Inspection on 14/01/10 for Aldergrove Manor Nursing Home

This inspection was carried out on 14th January 2010.

CQC found this care home to be providing an Poor 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aldergrove Manor Nursing Home 07/04/10

Aldergrove Manor Nursing Home 18/08/09

Aldergrove Manor Nursing Home 18/09/07

Aldergrove Manor Nursing Home 25/07/06

Aldergrove Manor Nursing Home 14/03/06

Aldergrove Manor Nursing Home 24/08/05

Aldergrove Manor Nursing Home 18/01/05

Aldergrove Manor Nursing Home 18/08/04

Aldergrove Manor Nursing Home 15/03/04

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Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 10/04/2010.

Key inspection report Care homes for older people Name: Address: Aldergrove Manor Nursing Home 280a Penn Road Penn Wolverhampton West Midlands WV4 4AD     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: Rosalind Dennis     Date: 1 4 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Aldergrove Manor Nursing Home 280a Penn Road Penn Wolverhampton West Midlands WV4 4AD 01902621840 01902621841 aldergrovemanor@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 70 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 70 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 70, Old age, not falling within any other category (OP) 70, Physical disability (PD) 70 Date of last inspection 1 8 0 8 2 0 0 9 70 0 70 Over 65 0 70 0 Care Homes for Older People Page 4 of 31 Brief description of the care home Aldergrove Manor is owned by Southern Cross Healthcare Ltd. It is a purpose built, two storey building, standing in its own grounds and is set back off the main road on one of the main routes into Wolverhampton city centre. It is on a main bus route, close to the city railway system and within easy access to local shops and community facilities. All 70 bedrooms are single with en-suite, some of which have interconnecting doors for couples. There is a passenger lift to enable access between floors. The home consists of a 19 bedded unit for older people with dementia, a 17 bedded unit for younger adults who have physical disabilities and a 34 bedded nursing unit. The door to the unit for people with dementia has a specific door entry system and the door is locked, to help keep people safe. Staff support people from this unit to access other parts of the home. People can obtain information about this service from the homes Statement of Purpose and Service User Guide. The Service User Guide notes the current fees charged by the home as ranging from £449.87 (residential) to £789.36 (nursing) per week depending on care required. The reader is advised to seek information direct from the service. Inspection reports produced by CQC can be obtained direct from the provider or are available on our website at www.cqc.org.uk. Care Homes for Older People Page 5 of 31 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 over one day by two inspectors, one of whom is our pharmacist. The home did not know we were going to visit. The focus of inspections we, the Commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. The purpose of this inspection was to assess all key standards - that is those areas of service delivery that are considered essential to the running of a care home - and to establish whether the provider has complied with requirements we have previously made. Our intention for this inspection had been to look at all areas of the home. However we only looked at the unit for people with nursing needs, because we identified concerns with how this unit was operating. The other areas of the home will be looked at on another occasion. We found that the service had not made improvements in respect of medicine management (apart from with how medicines are stored) and this resulted in us serving a Code B notice, which Care Homes for Older People Page 6 of 31 is used whenever we are involved in an investigation, which may result in a criminal prosecution. We are currently considering what action we will be taking as a result of these breaches. We case tracked some of the people we met during the inspection. Case tracking involves establishing individual experiences of living in the care home by meeting them, observing the care and support they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. Some people were able to tell us about their day to day life at the home and the support they receive from staff. We also observed staff working so we could see how they interacted with people living and visiting the home. We looked around some areas of the home and observed a sample of care, staff and health and safety records. We spoke with staff and the manager during the inspection to establish their views of working at the home and if anything needs to be improved. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: 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 8 of 31 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 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with improved information about the home to support them in their decision making. We were not able to fully assess this outcome group as the home has not had any new admissions for sometime. The rating remains unchanged from the last key inspection. Evidence: There have not been any recent new admissions to the home, therefore at this inspection we were unable to establish peoples experience of moving to the home and look at the processes used. We have previously seen that the company has the supportive documentation to guide staff to ensure people have their needs fully assessed prior to and on admission to the home. We saw a copy of the service user guide