Inspection on 08/02/10 for Abbeydale Residential Home

This inspection was carried out on 8th February 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeydale Residential Home 05/11/09

Abbeydale Residential Home 04/11/08

Abbeydale Residential Home 13/11/07

Abbeydale Residential Home 05/12/06

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 25/04/2010.

Key inspection report Care homes for older people Name: Address: Abbeydale Residential Home 281 Gloucester Road Cheltenham Glos GL51 7AD     The quality rating for this care home is:   zero star poor 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: Janice Patrick1     Date: 0 9 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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: Abbeydale Residential Home 281 Gloucester Road Cheltenham Glos GL51 7AD 01242525107 01242522671 abbeydalerh@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Charlton Care Ltd care home 13 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of sevice users who can be accommodated is 13. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - (Code OP) Date of last inspection Brief description of the care home Abbeydale is an adapted older property situated in the residential area of St Marks, within easy reach of local shops and the railway station. The Home is also on a bus route to Cheltenham town centre. Charlton Care Ltd purchased the home in 2006. Single accommodation for thirteen older people, who require personal care, is provided on two floors. All the bedrooms are in good decorative order and are furnished. Each room has en-suite facilities. On the ground floor there is a lounge and conservatory which acts as space for the dining room. The well maintained garden has easy access for people who are mobile and for those who use a wheelchair. A passenger lift allows access to the first floor for people who cannot use the stairs. Care Homes for Older People Page 4 of 46 Over 65 13 0 0 9 1 1 2 0 0 9 Brief description of the care home There is some off road parking at the front of the property. A copy of the most recent inspection report is contained in an information folder located in the main hall of the home. Current fees range from 500 pounds to 750 pounds. Prices for hairdressing, chiropody and any personal items are available on request. 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out in response to concerns reported to the Care Quality Commission. These concerns were predominantly about the processes in place for the safe administration of medicines and relevant record keeping. Before a visit to the care home we (the Care Quality Commission) considered the findings from the previous inspection, carried out in November 2009, any requirements made of the home at that time and the homes response to these. We also considered any additional information we had gathered since November 2009, which included any notifications received from the home relating to incidents and accidents that may have taken place within the home. These notifications are a legal requirement under the Care Home Regulations 2001. An unannounced visit was then carried out by the Regulatory Inspector for the home and a Pharmacist Inspector. The site visit was over two days between the hours of 10.35am and 7pm on the first day and 12 midday and 5.15pm on the second day. Care Homes for Older People Page 6 of 46 During the inspection, which included speaking to staff and several service users, photocopies of certain records were taken with the Registered Managers consent. During this inspection an Immediate Requirement (a requirement given when shortfalls require urgent/immediate action to protect the health and welfare of the service users) was issued in relation to the identified shortfalls in medication practices and recording. The Pharmacist Inspector then carried out a further visit on 25/02/2010 to check for compliance. 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 must only admit people it is registered to provide care for and for which the staffs skills can meet. The system for care planning is not currently providing the home with what it requires and the staff with accurate guidance. This must be addressed by improving the attention given to individualising each care plan, by providing staff with care plan training if this is felt to be necessary and by ensuring that care documentation is correctly reviewed and effectively audited. The home must be able to demonstrate that it robustly monitors peoples health needs. In particular, those that relate to peoples nutritional intake and subsequent weight loss and potential risks associated with the development of pressure sores. This will help ensure that people do not deteriorate through a lack of basic monitoring. Managers must ensure that the requirements and recommendations given as a result of this inspection, in relation to the safe administration of medicines are fully complied with in order to protect people from unnecessary harm. The home must identify everyones recreational and social needs and where possible meet their preferences. Arrangements must be made to support and train staff to meet the recreational and social needs of those with a cognitive impairment. Ensure that service users emotional and psychological needs are properly identified and that staff are given clear guidance, support and training to meet these Care Homes for Older People Page 8 of 46 appropriately. Arrangements must be made to demonstrate that any challenging behaviour is being managed in a manner that protects the service user/s from harm and in a way that does not compromise their basic rights. Provide a true choice of food at lunchtime. Ensure that staff understand and adhere to local safeguarding protocols in order for people to be protected from abuse. Take advice on what training is required to improve the current knowledge base of the staff and provide what is required. Ensure that staff who are given the responsibility of managing other staff, training other staff and supervising other staff have the required knowledge and skill to do this effectively. Review the current quality assurance system and ensure that all audits and reviews of care provision are benefiting the people who live in the home. Ensure that all required record keeping is up to date in order for the home to be able to demonstrate compliance with the Care Home Regulations at all times. Make arrangements for the correct and appropriate notification of incidents and accidents that occur within the home. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. By not adhering to its category of registration at the point of someones admission, people are being put at risk of not having their needs fully met and of their placement breaking down and potentially needing to experience a further move. Evidence: The homes Annual Quality Assurance Assessment, AQAA tells us that some improvements have been made to the overall admission process. This was confirmed as having taken place in the previous inspection in November 2009. The AQAA tells us that issues relating to Equality and Diversity are now explored more thoroughly during the pre admission process. We read pre admission assessments relating to three admissions during this inspection. The assessment uses a simplistic scoring system to indicate the persons degree of need but we were told that this is then used in conjunction with information and assessments received from other sources such as the funding authority or other Care Homes for Older People Page 11 of 46 Evidence: health care professionals. We read one comprehensive assessment completed by an external health care professional and provided for the homes information as part of the pre admission process that clearly stated that the person had needs that the home was not registered to meet. This also seemed to be the case for another person who was admitted in 2009. When we asked the manager why the admission had gone ahead his reply was that local health