for the safe handling of medicines and all staff who administer medicines are trained to undertake this task. There are currently not enough non-nursing staff trained to administer medicines and the home has to rely on agency nurses to carry out this duty on many shifts. The medication administration records were printed by the pharmacy and any handwritten additions were clear and checked by two members of staff. The records of creams that had been applied by the carers were only ticked by the nurse on duty not signed by the person doing the application. The nurse stated that carers should record the use of creams in the care records but the two examples we looked at were incomplete. The use of some medicines prescribed for use as required was not always recorded clearly as the medicine was recorded as not given or not needed at set times of day rather than left and only recorded on the rare occasions it was needed which would give a clearer picture of its use. We observed occasions where topical applications were not named or dated on opening. The home continues to need to put in systems to ensure that this does take place, otherwise there is a risk of cross infection. Some people in the home were prescribed an anti-coagulant medicine which requires regular monitoring. The records for this were kept with the medication administration records as current good practice guidelines recommend, however the old ones were left in the file and not discarded. After the inspection we were informed by the home of an error which had occurred prior to the inspection involving this medicine. It is possible that the records being kept in this way contributed to the error. We saw the records of one person who spends time away from the home. There was Care Homes for Older People Page 18 of 46 Evidence: no clear procedure for the transfer of information between GP and care home about the persons medication, however we observed good practice from the nurse on duty in establishing the information she needed before administering the medicine. Care Homes for Older People Page 19 of 46 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 poor 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 some service delivery in relation to their daily lives and social activities but more development is needed, so that peoples individual choices can be up-held. Residents are not supported by service provision at mealtimes. Evidence: In their AQAA, the home reported among other areas that care plans are individual and based on the residents choices and that the home has a detailed activities programme. They report that meal times are relaxed and that residents individual likes and dislikes and dietary needs have been placed in a folder in the kitchen for chef to refer to and chef meets all new residents within the first two days to ascertain the residents choices. All apart from one person commented in surveys that the home always or usually arranged activities that they could take part in. Three people reported that they always and five usually liked the meals. At the time of the inspection it was reported that the activities coordinator was off sick and had been so for some time, so it had not been possible to organise structured activities because of this. The new manager reported that they were currently recruiting a new activities coordinator and had had a good response to the recruitment campaign. A resident reported to us on the effects Care Homes for Older People Page 20 of 46 Evidence: of this, reporting on what had taken place at Christmas and how they had enjoyed the activities then but that there was nothing at present. A member of staff reported that they were aware of the importance of activities to residents, particularly people with dementia, but that due to peoples complex individual care needs, they did not always find that they had time to fully support people. This was echoed by several other staff, one reporting that there had been little purposeful attention to activities in the dementia care units. One relative reported to us that staff were busy and that they had the impression that staff were not allowed to sit and talk to residents. One resident who did not leave their room told us that they did receive one-to-one support from staff at times and that they were teaching a member of staff how to crochet. The home is progressively developing activities care plans for residents, including individual likes and preferences and benefit to the resident themselves. Once the home has a dedicated member of staff in post, this is an area which will benefit from improvements. Residents had standard questionnaires about their preference in their records. Most of these had not been completed, therefore it was not possible to assess if their individual preferences for how they wished to spend their days had been planned for. Two of the people we considered in detail had clear social care plans, including the beginnings of life history development. We met with several residents relatives during the inspection. All of the people we met with said that they were able to visit the home at any time. Many were complimentary about the dedication of the permanent staff but felt that the high usage of agency staff meant that their links with the resident were not always fully supported. During the inspection, we observed that one residents family was supported in taking meal in a private dining room with them. Another resident was due to go out during the afternoon with their relative. The staff were fully aware of this and had supported the resident in planning their morning so that they could rest as much as possible, before going out for the afternoon. The homes chef was away on annual leave at the time of the inspection and an agency chef was cooking the meal. The menu choices for the