and statement of purpose was available for people to read in the main reception area. Since the last inspection the guide has been amended so that it includes information on the range of fees charged by the home. The guide can be made available in different formats, such as Braille, large print and Care Homes for Older People Page 10 of 31 Evidence: audio-cassette so that people with varying communication needs can access the information. Care Homes for Older People Page 11 of 31 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. People receive support and care from staff who ensure their dignity is respected, however people are being placed at risk of not receiving the medication they need because medication practices are not robust. Evidence: One inspector spent time in different parts of the unit for people with nursing needs and observed carers to be kind and respectful when they spoke with people. Four people told us that they view they are looked after well. Another person was not able to give us lots of information but was able to indicate they are satisfied with the home. We observed some people in bed late afternoon and all appeared to be positioned well to achieve comfort. We spoke with one visitor who told us they are satisfied with the care given to their relative and that staff keep them informed of any changes to their relatives condition. We observed throughout the day that staff were clearly working hard to attend to peoples care needs. We looked at care records for the people we case tracked and for others when we looked at their medication. We saw improvements had taken place with how staff Care Homes for Older People Page 12 of 31 Evidence: assess and plan care, although we also identified areas where action still needs to be taken. We saw that for two people who currently have wounds, there was clear documentation in their file showing the care needed of the wounds to promote healing, including the type of wound dressing and how often it needs to be changed. The wound had been checked and measured on a frequent basis so that staff could determine if the wound was healing. We also saw that the home had contacted wound care specialists promptly for advice and to request visits when concerns arose. We saw that when a person had gone to hospital from the home staff had assessed the persons needs quickly on their return to the home and fully documented changes to their care and nursing needs. We observed that, for people assessed as being at risk of developing pressure sores they had specific mattresses on their beds and cushions on their chairs, which are designed to reduce the risk of pressure sores occurring and care plans described clearly what staff need to do. We saw that staff followed the plan, assisting people to stand and move at regular intervals. We saw from looking at written records that people in bed were being supported by staff to move their position. Peoples care records described the equipment and techniques needed by staff to move them safely. We later saw staff using the equipment safely and as described in the care plan. Staff had good approaches with people, providing reassurance and explanation when using the equipment and maintaining peoples dignity. We observed people whose appearance reflected what was written in their care plan of how they prefer to look and dress. For a person who has a condition where they need medicine to help control the level of sugar in their blood, we saw that staff have monitoring practices in place, although identified that when agency staff are working the process could be improved to ensure consistency with where staff record information. We saw that for a person who experiences some difficulty with communicating their needs their care plan provided guidance to staff on how to support them to promote communication. We heard staff speaking with the person as described in their care plan, which shows that staff were aware of how care should be given to this person. We saw that the care records for a person whose file we looked at during the last key inspection suggests that staff working on the nursing unit still need further awareness in assessing and managing behaviours of concern. Care Homes for Older People Page 13 of 31 Evidence: We found that the medicines management systems within the home were still poor and were not safeguarding those living in the home. As a consequence of a continued breach of the Care Homes Regulations 2001 with respect to the management of medicines a number of medication records and care plans were seized under the provision of the Police and Criminal Evidence Act 1984. During the inspection we examined how the home was managing the medicines of three people who used the service. All of these people were living on the nursing unit. We found with the first person that the home had been administering some liquid medicine that had gone out of date. This medicine had been prescribed to prevent epileptic seizures. When examining the care records for this person we found that the home did not appear to be aware that this person was an epileptic. We found no care plan describing what type of epilepsy this person suffered from. We found no information about how the condition should be monitored or managed. We found when examining the administration records that medicines could not be accounted for. We found a gap in the administration record for some tablets used in the treatment of Parkinsons disease and therefore we were not able to confirm whether this tablet had been administered as prescribed. We found that a tablet used to treat spasms had been removed from the Monitored Dosage System three days before