Inspection on 18/08/09 for Aldergrove Manor Nursing Home

This inspection was carried out on 18th August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 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 14/01/10

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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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

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 8 0 8 2 0 0 9 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 38 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 38 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 70 0 70 Over 65 0 70 0 Care Homes for Older People Page 4 of 38 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 did not contain information on the actual fees charged, therefore 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 38 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 key inspection was carried out over one day by two inspectors and a pharmacist inspector attended on another day. 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. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last annual service review. This included notifications received from the home. These are reports about things that have happened in the home that they have to let us know about by law, and an Annual Quality Assurance Assessment (AQAA). This is a document that provides information about the home and how they think it meets the needs of people living there. The AQAA had been completed by the previous deputy manager and therefore did not reflect many changes which have Care Homes for Older People Page 6 of 38 happened in a short period of time at the home. Our last key inspection of this service was completed on 18th September 2007. Three people living in different areas of the home were case tracked in detail. This involves establishing individuals 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. One person who we case tracked was able to tell us about their day to day life at the home and the support they receive from staff. Two other people we case tracked were not able to give us information but their relatives told us they are very satisfied with the home and the care given to their relative. We spoke with other people who we did not case track and we spent time observing how staff interact with people. We also looked at feedback given by five people and two relatives when they completed surveys for us and spoke with people visiting the home during the inspection. We had a group discussion with seven people who live on the younger persons unit which demonstrated that more needs to be done to meet their social needs and improve their outcomes. We looked around some areas of the home and observed a sample of care, staff and health and safety records. We spoke with staff during the inspection to establish their views of working at the home and if anything needs to be improved. The new manager, Ms Geanette Pinches and company operations manager, Ms Sandra Grierson were present during the first day of the inspection and provided their assistance throughout the day. They were both present when we provided feedback at the end of the first day. Our pharmacist attended on the 17th September 2009 as part of the key inspection to fully assess the way the home is managing medicine on behalf of the people who use the service. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: This inspection identifies that there has been a change in rating of the service and people are now receiving poor quality outcomes The home needs to ensure that:People needing bed rails must have a risk assessment undertaken. This is to ensure bed rails are used appropriately, safely and in accordance with guidance provided by the HSE and MHRA. People should have care plans which are current and clearly show how their needs are to be met All people living at the home should be provided with opportunities to enhance their social well being and be involved in developing menus so they have meals which meet their preferences. 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. The home has a complaints procedure but it is not always made available to people, therefore the home needs to consider providing copies of the complaints procedure in different locations of the home. People are not fully protected from the risk of harm and abuse because processes such as recruitment, care planning, risk assessment and administration of medication are not robust. New staff must provided with an induction when they first start working at the home so that they have the knowledge and skills to meet peoples needs. Staff recruited by the home must have all required pre-employment checks Care Homes for Older People Page 8 of 38 undertaken. This is to protect people from being cared for by staff who may be unsuitable to work with vulnerable adults. Sufficient staff should always be available to meet the needs of people who are assessed as needing constant supervision and observation. The manager, Ms Geanette Pinches who has recently started working at Aldergrove Manor and the company operations manager agreed that action will be taken to ensure these deficits are dealt with and the service improved. 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 38 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 38 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 able to visit the home and have their needs assessed before they make the decision to move in, which means the home should know enough about them to meet their needs. People are not always provided with enough information about the home to help with their decision making. Evidence: We looked at the care records for one person who moved to the younger adults unit at Aldergrove Manor earlier this year and we spoke with them about their experience. They told us they were able to visit the home before they were admitted and were satisfied with the admission process. Their care records showed their needs had been assessed before they made the decision to move into the home. This helps to ensure that only people whose needs can be met at the home are admitted. The information from the initial assessment had been used to write care plans to provide guidance to staff on how to meet the persons needs. This helps staff to know how to give care Care Homes for Older People Page 11 of 38 Evidence: based on the persons needs and wishes. We looked at the service user guide, which contains information about the home, so that people know what the service provides. We saw a copy of the guide in the reception along with the homes statement of purpose. The companys operations manager told us that copies of the guide have been supplied to each person. The guide can be made available in different formats, such as Braille, large print and audio-cassette so that people with varying communication needs can access the information. The guide had been updated to reflect changes with the management arrangements at the home. We noticed the guide contains information