care professionals think the home do a good job with some types of people. When we pointed out that he has a responsibility to admit people for which the home is registered for there seemed to be little regard for the fact that this had not happened. We were told that each relative is told that the home is not registered to meet these needs (in these cases dementia needs) but that the home was happy to see if it works out. This is a total disregard for the Care Home Regulations and puts people at risk of not having their needs adequately identified and met. We did see examples of people having been admitted correctly and we spoke to one such person who said that it had been a huge decision, but a right one and that so far, they are very happy with their care. This highlights that for most people moving into a care home it is a huge decision. For those in particular who do not have total command over the decisions being made it is important that the professional making the placement and the care home act responsibly. Staff training records show that some training in dementia care has been given, we were informed that this was a half day session with a trainer. This report goes on to evidence shortfalls in staff skills and in the care planning for people with these needs. Care Homes for Older People Page 12 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Through a lack of robust care planning and monitoring peoples needs are not being fully met at all times putting them at risk. The arrangements for managing medicines had particular weaknesses that need attention so that people living in the home are not put at unnecessary risks to their health and wellbeing and so that there is full accountability for medicines the home handles on behalf of people who live here. Evidence: Following the pre admission and admission process the service is required to devise plans of care that clearly identify the service users needs and give guidance to staff on how these are to be met. A requirement was made during the November 2009 inspection for care plans to be devised, without delay, following someones admission. This was made as there had been an unacceptable length of time before care plans were being devised following admission. and therefore staff were not being provided with clear guidance. On checking compliance with this requirement we were shown care plans relating to Care Homes for Older People Page 13 of 46 Evidence: someone who had been admitted approximately two weeks prior to this inspection. The care plans were brief and we commented on the contents of the care plan for sleeping which stated ensure .... is settled at night and check constantly. We asked, how is the person to be settled, what has the home found out about what helps the person to settle and what does not work and what does constantly mean where there is one waking night carer on duty. The manager explained that this care plan had only been written because the previous Inspector had required it, he considered it to be a waste of time. The manager explained that he felt the home got far more guidance from the care plan provided by the admitting health care professional or the funding authority. This demonstrates to us that the manager has a fundamental shortfall in his understanding of why the home should formulate its own care plans and of an effective evaluation process. Some care files demonstrate that the care planning process has been shared with the service user and or a representative. This allows for individuals to express their personal preferences and wishes. The manager did explain that some service users and relatives prefer not to be involved in the care planning or the review process. A comprehensive care plan gives staff a formal point of reference on how someones needs are to be met. They should also include the persons own wishes, as explained above but they must provide staff with specific instructions/guidance on areas of care that carry potential or actual risks. These risks may relate to an inability to maintain weight, development of pressure sores, risk of falls, pain and its control, the appropriate use of some medicines, safe management of challenging behaviour and subsequent support for the person demonstrating this and risks associated with the use of some equipment. Clear guidance for staff helps to protect people from unsafe or poor practices. The system chosen by the service to formulate care plans is computerised. It relies on information being put in through a series of electronic options. It then calculates a level of risk and produces a list of actions/guidance for staff to follow. However, the content of the care plan produced is an electronic response to what information and options were initially fed in. A member of staff is then required to individualise the care plan and make it relevant to the service users current needs. We were told that this happens but in several care plans we read the content was often made up of generalised statements, which in places contradicted themselves because of the original options fed in. This has resulted in many care plans being confusing and in the case of one service users supposed use of bed rails, bore no relation to what equipment was actually in use. It did however leave the home with a care plan that Care Homes for Older People Page 14 of 46 Evidence: identified specific risks for this person, which looked as if they had not been addressed. This becomes very concerning when the guidance is confusing and relates to medication, pressure relief and nutritional monitoring, as was the case in several care plans we read. Even when the care plan had given a specific instruction, such as in the monitoring of peoples weights or the monitoring of pressure sore development, there was often no evidence to show that this had been carried out. When talking to staff responsible for the care planning it was apparent that they did not always know what was required and lacked care planning skills. This was particularly evident in the general lack of care plan auditing and the recorded review process. For one person that had presented with serious challenging behaviour which potentially put themselves at risk and others in the home there was no care plan associated to this, therefore no guidance for staff on how to best manage these risks. Where people obviously required some degree of psychological and emotional support the guidance was generalised and did not give staff any guidance on how to support the actual individual concerned. We witnessed one person become agitated and upset, there was a clear element of confusion in what was being expressed. The staff member that responded to this did so in a dismissive and unsupportive way by telling us, in front of the person, that this behaviour was being demonstrated because there was an audience, us. This same person had an accident form completed for an incident that was described in the records as being attention seeking. On inspection of the persons care plans the care plan for emotional needs informed us that there were none. There was no clear guidance for staff on how to manage the needs of this person in a supportive and therapeutic manner. What we saw during the inspection was a demonstration of poor and unkind practice. Daily electronic records, completed by staff told us that external health care professionals visit the service. One persons electronic record recorded a weight loss of 9 kilograms in 21 days in August 2009. The record had also recorded a visit by the doctor just prior to the weight loss being identified because the person had appeared weak and tired. The records did not go on to tell us what was specifically done to address this weight loss and the care plan was only amended, addressing the nutritional risk, a month later. Records later indicate that this person gained weight but the current care plan says that ongoing monitoring is required. We were therefore wanting to find evidence that this was being carried