it should have been and there was no account of why this had occurred. An audit of the persons analgesic suspension showed that some of the medication was missing. The MAR chart showed that 40ml had been administered but the quantity removed from the bottles was calculated at being 200ml. We also found with some liquid medicine that was used to treat constipation that 500ml had been received. We found that the MAR chart showed that 480ml had been administered so we expected to find 20ml remaining. We found that 95 ml was left in the bottle and therefore this indicated that the nursing staff had been signing the MAR chart but not administering the medication. We found similar issues with the second person we looked at in detail. We again found evidence of where the nursing staff had signed the MAR chart but had not administered the medication. We found that 30 antidepressant tablets had been received and the MAR chart showed that 24 of these tablets had been administered. We therefore expected to find 6 tablets remaining but we actually found 11 tablets. We found another example of where an antipsychotic tablet was still present in the MDS system yet the corresponding entry on the MAR chart was signed indicating that this tablet had been administered to this person. We again could not account for some of the medication. We found that 100 analgesic tablets had been received and 6 tablets had been administered. We therefore expected to find 94 tablets remaining in the box but we actually found 88 tablets. We found that some antihistamine tablets Care Homes for Older People Page 14 of 31 Evidence: were last administered on the 7th January 2010 and none had been administered since then because the home was out of stock of them. We also found a similar case with some sleeping tablets which had not been administered on the 21st 22nd and 23rd December 2009 because the home was again out of stock. We also found that the tablet on the 21st December 2009 had since been removed from the MDS system without any reason for this being recorded. We also found similar issues with the third person we looked at in detail. We found further evidence of where the nursing staff were signing the MAR charts but not actually administering the prescribed medication. We found that 20 antibiotic capsules had been received yet there were 22 signatures on the MAR chart before the course was completed. We found that 60 tablets used to treat angina had been received and 48 of those tablets had been administered according to the MAR chart. We therefore expected to find 12 tablets remaining but we actually found 15 tablets. We again found that the home had been out of stock of some analgesic capsules for a period of three days. The records appear to show that the home should have had plenty in stock to meet the person needs. We found that at the beginning of the current medication cycle 282 capsules had been recorded as being present in the home. The administration record showed that a total of 93 capsules had been used so we expected to find plenty of capsules in stock. The home was unable to account for the missing capsules. We found that a number of medicines had according to the MAR charts been refused by this person and had consequently been destroyed. We could find no records in the disposal register to confirm that this action had taken place. We again found gaps in the administration round and therefore we were not able to confirm whether these medicines had been administered as prescribed. In light of what we found we deemed that the nursing staff were not competent to handle and administer medicines safely and accurately. We found that none of the staff had undergone any form of competency assessments to determine whether they were able to handle and administer medicines safely and accurately. We found that the home had been carrying out monthly medication audits. We found that the audits for November and December 2009 had reached a score of 91 percent but the score for January 2010 had only reached a score of 81 percent. We found that the only factor that was different over this period of time was the number of nurses working the day shift on the nursing unit. We found that during November and December 2009 the unit had been running with two nurses on the day shift but in January 2010 the staffing level for the nurses on the day shift had been reduced to one nurse. We found that the home had been maintaining the temperature of the medication fridge within the correct temperature range. We also found that the insulin in use was Care Homes for Older People Page 15 of 31 Evidence: being stored correctly in the mobile drugs trolleys. We found that this insulin had been dated with the dates of opening and was in date. Care Homes for Older People Page 16 of 31 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. There is a lack of evidence to show that sufficient activities take place to provide people with opportunities to promote their social well-being or to show that activities are based on what people want to do according to their needs and capabilities. Evidence: As this inspection focussed on the unit for people with nursing needs we did not have opportunity to assess whether improvements in promoting the social well-being of people living on the younger persons unit have taken place. The manager informed us that a staff member responsible for activities is now taking responsibility two days per week for promoting activities with younger people and with people who have dementia. The manager discussed that she considers there is now more going on with the younger people living at the home but recognises more work is still