day were displayed in the main entrance area and outside the dining room on the first floor. The two menu choices did not agree with each other. We subsequently found that the actual menu choice given was that displayed on the first floor. A relative informed us that residents were not always offered the choices displayed, particularly when the chef was away. We received a wide variety of comments about the meals. One person reported on how much they enjoyed their meals, reporting that they had put on weight since their admission, six months ago. Another person reported that meals were good enough Care Homes for Older People Page 21 of 46 Evidence: but nothing to get excited about, another that meals were not very appealing and another dreadful. Several people commented on the temperature of the meal, some reporting that because there were not enough staff, meals became cold. One person commented that they appreciated how staff noticed little matters, such as giving the first course and dessert separately, so that people with poor appetites did not eat their dessert and leave their main course. We observed a mealtime. Residents can eat in one of the two larger dining rooms, in the sitting/dining rooms or their own room, as they chose. We observed that the lunch trolleys arrived later than anticipated. This caused difficulties in the dementia care units, particularly in orientation of residents, who had been assisted to table, or provided with an over-knee table, and staff had explained it was lunch time, as by the time of the service of the meal, two were wandering away and one had fallen asleep. This added to pressure on the two staff to serve the meal. The meal was served at the time expected on the ground floor residential unit, however as only one member of staff was observed to be available to support residents, this took some time. The meal trolley was not delivered to the first floor nursing unit until after 1:00pm and the two people who needed full assistance from staff to eat their meals did not receive the supports they needed until after 1:20pm. We observed that while the meal was being served that lids were left off the meals in the hot trolleys. When meals were taken to residents, there was no steam coming off meals, which indicated that they might be cold. Two relatives confirmed that meals were often served cold. The quality of the meals appeared to need improvement. We observed that one resident was given a plate by a carer with their meal, so that they could pick out the parts of the meal which they did not like. Another resident at the same table described the meat as unidentifiable and that the beans were trouble as usual. A third resident was observed to show signs of difficulty in putting their fork into the meat and to chew the meat again and again, discarding most of it on their plate. On the first floor the size of the cubes of meat were observed to be too large for a person who could not open their mouth wide to put in their mouth. Another frail person was observed to try to put their fork into the piece of meat but the persons fork bounced back, due to the quality of the meat provided, so the person stopped trying to eat that part of their meal. We observed that carers sat down with residents to support them in eating and tried to make it a social occasion for them. However at one time a carer was supporting a Care Homes for Older People Page 22 of 46 Evidence: resident to eat but had to leave the resident to urgently support another resident to eat their meal, they apologised very nicely to the resident, but if more staff had been available, the carer would not have needed to do this. On the dementia care units residents were not involved in any way in service of the meal. Gravy was served from a large catering jug over the hot trolley, when a small jug could have been used at table for self service with such assistance as necessary. Two people required one-to-one assistance to eat, which took all the staffs time and so reduced their capacity to observe and assist others. One person struggled to get food onto their fork and then to their mouth, usually dropping contents back onto the plate. One carer took a meal to a person in their own room, where they gave assistance, leaving one member of staff in the dining room. A drink was spilt on the floor by a person known to have complex mood changes. The remaining member of staff was concerned about how to address this as they felt they could not leave the person they were assisting directly. They asked the registered nurse when they arrived if they could mop up, but the registered nurse was there to do the perform the medicines round, so left the task for the other carer when they returned. This presented a slip hazard until dealt with. The dining rooms were all very attractive in appearance. New, modern dining tables and chairs were available and the provider reported on the research-based information about the types of crockery and cutlery used for residents. We observed that foodstuffs were correctly stored in some parts of the building, however in other cupboards, we observed breakfast cereals stored with no lids on them, this will not keep them fresh. On the dementia care units, the trolleys for used crockery, plates and food for disposal showed deposits of dried-on debris on the under-surfaces. Care Homes for Older People Page 23 of 46 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. Residents will live in a home where management is positive in ensuring that they are safeguarded and have their concerns listened to and acted upon. As the homes management systems were still being developed, all areas to ensure their concerns are listened to and people are safeguarded had not been fully acted upon. Evidence: In their AQAA, the home reported on their robust complaints procedure