out but the last recorded weight Care Homes for Older People Page 15 of 46 Evidence: that we could find in the care file was in October 2009. A similar shortfall in monitoring was also seen in one other persons care file where according to the weight record the person lost 5 kilograms between August and September last year. Again, the care plan gives instructions for ongoing monitoring to take place but the weight record stops at the time of the weight loss, September 2009. This puts people at risk of deteriorating through a lack of adequate monitoring. Another person has been taking strong pain relief for some considerable time, this has been referenced in the Pharmacist Inspectors report, however there was no reference to pain or the monitoring of pain in the persons care plan. When we asked the deputy manager why the person was taking this medicine we were told it was for a condition that had not been recorded in the care file at all. Pharmacist inspectors report about arrangements for the handling of medicines found on 8th and 25th February 2010. As a part of this key inspection one of our (the Care Quality Commission) pharmacist inspectors specifically examined some of the arrangements for the handling of medicines. We looked at some stocks and storage arrangements for medicines and various records about medicines. We spoke to the manager, deputy manager and three members of staff on duty one of whom administered medicines. The first day of the medicine inspection took place over an eight and a half hour period on a Monday. The inspection found there were slack practices with some of the arrangements for managing and administering medicines. We left an immediate requirement form with the manager to take action to attend to these particular matters by 9am on 11th February 2010. A safe system of witnessed administration for controlled drugs was not followed and some signatures in the controlled drug record book have been written by other staff. This happened when one particular member of staff had signed as responsible for the administration. Staff who were in the record book as having witnessed this had not always actually seen the person receive and take the tablet. Some of the staff whose names were in the controlled drug record book as a witness were not properly trained in the safe handling of medicines so it is questionable if they understood what they were witnessing. The use of a witness is an important role and we provide more information about this on our website (www.cqc.org.uk). In summary it is intended to reduce the possibility of an error occurring. To be effective, the witness must understand what the authorised carer administering the medicine is doing and Care Homes for Older People Page 16 of 46 Evidence: therefore needs the same level of training. Accepted safe practices were not always carried out in the home. There was some doubt on occasions if the name of the person who appeared as witness was aware of this or actually on duty at the time. There were changes to entries in the controlled drug record book on a number of pages. This is not acceptable practice. One medicine recorded in the controlled drug record book could not be accounted for. This solution was not in the cupboard used to store controlled drugs and staff could not provide an explanation for this. The recorded stock balance of another controlled drug agreed with the stock we counted. Controlled drugs were not correctly stored in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973 as amended. Our findings on 8th February 2010 about the rest of the medicine arrangements were as follows. We looked at some of the arrangements for recording medicines. Accurate, clear and complete records about medicines are very important in a care home so that people are not at risk from mistakes with their medicines because of poor records and so that there is a full account of the medicines the home is responsible for on behalf of the people living here. We found many weaknesses and concerns with these records that demonstrated that these were not always accurate clear and complete. This was a risk to the health and wellbeing of people living in this home. The pharmacy provided printed medicine charts each month on which to keep records of the medicines prescribed and administered. The space to record allergies on the medicine charts was blank. It is good practice to make an entry in this special section even if this is none known as an indication that this important issue has been considered. Allergy information was included on a cover sheet for each person with their medicine chart. One such sheet indicated a person had a penicillin allergy but the space on the medicine chart to record this was still blank. It is very important for the pharmacy to be made aware of allergy information and to print this on the medicine chart as one action to reduce the risk of providing a medicine to which the person is allergic. A number of medicine record charts included medicines (including creams and ointments applied to the skin) that were not signed as having been administered since 12th January 2010 so we were concerned that people were not receiving the medicines they needed. We asked the deputy manager and the carer responsible for medicines on the first day of the inspection about this. They explained that these Care Homes for Older People Page 17 of 46 Evidence: medicines were not being used now. The medicine records were not up to date or accurate so could put people in the home at risk. For another person, a medicine prescribed to give twice daily, was only signed as given once each day since 12th January 2010. One member of staff told us that she was told only to give this once a day. We asked the deputy manager about this and she told us that the person refused the medicine at other times. If that was the case then the records need to indicate this and action taken to obtain advice from the doctor. We were concerned as one person living in the home needed two different eye drop treatments. Staff were not aware of the need to leave a suitable interval between instilling the two different types of drops in the morning. A member of staff who had only been working in the home for a short period and who had no formal safe handling of medicines training was assisting with this treatment. We were told that this staff member had been shown what to do. We publish information about training staff to safely handle medicines on our website (www.cqc.org.uk). Staff handwrote some medicine charts when people were first admitted or for one person who had a weekly medicine pack. We saw there were two initials on the charts but we found mistakes. In some cases there were no starting dates for the charts and just numbers recorded in the column headings. This was insufficient to clearly show what day, month and year the medicine was given so would be useless once the records were filed. Some records were incomplete and inaccurate. Important information such as the name of a tablet, the strength of two inhalers, the full name of some tablets, the wrong dose units, a different dose to that on the medicine label and missing additional directions for administration were examples of what we found. For one of these people who was prescribed a tablet to take weekly with very specific directions on the label to take at least 30 minutes before first food, drink or medication of the day, to swallow a whole glass of water remaining sitting or standing for at least 30 minutes after taking. This information was not transferred to the medicine chart and the dose was indicated at tea time on a Thursday. A carer confirmed this tablet was given at teatime when this person had their tea. The specific directions were being ignored. We found one person had been given two doses of a sleeping tablet from a new supply recently received from the pharmacy for this person. This was not included on the medicine chart that was in use and no record of the administration had been