needed to provide greater social opportunities and life skills development. The manager discussed how she is currently looking at involvement from colleges to provide courses for people to attend if they wish. We saw that a complaint was made about a lack of activities shortly after our last inspection. At the start of the inspection people seated in one of the lounges on the nursing unit, appeared to be enjoying music playing and staff were engaged in conversations with Care Homes for Older People Page 17 of 31 Evidence: people. Later during the day, people in this part of the home were asked if they wanted to watch the rest of a film they had started to watch the day before, which they did and watched this during the afternoon of the inspection. For people who remained in their bedrooms we did not see staff having opportunity to promote their social well-being as they appeared busy in other parts of the unit. We saw that staff have started writing in peoples care records about activities they have taken part in and whether they appeared to enjoy the activity. However this was very sporadic and showed that people are not being provided with regular activities and opportunities. We observed staff serving and giving meals out to people at lunchtime and at tea. Meals reflected peoples preferences and specific dietary needs, such as swallowing and chewing difficulties. People appeared to enjoy their meal. We observed staff using good approaches with people who need help with eating and drinking and staff were observed providing people with regular drinks of what they wanted throughout the day, including for people who, because of their illness remained in their bedrooms. We saw that the company dignity advisor has been to the home to provide guidance on enhancing meal times. At the last key inspection we identified that a chef at the home lacked awareness of some of the conditions people may have which need additional nutritional requirements and we advised they have additional training. The manager informed us that training is still needed but described how a chef from another home has provided guidance along with advice provided by the manager. The manager recognises menus need more development to reflect different tastes and ages. Care Homes for Older People Page 18 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints procedure, which provides people with information so they know how to complain and ensures concerns and complaints are acted upon. Staff are provided with training so they know how to safeguard adults from harm and abuse, however people are not fully protected from the risk of harm because medication procedures are not robust. Evidence: We saw the complaints procedure is in the reception and service user guide. A comments and suggestions book was also visible for people to write in if they choose. We looked at the processes used by the company to respond and act on complaints which shows there is a good process in place, with complaints and the action taken recorded. We spoke with five staff working on the nursing unit and all could confirm their role in safeguarding adults who live at the home from the risk of harm or abuse. A training plan completed by the manager shows that almost all staff have now received training in safeguarding adults from abuse. The manager knows when to refer concerns to the local safeguarding adults team for investigation under their procedures and keeps agencies informed about any concerns with keeping people safe. The manager also has a good knowledge of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards however the staff we spoke with were not aware of Care Homes for Older People Page 19 of 31 Evidence: their roles in respect of the Act. The Act governs decision making on behalf of adults, and applies when people lose mental capacity at some point in their lives or where the incapacitating condition has been present since birth. It is important that staff know how to put the Act into every day practice and the procedure to follow when peoples freedom may need to be restricted. The manager is aware that all staff need to have awareness of the Act and described how she is currently looking at training organisations to provide this training. Care Homes for Older People Page 20 of 31 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. We looked at the nursing unit only at this inspection, therefore our rating for this outcome group remains as it did at the last inspection. The unit for people with nursing needs is homely and well-maintained. Evidence: We looked at the nursing unit only at this inspection, therefore our rating for this outcome group remains as it did at the last inspection, where we identified that more effort was needed to ensure the environment reflected individual tastes and preferences. We found improvements on the nursing unit with the appearance of communal areas and the bedrooms we saw and there were no noticeable offensive smells. We saw that people are able to bring in items which are important to them, such as photographs, pictures, religious items and small pieces of furniture. Each persons bedroom has an en-suite. We saw the home has equipment to help move people safely such as hoists and there is a choice of stairs or passenger lift to the first floor. Mattresses designed to provide relief of pressure when people are less mobile were seen on the beds of people we case tracked who had been assessed as being at risk of developing pressure sores. At our last inspection we saw that a lounge did not reflect the age group of the people Care Homes for Older People Page 21 of 31 Evidence: who live on the younger persons unit. We