with residents and their relatives being aware of who to complain to. They reported that any complaints, whether verbal or written, are recorded and a written response sent within 28 days. They report on their robust allegation of abuse and neglect policy and on allowing staff to raise concerns within the home or with senior staff outside the home. They also report on their whistle blowing policy and that all staff receive training on protection of vulnerable adults. All of the people who responded to us in questionnaires reported that they knew how to raise issues informally. Five people reported that they knew how to raise a formal complaint but three people reported that they did not. One person reported to us that they knew how to raise complaints, citing several occasions when they had complained about the quality of the vegetables. A person reported that they told staff about their concerns and that they usually do something, another person reported that they spoke to the head of care or the assistant manager and that anything that they were able to address they would do, and within an agreed timescale. One relative Care Homes for Older People Page 24 of 46 Evidence: did report that the new manager had a lot to do in the home and was too busy to be approached. The new manager has fully developed the homes approach to complaints. We reviewed their complaints log and saw that both formal and informal complaints were logged, with clear responses and action plans developed where indicated. We observed one informal complaint relating to the laundry and action plans relating to this. We did observe that the concerns from the person who felt they had complained about the vegetables had not been logged either in the complaints record or their care plan relating to preferences for meals, so the manager continues to need to ensure that all relevant matters are referred on to her, to ensure that she is aware of them and can take action on matters affecting the people they provide a service to. We are aware that a range of safeguarding referrals have been made about the home since the last inspection. This has been dealt with via the Wiltshire safeguarding adults procedures. The home has been fully involved at all relevant stages with investigations and where matters have been identified, have developed action plans, detailing how and when matters are to be addressed. These action plans were being regularly reviewed. Staff we spoke with all reported that they had been trained in safeguarding vulnerable adults. One carer we spoke with reported that training on abuse awareness had been covered well during their induction. The home uses a proforma care plan, such plans stated X does not have capacity to express wishes about their plan of care therefore ensure relatives views are considered. One of the people we met with had had no assessment about capacity and did not appear to have problems relating to this. Care plans need to relate to the individual and assessments relating to capacity should be made by someone trained to perform such assessments. Developments relating to assessment and care planning relating to mental capacity should be included in staff training programmes. Care Homes for Older People Page 25 of 46 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. Residents will benefit from an attractive, homely environment, with equipment to meet their needs, however systems to ensure prevention of spread of infection need to be further developed, to fully prevent risk to people. Evidence: In their AQAA, the home reported on its pleasant and airy feel with rooms which were safe and comfortable. They report on the maintenance programme and the supports to ensuring high standards in the environment, from the provider. The Winterbourne is a three storey building. Currently the second floor is not being used for service provision but much of the ground and first floor are occupied. The floors to the left of the entrance hall are for people with dementia care needs and facilities have been designed with the client group in mind. The floors to the right of the entrance area are for people who need general residential or nursing care. The home is equipped to a high specification, with attractive furnishings and fittings. All people who need nursing care have fully profiling beds. One person described their bed as lovely and comfortable. Another person described the lovely view from the dining room window. However one person did report to us that they did not go to the dining room because the chairs were too high for them to use. We asked staff about hoists and staff commented that they had enough hoists to Care Homes for Older People Page 26 of 46 Evidence: support people. We asked about hoist slings and staff reported that residents had been measured for hoist slings, which had been named for them. However we went into two different rooms for people who needed hoists and observed that the sling left in their room had not been named for the person and appeared to relate to a different room. This has to potential to put people at risk of cross-infection. The maintenance man showed us the record of weekly bedroom and bathroom checks, checks include water and air temperatures. Records showed that if water temperatures were outside limits, the maintenance man adjusted and rechecked immediately. Staff use maintenance books to write any requests for the maintenance mans attention, which they check daily and sign off as jobs accomplished. We advised them to record where they respond to verbal requests, as these are attended to with no record. We observed that staff do not consistently keep a record of water temperatures prior to giving a person a bath or a shower, as is advised by the Health and Safety Executive. When we inspected, there were no cleaners on duty during the