made yet two tablets were missing. A carer confirmed they had given these but had not written the medicine or the doses given on the medicine chart. Care Homes for Older People Page 18 of 46 Evidence: A check of the records for an antibiotic course for one person showed that only 26 capsules out of a prescribed 28 had been administered with no further explanation seen on the medicine records. Staff we spoke to were not able to provide any explanation for this. A controlled drug given at 8am on the morning of the inspection had no witness signature in the record book. The deputy manager confirmed she had witnessed this dose given and so then signed the record book. At 11.15am our lead inspector found one tablet in a medicine pot by the side of one person who was asleep yet all medicines for this person were signed as having been given on the morning of the inspection. Staff told us that they support four people with their medicines by leaving some of their medicines by their bed or handing it to them to take later and that there were risk assessments in place for this. One we looked at was wrong as the standard text in the care plan would read that the person was self administering their medicines and completely independent. The registered manager agreed that nobody was totally independently self administering their medicines and relied on staff to a large extent. Another consideration must be whether it is safe for everyone in the home for medicines to be left in bedrooms. There were people in the home suffering with dementia so this may be a risk to them. Without witnessing that the medicine has been taken staff cannot know that the medicine has been correctly taken just because it has gone from the pot by the bed. The medicine records need to accurately record what has happened. There were no complete records of medicines applied to the skin. In some cases these were included on the medicine charts but not always signed as used so we do not know if the treatment was not applied or staff had forgotten to make a proper record. Some directions on the medicine charts were not sufficient to give staff the full information of the treatment needed (for example, where and when to apply and how much). There was an example in the daily notes of an entry creams applied but this is not a sufficient record as for example it does not say what treatment, where applied, how much and the frequency. The registered manager told us on the second visit that he has obtained guidance from the PCT pharmacy team about improving these records but this has yet to be put in place. We have published information about this on our website (www.cqc.org.uk Pharmacy tip 9 - Administration and recording of creams and nutritional supplements). Two people living in the home were prescribed a sedative medicine for agitation to use when required. The printed directions for one person were half a tablet as required up Care Homes for Older People Page 19 of 46 Evidence: to twice a day. Since 12th January 2010 this was signed as given twice every day. The care plan stated a once daily dose but there was no written guidance for staff about how to make a decision about when a dose was needed or if the person was able to say when they needed the medicine. So that there is some consistency and agreed actions this type of record is needed. The provisions of the Mental Capacity Act 2005 must be taken into account particularly where people may lack capacity to understand or consent to their medicines. A similar situation applied for another person where the directions on the medicine chart were for one tablet up to three times daily only if needed for agitation. This was signed as being given regularly twice a day since 12th January 2010. Records were not properly kept of what medicines were received into the home on behalf of the people living there. A tick is insufficient to account for what medicines have been received and when. Staff had not completed the spaces provided on the medicine charts for this information and were not aware that there was a section on the chart for this. Locked storage areas were provided specifically for medicines. When we first arrived the keys to this had been left in the kitchen but after this we saw that keys were kept safely. A bottle of eye drops that should be stored in the fridge were not there and a carer thought these were still in the bag as delivered from the pharmacy in the main medicines cupboard. This could affect the potency of the drops. Staff we spoke to did not seem to be aware of the need to routinely replace eye drops after 28 days in use in order to reduce risks from contamination. There were arrangements in place to correctly dispose of medicines that people living in the home no longer needed, via the pharmacy. We saw a record of staff signatures and initials but the deputy manager told us that only four staff members on this list were trained and authorised to administer medicines. Some people on this record had left and one person who had signed on a number of occasions as a witness in the controlled drug record book was not included on this list. There were two different signatures for this person in the controlled drug record book so it was not possible to check which one was a genuine entry or who had written the others. The deputy manager told us she had done college based safe handling of medicines training but about six years ago. A carer we spoke to said she had undertaken a formal medicines training module and also had training within the home. Another member of staff had been involved with administering medicines but had no formal safe handling of medicines training and had just been shown what to do in the home. Care Homes for Older People Page 20 of 46 Evidence: This person was no longer administering medicines. The evidence from this inspection indicates that best practices are not always followed or understood. Staff may not have sufficient training or understanding about the safe handling of medicines. Training provided within the home may not be demonstrating accepted best practice. During the inspection the manager gave us a copy of the medicines policy which he said was kept in the policy file for staff and that staff sign to confirm they have read this. This was signed as reviewed in March 2009. Staff were not always following this policy. We had to point out to the registered manager that some information was wrong and included unsafe practice such as possibly transferring a medicine to a container other than that supplied by the pharmacy. Whilst we found no evidence of this during our inspection it is a concern that the policy even considered and still included this. Staff need to be provided with clear, safe and up to date procedures as to how the company expects them to manage medicines. At the inspection we reminded the registered manager that we publish guidance on our website (www.cqc.org.uk ) and accepted good practice guidance is in The Handling of Medicines in Social Care , Published October 2007 by the Royal Pharmaceutical Society of Great Britain, (www.rpsgb.org). We would expect the registered manager and responsible individual to already have made themselves aware of this guidance and used these to inform good practice within this home. The registered manager told us he conducts a weekly audit and the deputy manager a daily audit of medicines. This audit consists of checking the medicine administration charts. Our inspection indicates this is not an effective and sufficiently robust process to protect people who live in this home from risks with medicines. The responsible individual also must report on monthly visits to the home under Regulation 26 to monitor the standard of care provided in the home. The issues found with medicines had also not been picked up at these visits so more robust checks of medicine arrangements are needed. It is the responsibility of the registered manager and responsible individual to manage the home and make sure there are safe and