were informed at this inspection that the unit is awaiting new furniture. Care Homes for Older People Page 22 of 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is failing to ensure that sufficient numbers of staff are available to meet the dependency and all of the needs of people living on the nursing unit. Improvements with recruitment processes now mean people can be reassured that staff are checked for their suitability to work with vulnerable adults. Evidence: At the time of the last key inspection staff told us there were sufficient staff during the day and evening to attend to peoples care and nursing needs. At this inspection feedback from all the staff working on the unit for people with nursing needs were clear in their view that there are not enough staff to meet the needs and dependency of the people currently living here. One staff member viewed that staffing levels are unsafe at times, however the other staff we spoke with view that staffing levels are just about safe, describing how they are only just able to meet peoples needs and that people are having to wait for staff to attend to them. On the day of our inspection there were four care staff and a nurse working on the nursing unit. We observed staff working in different areas of the unit and at different times of the day and saw that staff were working very hard. Staff described how most of the people they were allocated to look after need two staff to care for them. In addition, two people living in different parts of the unit need to be observed. At one time during the inspection all the care staff were busy attending to people and the Care Homes for Older People Page 23 of 31 Evidence: nurse had started the medication round, this meant that if people would have needed assistance staff would not have been available to help them. We established that included in the numbers of care staff was a staff member who had not previously worked in a care environment. Although they had completed a week induction away from the home, they spoke about their concern about the impact their lack of experience was having in providing peoples care, as it meant finding additional staff to assist in some of the moving and handling techniques. We spoke with the nurse on duty who described how the nurse usually assists with care duties but this can then impact on their nursing role. This staff member viewed that more competent care staff are needed. We made two recommendations at the last key inspection, in respect of keeping staffing levels under review, however our findings at this inspection indicate our recommendations have not been followed. Our observations indicate that there are people living at the home who need a high amount of care and would benefit from more social stimulation. We therefore require the home to review staffing levels so that outcomes for people are improved. We looked at written records which showed the training which has been undertaken by staff and training which is planned. This demonstrates that regular staff training is taking place, including training in safe working practice topics such as fire safety, moving and handling, safe use of bed rails as well as more specific training such as pressure area care and dementia awareness. Two staff told us they would like additional training regarding specific health conditions people may have such as diabetes and epilepsy. The manager acknowledged this and described some good ideas to fully meet training needs now and in the future. We saw from the training plan that some staff undergo training in medicines, however what hasnt happened since the last inspection is the development of an ongoing assessment programme to ensure nursing staff are administering medication safely. We looked at the process used by the home to recruit two members of staff who have started working at the home since the last key inspection. All parts of the recruitment process were accurately recorded and demonstrated that pre-employment information, such as references and Criminal Record Bureau Disclosures had been sought prior to two of these staff working at the home. We also saw that checks are made on nurses to ensure they have an effective registration with their professional register (Nursing and Midwifery Council). We saw that information is sought from agency staff employers to ensure agency staff who come to work at the home have been checked for their suitability to work with vulnerable adults. Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager, Ms Geanette Pinches knows the action which needs to be taken with many aspects of the service to improve outcomes for people and ensure the service is run in their best interests. However further effort is needed by the company to enable and support the manager to be effective in her role in initiating these improvements so that people and staff benefit. Evidence: The manager Ms Geanette Pinches demonstrates that she has the knowledge, competence and abilities to manage and lead the home. As we noted at the last inspection she is aware of where improvements need to be made to improve outcomes for people and provide stability. We also find the manager knows where there are weaknesses. Staff gave positive feedback about the manager and said they feel supported to give good care. The home currently does not have a Deputy Manager, therefore the manager appears to be having to oversee all aspects of the home as well as strive for improvement. On the day of our inspection the homes administrator was not available therefore the manager was involved in dealing with the majority of the Care Homes for Older People Page 25 of 31 Evidence: phone calls coming