morning. We met with a cleaner during the afternoon and they advised that generally there were more cleaners on duty, but that people were off sick. The manager reported that they were actively recruiting new cleaners. The cleaner reported to us that they were aware of the role they needed to perform and would be able to ensure that all relevant areas which needed cleaning would be addressed during their shift. They reported that they had a ready supply of cleaning chemicals and equipment. We did observe that several small areas of the home such as door handles were sticky, with tactile debris, this was probably due to the cleaner not having enough time to attend to such fine details. The home has sluice rooms for disposal of items used in care. We observed that a yellow bag for potentially infected waste had been left full to overflowing in a bathroom, this was also the case for a similar bin in a sluice room. We observed that in some sluice rooms, articles such as disposables were stored on the floor, this is not ideal and we recommend that shelving be provided, so that items can be stored off the floor. None of the sluice rooms were provided with locks, this was of concern on the dementia care units, where several residents had complex behaviours, including wandering behaviours. In order to ensure that residents are protected from the risks presented by sluice rooms, a suitable locking facility needs to be be provided. We observed that a resident had exhibited the potential for an infectious disease, on the morning of the inspection. We noted as good practice that the senior carer had already instituted standard precautions to prevent risk of spread of infection. A carer reported that the home was well provided with equipment and disposables needed in Care Homes for Older People Page 27 of 46 Evidence: care. We met with a resident who was administered a drug via a nebuliser. There was a notice above the nebuliser instructing staff that they must ensure that the reservoir for the nebuliser was left clean and dry after administration. This was observed not to be the case, with fluid visible in the base of the nebuliser. This matter was identified at the previous inspection and a requirement set because of the risks to re-infection presented by using breathing equipment which as not been properly cleaned and dried after use. We visited the laundry. We observed that the washing machine included items which needed different types of washing mixed together. We also observed a red plastic alginate bag for infected laundry left on a surface; the bag was filled to over-flowing, with breaks in the plastic and some of the contents spilling out over the surface. When we looked in laundry bags across the home, we observed that red alginate bags had mixes of different types of laundry in them and while the home had systems for separation of laundry at source, this was not taking place in practice. We discussed this with the laundry person. They reported that they they did not want to separate potentially infected laundry, so had put the whole alginate bag on a cooler sluice wash and would then separate and wash items again at appropriate temperatures, once the sluice wash had finished. They reported that items being mixed together and too many items being placed in alginate bags happened quite often, reporting that they thought it related to agency staff. They reported that at some times, items such as continence pads, wipes and solids were placed in laundry bags and they had to remove them prior to washing, as they damaged washing machines. The laundry persons supervisions showed that they had brought such matters up more than once with their line manager, so action must take place, as such practice is a major risk to cross infection. When we toured the home, we observed that some sheets were clean but showed staining, the same was observed for some linen stored in the laundry. A relative told us that this concerned them too. We discussed this with the laundry person who reported that as they used agency staff in the laundry, some workers did not show the same standards as others. The manager reported that they were currently recruiting more staff to work in the laundry. The laundry contains a large amount of items which were not named. The laundry person reported that the amount increased every day. A similar observation was made at the key inspection of 30th June 2009, and a requirement was set. The receptacles for un-named clothes included net underwear, dark socks and pop socks. Such items tend to look similar, so identifying who they belong to is difficult. We asked the laundry person if staff took such items for residents who needed them and they Care Homes for Older People Page 28 of 46 Evidence: reported that they did; this was especially the case for agency staff. While the home continues to have so many un-named clothes, there is a real risk that underclothes will be used communally by staff, who are in a hurry or staff who are not familiar with the detail of different peoples needs. Communal use of underclothes presents a risk to cross infection as some micro-organisms, particularly fungal organisms, may not always be removed even at high temperature washing. Having so many un-named clothes also means that residents who have dementia and who will not be able to identify their clothes will not have access to their own possessions. Care Homes for Older People Page 29 of 46 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be protected by staff who have been safely recruited and inducted, who are trained in basic areas. Residents would be more supported if the numbers and skill mix of staff were further reviewed and if training in areas specific to the client group were developed. Evidence: In their AQAA, the home reported we endeavour to maintain agreed