on what is included in the fees however it doesnt state the weekly fees charged which it should do, so that people know the exact fee. The operations manager acknowledged that information on the actual fees charged was missing from the guide. The person we spoke with told us they had not been provided with a Service User guide at the time of their admission, they could recall their social worker had told them about the fees but could not recall the home telling them that information. The local authority recently took the decision to suspend new placements at the home therefore no new people have been admitted to Aldergrove Manor since June 2009. Care Homes for Older People Page 12 of 38 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. The home does not have robust processes in place to ensure that the personal and health needs of everyone living at the home are met, this means that people are placed at risk of not receiving the care and medication they need. Evidence: We spent time in different areas of the home, speaking with people who live there, observing staff working, looking at documentation to show how peoples needs are met and speaking with staff. We also had opportunity to speak with some relatives. In the area of the home where people with dementia live, we observed staff interacting very well with people, providing guidance when necessary and promoting positive reactions. There was a calm atmosphere, people appeared content and showed signs of well-being. There appeared to be a good relationship between staff, people living in this area of the home and their visitors. We looked at the care records for one person we case tracked. Their care plans were clear and assessments of possible risk to their health, safety and welfare were documented well. Their care plan describes how they like to be independent but this can sometimes place them at risk Care Homes for Older People Page 13 of 38 Evidence: of falls. There was good guidance in place for staff to manage this risk and we observed staff putting this into action during the inspection. This shows staff are aware of what is documented in the care plan to meet the persons needs safely. We saw the person had been assessed for the risk of developing pressure sores, their records show this risk is monitored regularly and they have a specific mattress on their bed to reduce the risk of pressure sores occurring. Staff had contacted the GP quickly when they became concerned that the person had developed a sore area on their skin. The GP prescribed a cream and a care plan was then written to inform staff of where to apply a cream. We looked at their medication chart and saw staff had completed this accurately with all medication signed and accounted for. We spoke with two visitors on this unit who told us they are very pleased with how their relative is looked after. They told us they are happy with their relatives appearance and were pleased to see the person was wearing something which has always been special to them. They confirmed staff are quick to respond to any changes in their relatives condition, such as seeking medical advice and keeping them informed. A person we case tracked on the younger persons unit, gave us very positive feedback about the care they receive. We looked at their care plan which reflected their description of how they like their needs met and the action needed by staff to meet these needs. For example, their care plan describes the time they like to get up and go to bed and they confirmed that staff follow this plan, unless their sleep pattern varies. The person confirmed staff check on his needs regularly and assist him to move. A care plan was in place describing the equipment and techniques needed by staff to move him safely and the person told us this always happens, which demonstrates staff follow what is documented in the care plan. When the person developed a sore area on part of their body, their records described the action which was taken and the person told us and their records show the sore area has now healed. The person told us staff always contact the doctor straight away and observation of their records confirmed this happens, as well as contact with other healthcare professionals such as District Nurses. A discussion with a member of staff demonstrated their awareness of how to meet this persons needs. We looked at this persons bedroom and saw they had a special mattress on their bed. We also saw bed rails were in place on the side of their bed, which are designed to reduce the risk of falls out of bed. The bed rails were fitted correctly but there was nothing written down in the form of a risk assessment to show that the risk to the individual of bed rails being used had been looked at. During our inspection of the younger persons unit we spoke with other people who live Care Homes for Older People Page 14 of 38 Evidence: there, all were happy with how their health is supported commenting that staff react quickly to changes in their health and they are satisfied with the approach of staff during the provision of personal care. Two people told us they had not been able to have a bath when they wanted to recently, because they viewed there were not enough staff on duty. We informed the manager of this and heard the manager speaking with one of these people, agreeing that it was not acceptable and that better planning was needed in respect of how staff are allocated. We were informed that on the morning of the inspection a staff member from the younger persons unit had gone to assist on the dementia care unit to cover for a staff member who was supporting a person during a hospital visit. We looked at the medication for the person we case tracked on the younger persons unit and saw the medication needed by this person was available and as detailed on their medication chart. However on looking at the chart we saw that staff are not always checking or recording amounts of tablets received from the chemist or when they transfer information onto a new medication chart. This makes it difficult to accurately check and audit whether medication is being successfully given as prescribed. Both senior members of staff on this unit accepted the need to improve the way medication is recorded. We met people who require nursing care, however most people because of their illnesses were unable to give their views on the home. Two people we spoke with told us they feel well-cared for and the staff look after them well. Four visitors described how they are satisfied with the care given to their relative and confirmed the home keeps them informed of any changes to their relatives condition. A person contacted us just after the inspection raising concerns with the care of their relative and these concerns are being looked at by the safeguarding adults team. One person we case tracked spent most of the day seated in the lounge on the nursing unit. One carer was present in the lounge throughout the day and was seen assisting this person with their drinks or speaking with them and to