effective arrangements in place for handling medicines. One concern as a result of this inspection was that staff in the home did not always seem aware of the issues we highlighted about medicines and that these would not have been picked up but for this inspection. On 11th February 2010 the responsible individual wrote to us with information telling us about the actions taken and arrangements put in place to address some of the immediate requirements we left following the medicines inspection on 8th February 2010. The response did not address all the issues we were concerned about and included in the immediate requirements. Care Homes for Older People Page 21 of 46 Evidence: On 25th February 2010 our pharmacist returned to specifically look at the actions taken and to check that effective arrangements were in place for controlled drugs. The pharmacist spoke to the registered manager and responsible individual about this, looked at various records and made further checks for controlled drugs. The responsible individual has undertaken a full investigation of the issues we identified and has provided us with information about his findings and actions taken to deal with this. A new medicine policy was on file but the registered manager and responsible individual are both aware that more work is needed to make these relevant to the home and they told us this was actively being worked on. The registered manager told us that accepted safe practices when administering controlled drugs were in place and that there was a now proper witness system used. Evidence from recent records supported this. We were told that more supervision and training for staff involved with medicines was planned. We saw evidence that a new controlled drugs cupboard had been ordered so must now be fitted correctly in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973 (as amended) when it is delivered. We will be checking on these points at a future inspection. Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Opportunities are provided for people to make choices but not everyones social and recreational needs are being met fully. Evidence: During our visit we saw people making simple daily choices. Some people were choosing to sit in the lounge and others said they prefer to spend time in their bedroom. One person told us they prefer to stay in their bedroom quietly and surrounded by their personal effects. Another person initially told us they never came out of their bedroom but were later seen downstairs in the lounge and joining in the Tuesday afternoon entertainment. We saw one person being able to go outside to smoke when they wanted to. We asked the manager what activities are made available and how the service aims to meet peoples expectations and preferences. We were told that the homes routine is flexible; people can get up, go to bed and have visitors when they wish. We were shown photographs of activities that had taken place and on our second day we witnessed a session provided by an external entertainer who visits the home every Tuesday and Thursday. This resulted in a really positive reaction from people who took part. Care Homes for Older People Page 23 of 46 Evidence: Apart from this we noticed that although we could always find staff, two members of staff were usually found standing in the hall just outside of the lounge, whilst service users sat in the lounge. This seemed to be the situation on our first day each time we visited the lounge. Some service users were sleeping others had their eyes shut but opened them when we walked by. One service user commented theres not a lot happening. The television was on in the second half of the lounge, but there was no one there. The manager explained that usually on a Monday afternoon there is a trip out, visiting places within the Cotswolds but this had been postponed due to the weather. On the second day we sat next to a person who, on our first day, we had noticed to be one of the people sitting with her eyes shut. When we initiated conversation this person was clearly confused but was able to express fears and worries and indicate that the time spent with her had been welcomed. We continued to observe this person unobtrusively for the next hour and a half where she returned to closing her eyes quite often but there was no interaction from staff. We asked the manager specifically what kind of activities and approaches were used within the home with people who had poor cognitive abilities and poor concentration. He said there was very little really because it is difficult with this type of person, but that the home had recognised that more needed to take place. We are aware that an Expert by Experience (a person who because of their shared experience in/or ways of communicating, visits a service with an Inspector to help them get a picture of what it is like to live in the service) accompanied the Inspector in November 2009 and had spoken to service users about activities in the home. It was noted then that there was a set activity progarmme during the week days; trip out on Mondays, Music Man on Tuesday afternoon, hairdresser on Wednesday, Music Man on Thursday afternoon, Friday bingo/quiz. The AQAA, written before November tells us that the home wants to increase what activities are available. During this inspection we were told that service users had requested jig saw puzzles and we were shown one that had been completed. One service user had since requested a jig saw with larger pieces so they could see them better. The AQAA also tells us that the home recognises that it could do better in providing more one to one care for people during the day but this would involve employing a great deal more staff and the home must stay within its finances to remain viable. However, what we saw on the days of this inspection was a general lack of staff involvement at times when there appeared to be staff free to do this. We did observe additional, brief interactions with some service users that were caring and helpful but some people have specific needs that staff do not have the skills to Care Homes for Older People Page 24 of 46 Evidence: fully meet. This brings us back to the evidence discussed in the first outcome of this report. At lunchtime one main option is cooked although the cook explained that the staff know what people do not like and an alternative can be provided at anytime. Records of lunchtime alternatives were therefore requested. These only recorded two people having an alternative, sausages, each time when fish and chips were served on a Friday. Although the AQAA tells us that meals are provided in line with the service users preferences this does not demonstrate to us that people are given a daily choice of what they would like to eat at lunchtime. We noted similar comments were made in the November 2009 inspection and take it that the situation has not improved. We asked how the staff help someone who is cognitively impaired and new to make a choice at lunchtime and we were told that staff will get used to what the person likes and does not like as time goes on. People we asked did not know what was for lunch but said it is usually nice. We saw fresh fruit available and one service user eating this in the afternoon. Care Homes for Older People Page 25 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although staff have received training on safeguarding adults from abuse and the correct policy and procedures are in place, the latter have not been adhered to and people have been placed at risk. Evidence: This inspection was carried out in response to concerns we received about processes relating to the safe administration of controlled medication. Our findings have been fully reported on in the Personal Care and Health outcome of this report by the Pharmacist Inspector. We have not received any further concerns or complaints about the care home since the last inspection. The home itself has a complaints policy with procedures. We asked to see any records held in