staffing levels at all times. During the past year, they reported they had audited personnel files and recruited and retained staff. They reported that during the next year they plan to improve their induction process, reduce agency usage and continue to monitor and improve training program for all staff. We received comments from people abut staffing levels in surveys. Seven people reported that staff were usually and one always available when they needed them. Comments in surveys included that the home needed to improve on answering the buzzer but of course, they do have other jobs and people to attend to, another that the home could do with a toilet rota often kept waiting to go, ringing and ringing and another that the home needed to have more permanent staff and less agency staff. One person reported that the layout of the home made it difficult to cope with the companys staffing levels and another that the home needed to employ more staff to relieve pressure on existing staff. Care Homes for Older People Page 30 of 46 Evidence: We discussed staffing levels and made observations of care during the inspection. One person reported that on the dementia care units, where a resident needed two people to perform personal care, there could be times when there was no-one left to supervise people in the communal rooms and that this could present a risk to residents with complex behaviours associated with dementia care needs. A member of staff reported that on the day of the inspection, they had two staff and one floating between units. This meant that the floating member of staff could not always supervise the lounges. On this unit, eight residents needed two carers for hoisting, which greatly reduced their availability to people and made the job task-orientated. A relative informed us that the day before the inspection, there has been two carers for eleven residents during the lunchtime meal. A resident who needed two people had needed the toilet, so the meal had had to wait and some relatives had assisted with putting up the meal for residents so that the meal was not very delayed. A relative advised us of times when a resident had been asked to wait for assistance because there had not been enough staff on duty. A resident reported that staff seemed pushed at times, call bells could take a long time to be answered, however once staff were with them, they never felt rushed by them. This person reported that they liked continuity of regular staff. Other people gave a different response, one person reported they come rushing in if they rang their bell and another that staff came at night when they needed them. As noted in Activities and Daily Lives above, our observations indicated that there were not sufficient staff on duty to ensure that all people received the supports that they needed at lunch-time. We also observed periods of time when residents with dementia care needs were not supported in communal rooms; this was because staff were busy supporting residents elsewhere on the wing. As noted in Heath and Personal Care above, there were a range of issues relating to non-completion of care plans and records. Staff we spoke with understood their responsibilities for and the importance of full and accurate documentation, however our observations indicate that, due to their wish to meet residents individual needs, they may not have the time to complete full documentation on their residents. Several staff commented on recent changes to the shift patters, which they felt had not been fully consulted with them. A member of staff felt that these changes had motivated staff. The new manager reported that they have increased staffing levels since they had come in post, particularly at night. They were also working hard to recruit permanent staff, to avoid the use of agency workers. The homes data-set showed that they continued to use high levels of agency staff, across all staff groupings. As much as possible, the manager reported that they booked the same Care Homes for Older People Page 31 of 46 Evidence: agency workers. This was echoed by an agency registered nurse who reported to us that they worked in the home on a semi-permanent basis. We looked at the employment files for three recently employed members of staff across all staff types. We observed that all staff had a proof of identity, a full employment history, two references, evidence that they were suitable to work with vulnerable people, criminal records checks and completed a heath status check, prior to employment. All staff were interviewed using an interview assessment tool. We would advise that this would be more useful document if the section on a prospective member of staffs strengths and weaknesses were expanded further. All staff are given a contract and job description, which both parties sign. One person was employed from abroad and while their references had been translated into English, it was not clear if they were to whom it may concern references; such references are not acceptable. The operations director reported that this had been identified as an issue by their head office and that the company were taking steps to ensure that there was evidence that all references were directly sourced. Where a prospective member of staffs first language was not English, there was evidence that their English language written skills were assessed, but not their verbal skills and this should take place, as verbal and written skills can vary. The home has an induction pack, which is based on current core standards. During the inspection, we met with the assistant manager who had very recently been given the role of supervising new staff through inductions. This person was able to describe their plan for development of this induction and that they would guide new staff personally through induction, as they