other people in the lounge. Their care records included preferences about their diet and we saw their lunchtime meal had been prepared to take account of this. Documentation was present to show staff look at the risk of people not receiving enough nutrition because of their condition and we saw records showing the person we case tracked has their weight monitored monthly and their weight is stable. Following a recent fall from a hoist the home had sought advice from a moving and handling trainer on how to move the person and we saw staff using this equipment competently and safely. Staff were able to tell us why they use the equipment and this corresponded with the advice which had been obtained and was written in the care records. Some parts of this Care Homes for Older People Page 15 of 38 Evidence: persons care records had been updated to reflect their changing moving and handling needs, however overall we found the documentation was not clear and therefore could be confusing to staff. In one area it said not to use specific equipment to assist with their moving but in another section of the care records it described how this equipment must be used. We were told that a new care plan had been written, however this could not be found at the time of inspection. We looked briefly at another persons care records who lives on the nursing unit. We found their care plan described some behaviours of concern. Their care records showed that advice had recently been sought about these behaviours. We discussed with the manager that staff working in this part of the home may not have the training needed to manage these behaviours and the way their care plan was written indicated a lack of understanding in this area. If it is deemed appropriate for this person to stay on this unit then staff need to have relevant training or the home needs to review, along with other professionals, this persons placement. The manager and nursing staff informed us that care records are being reviewed to ensure they are up to date and contain relevant information and guidance about how to meet peoples needs. We saw the service looks at ways to support most peoples religious and cultural needs and staff write this in care records. However one person on the younger persons unit, told us staff had not asked him whether he has any religious needs. This indicates a need for staff to ensure all people are given opportunity to talk about what is important to them, so that if a person has particular needs then measures can be put in place to meet them. Prior to the inspection we received two surveys which described how there needed to be better observation of medication at night. Soon after the inspection we received a complaint, which included concerns about staff leaving medication in front of people and not checking that people had taken it. We informed the manager of these concerns who assured us that action would be taken and staff will be reminded of their role in the safe administration of medicines. During the inspection we looked at where medication is stored on the nursing unit and found that the home stores it at the correct temperature. On one persons medication chart we saw they need to have a cream applied and a nurse on duty told us that care staff are asked to apply creams to people. We told the manager on the 18th August 2009, that care staff are being asked to do this task then they must be trained and assessed as competent to do so. The pharmacist inspector visited Aldergrove Manor on the 17th September 2009 as Care Homes for Older People Page 16 of 38 Evidence: part of the key inspection to fully assess the way the home was managing medicine on behalf of the people who used the service. In summary the medicines management systems within the home were found to be poor and were not safeguarding those living in the home. We found on the whole that the service was recording the receipt of medicines arriving at the home. However we found that medication which had been carried over from previous months had not been accounted for in the records and therefore as a consequence the home did not know whether this medication was being used appropriately. We examined a number of Medicine Administration Record (MAR) charts from both the nursing and young and physically disabled (YPD) units and found that they were not robust enough to demonstrate that the home had administered the medication as prescribed. We found on the whole that the medicines packed into the Monitored Dosage System (MDS) had been administered as the doctor had instructed. However problems arose with the medicines that had not been packed into the MDS system and had been sent from the pharmacy in boxes and bottles. We found evidence of where members of staff had signed the MAR charts but had not administered the medication. An example of this was found with one person on the nursing unit. We found with some capsules that were used to reduce excess stomach acid that 28 capsules had been received and the record showed that 18 capsules had been used. We therefore expected to find 10 capsules remaining but instead we found 11 capsules still in the box. We also found with some sachets that were used in the treatment of certain bone conditions in the elderly that 30 sachets had been received and the record showed that 16 sachets had been used. We therefore expected to find 14 sachets remaining but instead we found 16 sachets still in the box. Another example of this was found with a person on the young and physically disabled unit. We found with some water tablets that 56 tablets had been received and the record showed that 14 tablets had been used. We therefore expected to find 42 tablets remaining but instead we found 47 tablets still in the box. We also found with some tablets that were used in the treatment of indigestion, nausea and vomiting that 56 tablets had been received and the record showed that 56 tablets had been used. We therefore expected to find no tablets remaining but instead we found 10 tablets still in the box. We also found on the YPD unit that the unit had run out of a medicine for one person on two occasions resulting in the person not receiving this medicine for a period of six days. In general we found other problems with the MAR charts. We found that where variable doses had been prescribed the records did not always show what quantity had been given. Where medication had not been administered and a generic abbreviation Care Homes for Older People Page 17 of 38 Evidence: had been used the lack of defining some of these abbreviations meant that the reason for the non-administration was not evident. We found that staff initials confirming that administration had taken place were missing from the administration record and as a consequence the home could not confirm whether this medication had been administered. The audit trail also showed that some medication could not be accounted for and appeared to be missing. We found that the home was not accurately recording the disposal of medicines especially when the