through to the home. The company needs to ensure, through its support mechanisms, that there is sufficient opportunity for the manager to be able to develop and improve the home. We looked at some of the audits which the manager undertakes. An audit on pressure sores shows that for the week of this inspection two people have pressure sores. As described earlier in this report, we saw that audits are undertaken of medication practices. The manager keeps us informed of the occurrence of accidents and incidents and there is a good monitoring system in place which shows clearly the action taken following accidents and incidents. The manager demonstrates that she knows when to refer to other agencies. We saw that staff have training in health and safety practices, which ensures they are provided with the knowledge and skills to help people keep safe. For example, staff receive training in the safe use of bed rails, so they should know how to keep people safe when they are in bed. We also saw written records showing that checks are undertaken weekly to ensure bedrails and mattresses are fitted correctly and functioning. The people we case tracked who had bed rails on their bed had been assessed for the risks associated with the use of bed rails. Written records show that checks are undertaken of fire safety systems. The manager informed us that people have not yet been provided with opportunity to comment on the service through quality assurance systems, such as surveys. We saw minutes for a meeting which was recently held on the younger persons unit and the manager spoke of her intention to initiate further meetings throughout the home and for relatives. As at the last inspection a representative of the company monitors quality at regular intervals with monthly unannounced visits. We looked at the notes made for a visit in December 2009 which described the home as running well. Care Homes for Older People Page 26 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 Accurate, complete and up to 13/10/2009 date records must be kept of all medication received, administered, taken out of the home when residents are on leave and when medication is disposed of. This is to ensure that medication can be accounted for and is given as prescribed. 2 9 12 To ensure that there is an effective system in place to request obtain and retain adequate supplies of prescribed medicines including Controlled Drugs for people. This is to ensure that people can be given their medication as and when it is prescribed. 13/10/2009 3 9 18 Staff must be suitably 13/10/2009 qualified, experienced and competent to safely administer medication before they administer medication to people who use the service. This is to ensure people receive their medication as prescribed from skilled staff. 4 9 13 Appropriate information 13/10/2009 Page 27 of 31 Care Homes for Older People 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 relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including as directed, when required and self administered medication. This is to ensure that all medication is administered safely, correctly and as intended by the prescriber, to meet individual health needs Care Homes for Older People Page 28 of 31 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 27 12 Staffing levels for all shifts must be reviewed to take account of peoples needs, dependency and layout of the home. This is to ensure peoples needs are met safely and promptly. 04/03/2010 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 12 The home should ensure that all people living at the home are provided with opportunities to enhance their social well being. The effectiveness of these opportunities should be evaluated on an ongoing basis to ensure they are appropriate and meet with peoples expectations and needs. 14/01/2010-Not achieved Staff involved in meal preparation should be provided with training to ensure they have the skills and knowledge to meet the varying nutritional needs of people living at the home. 14/01/2010-Not fully achieved 2 15 Care Homes for Older People Page 29 of 31 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 3 15 People living at the home should be involved in developing menus so they have meals which meet their preferences. 14/01/2010-Not achieved The air-conditioning unit on the dementia care unit should be repaired and measures should be taken to ensure people are cared for in an environment which is at a temperature comfortable to them. 14/01/2010-Not assessed The home should consider reviewing its induction process so that staff who are new to care work are able to consolidate their corporate induction with opportunity to work in a supernumerary capacity at the home until such time they are competent and confident to attend to peoples care needs themselves. Staff should be provided with training about the Mental Capacity Act and Deprivation of Liberties. This is so that staff know how to put the Act into every day practice and the procedure to follow when peoples freedom may need to be restricted. The company should consider ways to support the manager so that the manager is able to initiate improvements so that people and staff benefit. A system for evaluating the quality of the services provided at the home should be introduced so that it actively seeks the views of people using the service, their representatives and other stakeholders. The results should then be used to improve the homes performance based on the feedback from others. 4 25 5 30 6 30 7 31 8 33 Care Homes for Older People Page 30 of 31 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. 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