felt it had been too rushed before. We met with a newly employed registered nurse who reported on their in-depth induction. Agency staff are also given an induction document, which they sign. However one agency member of staff we met with reported that they had had no meaningful induction relating to residents needs, particularly residents individual resuscitation status. The assistant manager has now been made responsible for ensuring that staff training and supervision takes place. This person saw it as a priority to develop a training plan. There was evidence of staff completion of mandatory courses, which were mainly based on e-learning. Whilst we were there, the assistant manager was sending out individual letters to staff that they had identified from records as due for various refreshers. They reported that they had discussed the need for further dementia training with the regional training officer. A member of staff we met with reported that they would like a lot more training opportunities, especially in relation to dementia and felt that other training inputs should take special account of people with dementia. Another carer reported that the dementia training arranged via Wiltshire Council had Care Homes for Older People Page 32 of 46 Evidence: been very useful; they also reported on recent training in care planning. A registered nurse reported that a speech and language therapist was coming to a staff meeting to teach staff about dysarthria and the use of cards for people with such a disability. Now that the home has a person leading on training, there is a need for a training plan to be developed relating to the client group cared for by the home, this should include as well as dementia, disease conditions which will be relevant to the home, such as diabetes, prevention of pressure ulceration, Parkinsons disease and stroke, as there were people with such conditions resident in the home. Care Homes for Older People Page 33 of 46 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. Residents will be supported by a manager who is aware of issues which need to be addressed. The provider has not ensured that they fully comply with requirements from us, to ensure the health safety and welfare of people. Evidence: In their AQAA, the home reported on their management systems, these included meetings such as health and safety and staff meetings, and feedback from residents and their relatives. They also reported on the management supports from the provider, including regular reviews of quality of service provision. They report that during the next year, they plan to undertake more internal audit and more comprehensive action plans and develop active risk assessment, reviewing the risks in the home. The Winterbourne has had four different managers since it was opened a year ago. The current manager came into post during the end of 2009. Changes of manager generally affect a home and its service provision. People were complimentary about Care Homes for Older People Page 34 of 46 Evidence: the new manager. One person reported that the new manager was going to be brilliant and another that the problems in the home were not [the new managers] fault. One person did feel that senior managers from the provider were keeping the new manager too busy, reporting that its the first time Ive seen [the new manager] around the home for weeks. People we spoke with were less complimentary about the provider, feeling that the work they were putting into service provision was not appreciated and that they were not being listened to, citing as an example what they considered was a lack of consultation about the new rosters. A senior manager from the company visits the home at least monthly and writes a report. The visit for January 2010 stated care plans are currently up to date and a schedule for reviews is in place. This inspection indicates that this was not an accurate statement. The homes AQAA also indicated that areas had been addressed but this inspection showed that they had not, and that a range of requirements remained un-met from previous inspections. It is appreciated that the new manager had only recently come in post, but it is of surprise that the provider did not submit an action plan on progress towards meeting requirements, following the random inspection of 9th October 2009, considering that some matters identified had implications for residents health, safety and welfare. Providers are expected to meet our requirements within timescales and on this occasion only we will not be taking action to ensure they are addressed, as the new manager has only recently come into post, however the provider needs to be aware that if they continue not to meet our requirements, action will be taken by us to ensure the health, safety and welfare of residents in the home. The provider performs annual resident satisfaction surveys, these with be completed a year after the home opened. The new manager has performed her own internal surveys to identify areas for action. She reports she has also among other areas, completed infection control audits, a health and safety audit, a mystery shopper audit of response times to call bells and unannounced visits to the home at night to review service provision. The assistant manager showed good evidence of supervision records. They were well organised, covered appropriate areas and demonstrated staff were encouraged to be reflective on their practice, including on outcomes where they were key workers. A carer reported that supervisions were very good now and another that supervisions with the assistant manager were very valuable. There was a matrix to ensure all supervisions were planned on time, to provide for two monthly supervision, plus annual appraisal. The assistant manager is currently undertaking a supervisory management course. As