relation to any concerns or complaints that they may have received. One written complaint had been received in January of this year from a relative. This was in relation to how one service users personal care had been delivered. Records had been kept of the action taken and the complainant informed of this. This complaint also included an allegation from the service user that they had been manhandled and hurt during the delivery of their personal care. The home does have a policy on Safeguarding Adults and Abuse with relevant procedures. These were inspected during the last key inspection so this was not repeated during this inspection. The homes Improvement Plan dated January 2009 Care Homes for Older People Page 26 of 46 Evidence: told us that processes relating to both the recording of complaints and the reporting of abuse allegation were made more robust and staff were reminded of their responsibilities in relation to this. Despite this neither the registered manager or the deputy manager thought it necessary to report the recent allegation to the local County Councils Safeguarding Adults Team or the Commission as part of their compliance under regulation 37 of the Care Home Regulations. During this inspection, two further incidents of concern were discussed, one of which had been brought to the managements attention by another member of staff using the homes whistle blowing procedure. Again, neither were brought to the attention of external agencies. We were told during this inspection that the carer had been spoken to about all incidents but had subsequently left before any further action could be taken. We explained to management staff that the home does not hold the responsibility of deciding whether a situation is relevant under safeguarding protocols, that this is for the local County Councils Safeguarding Team to determine. However, the home does have a responsibility to report any allegation or incident of possible abuse or harm to the appropriate external agency. The inspection in 2008 highlighted the need for staff to have confidence in appropriate action being taken if they use the whistle blowing procedure. If none of these procedures are adhered to and followed through correctly people will remain at risk of harm and abuse. The above evidence demonstrates that despite training having been provided, senior staff in particular do not have a full enough understanding of the protocols and what their responsibilities are in relation to these. A retrospective safeguarding referral, in relation to the incidents discussed at the time of this inspection, has been completed by the Inspector and forwarded to the Countys Safeguarding Team. Care Homes for Older People Page 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a home that encourages them to personalise their own bedrooms and which is domestic in character, generally well maintained and kept clean. Evidence: The homes environment is domestic in style, has been improved by the present provider. Each service user has their own furnished bedroom with washing and toilet facilities. On the ground floor there is a large lounge and dining area within an attached conservatory. There is a passenger lift to the first floor and wheelchair access to the garden at the back. Internally the home appeared clean and appeared generally well maintained, we did not notice any offensive odours. The exception to this good maintenance was the vacant bedroom which had a missing toilet seat in the ensuite, some knobs missing off the furniture and the central light fitting was partly hanging from the ceiling. There were processes in place to help promote good infection control. These included the provision of protective gloves and aprons for staff to wear when carrying out some personal care tasks. We observed staff washing their hands and there was an alcohol hand gel available for visitors use. Staff were observed wearing protective aprons if they entered the kitchen and the cook wore appropriate protective clothing. Training Care Homes for Older People Page 28 of 46 Evidence: records showed that some staff have received training in infection control, others still required this. There is a specific contract in place for the disposal of certain wastes from the home. We saw basic pressure relief equipment and specialised equipment can be found in bathrooms to help people have a bath. There is a call bell system, one person we visited was sitting over the opposite side of the room to her call bell, which was still looped over the bedside cabinet, presumably from the night time. Staff must make sure that service users have their call bells moved to where they are going to sit during the day. This person had a walking frame and in order to do this we noted that the call bell cord had to be stretched across the room. This is not an ideal situation and needs reviewing to ensure the persons health and safety. 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. Although there are enough staff and all have received training designed to help them carry out their jobs people living in the home are not always benefiting from this and at times are being put at unnecessary risk. Evidence: During this inspection the home appeared adequately staffed. On the two days we were present the manager was on duty and we were informed that he works from Monday to Friday, usually between the hours of 8am and 5pm. The deputy manager was also on duty and we noticed that this persons working hours, across a seven day week, were substantial. The current AQAA completed in October 2009 tells us that the home is aiming to reduce any excessive hours worked over 48 hours per week. In addition to the above senior staff there were two care staff on duty in the morning and we understand there to then be a total of two staff on duty each day from 4pm once the manager has left. At night, from 8pm, there is is one waking night carer who has access to another person within the building who is on call if required. There was one cook on duty until 2pm and one cleaner during this inspection. All staff are encouraged and provided with opportunities to attain a National Vocational Qualification, NVQ in care. All staff that have worked in the home for some time hold a NVQ and we spoke to one carer who is being supported to attain a higher level in this. Care Homes for Older People Page 30 of 46 Evidence: There were two recently recruited staff, we saw evidence of one having completed the homes first day of induction training. This consisted of a basic awareness of some of the homes policies and procedures. Computer records indicated that basic awareness in mandatory subjects such as safe moving and handling, safeguarding adults, food hygiene and health and safety had been booked via an external training provider. We were told that until these have been successfully completed and the person is thought to be competent, they shadow another member of staff when completing certain tasks. The new carer however did confirm that she had been asked to be a witness for controlled medication but had not yet received training in the safe administration of medicines. The importance of this training has been discussed by the Pharmacist Inspector. The November 2009 inspection report required the home to ensure all induction training is in line with The Common Induction Standards. We understand the home has begun to look into this and following this inspection we gave advice on who to contact to help with this. This requirement has therefore been removed. During this inspection senior staff demonstrated a distinct shortfall in their knowledge base. This was resulting in incorrect guidance and training being afforded to other staff. This is also affecting some areas of care, care auditing, record keeping, provision of activities, appropriate interaction, safeguarding of vulnerable adults and risk management. This was fed-back to the Registered Provider following this inspection and needs to be addressed as a matter of urgency. We