the home increases occupancy, the assistant managers plan Care Homes for Older People Page 35 of 46 Evidence: is for supervision to be delegated to senior care staff, whom they will supervise directly. The home manages moneys on behalf of some residents, using a system of envelopes for residents; they will also allow for cheques to be paid in. The activities person was reported to have their own system for recording in relation to their parts of management of residents individual moneys. They were reported to hold paper receipts relating to these transactions, however these were not available for inspection, as the person was off sick. This is not satisfactory and a full audit trail of all moneys received into and paid out from individual residents accounts needs to be available, to provide evidence of effective management of residents moneys by the home. During the inspection, we discussed modernisation of residents individual finances and the development of a cash-less system, which the new manager was keen to introduce. As noted in Choice of Home and Health and Personal Care above, not all records relating to provision of nursing and care had been dated and signed. All such records need dated and signed, to ensure that managers can identify who drew up the records and when, so that review can take place. The Winterbourne is a new purpose-build home. Many items remain under guarantee. The maintenance man reported that all snagging relating to the new build had been addressed. As noted in staffing above, the home ensured that staff are trained in matters relating to health and safety. However, as noted in Environment above, there is a need for development of services relating to the management of infected and potentially infected items, this needs to include training for all staff, including the maintenance man and laundry staff. We are aware that the home was visited by the fire safety officer on 2nd February 2010, who required a range of improvements to ensure fire safety. In their AQAA, the home reported that during they next year, they planned to review the fire risk assessment to make it more comprehensive, however they did not refer any further to the fire brigades requirements. In order to ensure that the home have taken adequate steps to ensure the safety of people in the home in the event of a fire, we require that they inform us of their current progress in meeting the fire brigades requirements. Care Homes for Older People Page 36 of 46 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 8 23 If a person is assessed as 30/11/2009 being at high risk of pressure ulceration, pressure relieving equipment which is consistent with this assessed degree of risk must be provided when the person is sitting out of bed. This requrement was identified at the random inspection of 9th October 2009. It has not been met within timescales. Risks of pressure ulceration do not reduce when a person is sitting out of bed. 2 26 13 The home must ensure safe 31/07/2009 practice in the laundry, including the correct handling of items for laundering, the availability of disposable gloves, aprons and rubbish bins and the marking of residents own items. Parts of this requirement is un-met from the inspection of 30th June 2009. Disposable gloves, aprons and a rubbish bin is now available. The rest of the requirement has not been addressed. Care Homes for Older People Page 37 of 46 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 If there are not safe systems in the laundry, there will be a risk of cross infection. 3 26 13 Nebuliser reservoirs must always be left clean and dry after administration is completed. This requirement is un-met from the random inspection of 9th October 2009. If a nebuliser reservoir is not clean clean and dry, there is a risk that micro-organisms will grow in the reservoir and the resident be at risk of reinfection when they use the nebuliser. 30/10/2009 Care Homes for Older People Page 38 of 46 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 3 14 All of a prospective residents needs and risks must be assessed in full before or immediately after admission. This is to ensure that the home can demonstrate it can meet individual residents needs. 31/05/2010 2 7 12 Where a resident has a risk 31/05/2010 or a need, a full and comprehensive care plan must always be put in place. care plans must be regularly evaluated and there must be full written evidence that they are being followed. Care plans direct staff on how an individuals needs are to be met, therefore care plans must be completed in full, be up-todate and there must be evidence that they are being followed. Care Homes for Older People Page 39 of 46 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 3 7 13 Where a person is assessed 30/04/2010 as being at high risk of pressure ulceration and is not able to change their position independantly, a record of their changes of position must always be put in place. The record must show that the person has had their position changed regularly, in accordance with research-based evidence. If a person develops pressure ulceration, such ulcers take and extended period to heal, are very painful and can be a source of infection. Therefore the emphasis must always be on prevention. 4 8 13 Where a person has a urinary catheter, there must always be clear evidence to show that the persons urinary catheter has been changed in accordance with manufacturers inspections. This is to prevent risk of infection to the person. 