inspected the personnel files of the two new staff. Each had a completed application form with no unexplained gaps of employment. Each had two references of which we sought clarification on one. Each person had been checked by the Independent Safeguarding Authority, ISA (previously the Protection of Vulnerable Adults, POVA list). One person had been cleared by the Criminal Record Bureau (CRB) and there was evidence of a completed risk assessment because the person had been started in the home before its return. The second person had no evidence of a risk assessment and no evidence of a returned CRB at the time of this inspection. Care Homes for Older People Page 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite there being processes in place that should help the home be effectively managed and comply with the Care Home Regulations this is not happening and as a result people have been put at unnecessary risk. Evidence: The current manager, Mr Brian Darlinson has been in post since 2006 and is registered with the Commission. He holds a NVQ Level 4 in Care and has obtained the Registered Manager Award. Despite this the inspection has identified substantial gaps in the knowledge and skills of the management team. Almost certainly due to a heavy reliance on the deputy manager, a lack of involvement and poor auditing skills has resulted in the home not being effectively managed. It therefore has been unable to comply with several areas of the Care Home Regulations, all of which are fundementally required to protect the health and wellfare of those living in the home. Some of these shortfalls have been compounded by the admission of people with needs that staff do not have adequate skills to meet as discussed within the first outcome of this report. As other staff in the home are effectively being guided and Care Homes for Older People Page 32 of 46 Evidence: trained by these managers so the situation must be addressed as soon as possible. The registered provider carries out a monthly visits to the home and produces a report on what he finds. This complies with regulation 26 of the Care Home Regulations. In this case the provider or a representative is present at the home far more than just once a month. This formal visit forms part of the providers quality assurance of the service. We read the last report dated 21st January 2010 which recorded many of the areas that we have associated with shortfalls, as being ok or up to date. This implies that the provider is partly reliant on the registered manager having the skills and knowledge to help ensure that compliance with the Care Home Regulations is maintained and presumes that this is being successfully achieved. This inspection has evidenced that this is not the case in several areas of compliance. The provider is required to also submit an Annual Quality Assurance Assessment, AQAA. The last one, completed in October 2009 was comprehensive and tells us that the provider is motivated to provide a good service. It gives clear details of how it plans to improve service provision to those living in the home. We were informed during this inspection that it is following an AQAA review that the homes own Improvement Plan is devised and it is from this that the home makes its improvements across a year. The AQAA tells us that the manager is involved in devising this and is therefore fully aware of what improvements the home aims to make. Included in the AQAA are identified barriers to some of these goals, such as the costs to a small home in sourcing staff training. We saw the latest Improvement Plan dated January 2010, which demonstrates that the service does genuinely want to improve its service provision and has a plan of action in place to address this. However, it is also evident that shortfalls in service provision are not being correctly identified. The home seeks the views of those who live in the home on an annual basis and as part of wishing to promote improvements in Equality and Diversity the AQAA tells us that these views will be sought on a 6 monthly basis instead. During this inspection it was evident that certain incidents and accidents that should have been reported to us as part of the homes compliance with regulation 37 had not been. When we spoke to the manager about some of these, he was unaware of this needing to be done. We inspected the homes current and past accident book and incidents and accidents had been recorded in these. The home should seek up to date advice on the keeping of accident records in a set accident book. There was evidence to show that staff had received up date training in safe moving Care Homes for Older People Page 33 of 46 Evidence: and handling practices and first aid but one accident report would suggest that the proper procedures were not followed following one persons fall. Other accident forms demonstrated that appropraite action had been taken. The manager explained that fire training was overdue but computer records did indicate that 3 out of 4 care staff working in the home in October 2009 had been updated, one still required an update according to these records. We were informed that a basic awareness of what to do in the event of a fire had been given to the new staff. We inspected various additional records which demonstrated that several health and safety checks are carried out to help keep people safe. We are also aware that the service has various contracts in place for the maintanence and servicing of equipment and utilities. The AQAA also gives us more detailed information on this. On seeking compliance with a requirement made during the November 2009 inspection for a risk assessment to be carried out on the lack of a window restrictor in bedroom 9, the manager has confirmed that although this service user is not in danger of falling out of the window and is aware of any dangers; a window restrictor has however been fitted. A record is made of whether people have capacity or not as is now required under the Mental Capacity Act 2005. In this case the record records a yes or no, but this can obviously vary depending on the situation, time and decision needing to made. We spoke about an incident that effected one persons ability to leave the home. This had not been viewed as needing a referral under the Deprivation of Liberty Safeguards, DOLS by the manager. There is no one in the home with a current referral under DOLs. Care Homes for Older People Page 34 of 46 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 35 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 1 9 13 Make arrangements to store all controlled drugs in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973 as amended. This is to make sure of safe storage of these medicines and to comply with the law. 11/02/2010 2 9 13 Always follow a safe system 11/02/2010 for the administration of controlled drugs following accepted and published good practice guidelines. This is to help make sure all medicines are accounted for, that people receive their prescribed medicines correctly and are not at risk of mistakes because of poor administration arrangements. 3 9 13 Investigate the discrepancy on page 29 of the controlled drug record book and provide an explanation for the recorded balance of an oral solution that was not in stock. This is to help make sure all medicines can be accounted for. 11/02/2010 Care Homes for Older People Page 36 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 1 3 14 The Registered Persons 22/03/2010 must, following an assessment of someones needs, only offer admission if the home is suitable to meet the persons needs. This is in relation to people that have been admitted with needs that the home is not registered to meet or where the staff do not have the knowledge or experience to fully meet the assessed needs. This is so that people are only admitted to the home where circumstances show that their needs can be both legally and fully met. 2 4 18 The Registered Persons must ensure that staff have the correct knowledge and skills to carry out the tasks they need to preform and to meet all of the needs of the people who live in the home. This is so that people may be protected against harm from poor or out dated practices. 22/03/2010 Care Homes for Older People Page 37 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 15 Ensure that all aspects of 22/03/2010 someones care are fully and correctly reviewed and up dated. This will help ensure that the present care being delivered remains relevant to the persons needs. 4 7 15 Ensure that the care plans 22/03/2010 devised give clear advice on how someones needs are to be specifically met, avoid generalised statements and personalise each care plan if the current system for care planning is to remain in place. This is so that staff know exactly how a specific individuals needs are to be met, not how the need can be or could be generally met. This is also so that the service users wishes and preferences are clearly identified and passed on to staff through the care plan. This is so that the care to be delivered is explained clearly which will resut in all needs being met correctly and safely. 5 7 15 Ensure that relevant and clear care plans exisit for each persons needs. 22/03/2010 Care Homes for Older People Page 38 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 so that each need a person has is clearly planned and recorded. This also helps to demonstrate a clear audit of care when care plans are kept correctly up to date. 6 8 12 Ensure that appropraite assessment is carried out regularly with regard to the potential risk of pressure sores. This is so that people do not develope pressure sores unnecessarily. 7 8 12 Ensure that appropriate assessments of peoples nutritional risk, to include their weight are maintained as required/as the care plan directs. This is so that people are not put at unnecessary risk of poor nutrition or loss of weight. 8 9 13 Arrange to review the 15/03/2010 assessments used about the various ways in which people who live in the home are supported with taking their medicines so that there is always a full written risk assessment and plan specific for that person that 22/03/2010 22/03/2010 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 accurately reflects the support that is given and is regularly reviewed to make sure the arrangements are safe for everyone in the home. This is so that risks with administering medicines are always accurately identified and safe systems put in place that protect everybody in the home. 9 9 13 Arrange to review medicine 31/03/2010 records and care plans for people living in the home to make sure that for all medicines prescribed with a direction when required or with a variable dose there is clear, up to date and detailed written guidance available to staff on how to reach decisions to administer the medicine and at a particular dose, taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure people living in the home receive the correct amounts of their medicines in a consistent way in line with planned actions. 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 10 9 13 Always keep accurate, clear, 15/03/2010 complete and up to date records about any medicines (including those products applied topically to the skin) received and administered to people who live in the home that provide full accountability for all prescribed medicines. (This is particularly to address the shortfalls identified at the inspection and included in the text of the report). This is to help make sure all medicines are accounted for, that people receive their prescribed medicines correctly and are not at risk of mistakes because of poor recording arrangements. 11 10 12 Ensure that all staff are 22/03/2010 aware of how to interact and respond to challenging situations. . In this case this is so that service users dignity is maintained and they are not responded to in a manner that undermines this. 12 12 16 Provide recreational and therapeutic activities according to peoples needs and capabilities. 22/03/2010 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 This so that support can be given to those people who require help to retain the skills and memories that they already have. 13 18 13 Ensure that staff adhere to safeguarding protocols. This is so that people who may be at risk of harm and abuse are fully protected. This is so that the staff in the home can have access to the support that associated agencies can give in achieving this. 14 27 18 Ensure that the staff have 22/03/2010 the skills and knowledge to carry out their jobs correctly and safely. This is so that people in the home are protected from poor practice. Ensure that the people or person responsible for managing the staff and leading the care does this in a way that makes proper provision for the health and welfare of service users. This is so that service users receive the care, supervision and support that is appropriate to their needs. 22/03/2010 22/03/2010 15 31 12 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 16 33 24 By making arrangements, 22/03/2010 ensure that the current system for quality assurance is effective. This is so that any shortfalls in systems and practice can be identified early and appropriate action taken to ensure all service users needs are met and ensure the care home complies with the Care Home Regulations at all times. 17 36 18 Provide effective and 22/03/2010 supportive supervision for senior staff within the home. This is so that these staff can effectively supervise and manage other staff in the home. 18 37 17 Ensure that all documentation relevant to this regulation and schedule 3 of the Care Home Regulations is fully recorded and kept up to date. This is required to enable the home to be able to demonstrate that appropraite care and action has been taken in relation to the care of those that live in the home. 22/03/2010 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 19 38 37 Ensure that appropriate notification is made to the Commission of incidents, events or accidents that are relevant to this regulation. This is so that service users are protected through information being shared with the Commission and through the home being transparent about incidents that occur in the home. 22/03/2010 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 9 Make sure that all staff who handle or administer medicines have sufficient training appropriate to the role they carry out with medicines and that they are regularly assessed as competent to carry out these duties. Liaise with the Pharmacy to make arrangements to accurately complete the allergy section on all medicine administration records as an action that can reduce the risk of people being supplied with a medicine to which they are known to be allergic. Review and update the medicine policy and procedures to make sure that all aspects about the management and handling of medicines are specific for this home, are up to date and reflect accepted best practice so that staff have access to good information about the way in which they are expected to handle medicines. Introduce more robust regular audits of medicine arrangements with appropriate actions taken following each audit to improve on any shortfalls and risks found. Introduce regular recorded checks of the controlled drugs Page 44 of 46 2 9 3 9 4 9 5 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 record book and stocks. This is to make sure that these medicines can always be accounted for and any discrepancies are quickly identified and dealt with. 6 15 Arrangements should be made to improve peoples choice of food at lunchtime by either cooking a second choice on a daily basis or ensuring that a selection of alternatives can be chosen in time for these to be cooked for lunchtime; therefore providing a true choice of food. 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. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 46 of 46 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!