30/04/2010 5 9 13 All medicines must be recorded when they are given, by the signature of the member of staff who administered them, this 30/04/2010 Care Homes for Older People Page 40 of 46 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 includes creams and other external preparations. This will ensure that an accountable record is maintained of all medicines administered in the home. 6 15 12 The home must fully review all aspects of mealtimes for residents, to ensure that residents are given nutritious meals, in a timely manner and are supported by sufficient numbers of staff. Mealtimes are a key area for residents, they support social engagement and ensure adequate nutritional in-puts. 7 26 13 The home must ensure that all staff follow its policies and procedures on the use of hoist slings and ensure that they are used only for the person they are named for. Communal use of slings can present a risk of crossinfection and use of hoist slings which have not been measured for the person can put them at risk. 30/04/2010 31/05/2010 Care Homes for Older People Page 41 of 46 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 8 26 13 Suitable securing systems must be put in place on sluice room doors in dementia care units. This is to prevent risk to residents with dementia care needs. 30/04/2010 9 26 13 All people must conform to the principals of prevention of spread of infection when handing potentially infected items. This is to prevent risk of spread of infection. 30/04/2010 10 27 18 The provider must further 31/05/2010 review staffing levels, to ensure among other areas, that sufficient staff are on duty to support residents at all times, particularly at mealtimes, to ensure that residents with dementia care needs are not left unsupervised in lounges and that staff have time to fully complete documentation required in nursing and care. This is to ensure that residents have their needs met. 11 30 18 A staff training plan must be 31/05/2010 developed, to ensure that all staff are trained in areas relating to the nursing and Care Homes for Older People Page 42 of 46 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 care needs of residents in the home. This is to ensure that staff can meet residents diverse needs. 12 33 24 The provider must ensure 31/05/2010 that it accurately updates us on progress towards meeting our requirements. This is to ensure the health, safety and welfare of people. 13 37 17 All documentation relating to 30/04/2010 nursing and care must be signed and dated by the person who drew up the document. This is to identify who drew up the document and when, which will to facilitate review. 14 38 13 All relevant staff must be trained in procedures for ensuring good practice to up-hold the princials of infection control. This is to prevent risk of infection to people. 15 38 23 The provider must inform us 31/05/2010 of their action plans and progress towards meeting the requirements of the fire brigade. 30/06/2010 Care Homes for Older People Page 43 of 46 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure fire safety for people in the home. 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 3 Where a person is known not have a next of kin, assessments of how they are to be supported should be included in their pre-admission assessment. The home should always follow NICE guideleines relating to assessments for risk of pressure ulceration for residents after admission. The home should further review and develop its systems for handover and report to improve communication about individual residents conditions and needs. The home should introdice a fell key worker system for residents. Care plans should use clear and measurable terms. Nonindividual standard care plans should be avoided as much as possible. A similar recommendation was identified at the key inspection of 30th June 2009 and random inspection of 9th October 2009. 2 3 3 7 4 5 7 7 6 7 All fluid charts should always be totalled every 24 hours and the information gained used in care planning evaluation. This recommendation was identified at the key inspection of 30th June 2009 and random inspection of 9th October 2009. 7 9 Procedures should be put in place so that the person performing the medicines adminstration round does not also have to answer the phone for the home. Any additional information kept with the medication Page 44 of 46 8 9 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 administration records should be current and out of date information removed. 9 9 A procedure should be drawn up and followed for handling medicines and related information when people spend time away from the care home. All breakfast cereals should be stored in sealed containers, to keep them fresh. The menu on display should always relate to the meal being served and systems should be put in place to inform people of any changes in the menu. All staff should be reminded of their individual responsibilities for documenting and informing relevant people of complaints and concerns made by residents and their supporters. Staff should be trained in the Mental Capacity Act and their role in documentation about individual residents needs relating to this. Where maintenance requests are made verbally, documentation relating to the request should also be made, to provide a full audit trail. Shelving for items used in nursing and care should be provided in sluice rooms, to prevent items being stored on the floor. Staff should always document water temperatures before they bathe or shower a person. All topical creams and lotions should be named and dated on opening. This recommendation has not been actioned in full from the key inspection of 30th June 2009. 18 29 Prospective members of staff whose first language is not English should have their English verbal skills assessed, as well as their written English language skills. The provider should retain evidence of all receipts relating to residents individual finances. 10 11 15 15 12 16 13 18 14 19 15 19 16 17 19 26 19 35 Care Homes for Older People Page 45 of 46 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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