medication had been refused and destroyed. We found overall that the care plans were poor for containing information about the administration of medicines. In particular we found little or no information about how and when medicines prescribed on a when required basis should be administered. We found little evidence to support the administration of when required medication. We found very little information about when and why medication had been changed or discontinued. We found that a number of people were self administering part of their own medication, however there was no documented assessment of the risks, to either themselves or other people in the home, associated with this activity. In both the treatment rooms we saw that the Controlled Drugs cabinets were not being used to store Controlled Drugs instead that were being used to store either valuables or cigarettes. We found when examining the Controlled Drug records that a person using the service had not received the proper dose of their high dose analgesic medication for period of five days. The medication had been prescribed on a twice daily basis but on the first day of this period only one dose was administered in the morning. On the second day the home only had enough tablets to make up half of the dose before the supply ran out. At this point a low strength liquid supply of the same medication arrived in the home which was assumed to be a mistake by the doctors surgery. We were told that the surgery had told them to use the liquid until the tablets arrived, although we could find no written evidence of this. We found looking through the care notes that the liquid preparation had been prescribed as a top up if the person using the service experienced some pain that was not being controlled by the high dose analgesic medication. As a consequence the directions on the label were for a small dose of this medication. We found that for the second dose on the second day and for the third fourth and fifth days the top up dose was used and this amounted to the home administering only a fifth of the prescribed daily dose. We also found a week later when the correct prescribed dose was being administered that the liquid analgesic was used as a top up but we could find no evidence in the care notes that this dose had Care Homes for Older People Page 18 of 38 Evidence: been required nor was there any evidence that the monitoring requirements set out by the residents GP had been followed. We advised the manager that this issue should be reported to the local safeguarding adults team and we also made a referral for this to be looked at as part of the safeguarding adults process. We found that the home did not have an ongoing assessment programme to ensure that the nursing staff were administering medication safely and in accordance with the homes policies and procedures. We also found that the care staff were administering medication in the form of creams and ointments. We found that none of these staff had been trained or assessed as competent to carry out these tasks. In light of the issues identified during the inspection the training and assessment of the staffs competency to administer all forms of treatments safely must be carried out as a matter of urgency. We found that not all prescribed medication was being kept secure. We saw that medicated creams/ointments were located in the bedrooms of the people who use the service. As a consequence all occupants and visitors had access to this medication which could if used inappropriately affect the health and welfare of those concerned. We also found that insulin in use was rightly being stored outside of the fridge however the insulin was being stored in a container attached to the side of the trolleys. This meant that it was not being kept secure and when the trolley was out around the home some occupants and visitors could gain access to this insulin. On examination of the insulin we found that one of the vials had not been dated to when the use of it had started. We found that one of the vials being used was out of date. The use of the insulin had started on the 4th August 2009 and the instructions from the manufacturer stated that it could be kept at room temperature for a period of 28 days before it had to be discarded. This meant that the insulin should have been discarded on the 1st September 2009 but it was still being used on the day of the inspection the 17th September 2009. We also examined the blood sugar records of this person to see if the administration of out of date insulin had had an effect on the blood sugar levels. We found that these records were incomplete. We also found that following contact with the diabetic centre the service was told to increase the level of monitoring to twice a day on alternate days for a period of two weeks. We found no evidence that this request had been carried out by the service. We advised the manager that this issue should be reported to the appropriate safeguarding committee. Care Homes for Older People Page 19 of 38 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. Some people are provided with good opportunities to enhance their social well-being and they receive meals which are based on their likes and dislikes. For other people their social needs are not being met and they do not always have a diet which reflects their preferences. Evidence: On arriving on the dementia care unit we found there to be a buzz of activity, three people were playing hoopla with a staff member, skittles were available on the floor for people to use and people not engaged in activities were chatting to each other and staff . Everyone appeared content and showed signs of well-being. The lounge and corridors are bright and colourful and photographs of recent events held at the home are displayed on the wall along with photographs of staff and the people who live in this part of the home. This helps to promote and encourage responses from the people who live here. A staff member told us about how she is involved in organising activities on this unit and has recently supported people with cooking biscuits and cakes and is planning a trip to Ironbridge. Two visitors we spoke with view that there is enough to stimulate people on this unit and gave examples of their relative exercising and painting, which we observed them doing. Care Homes for Older People Page 20 of 38 Evidence: During the inspection we found very little in the way of activities on the nursing and younger persons unit. A staff member initiated a short game of hoopla with two people with nursing needs, and music was put on in the main lounge which some people seemed to enjoy listening to, we did not see anything else to suggest peoples social needs were being met. A person we case tracked on the younger persons unit described how they just watch TV commenting they are happy to do this but described how they had not been offered any other options. Six other people chose to speak with us as part of a group discussion and they told us they viewed there is a real lack of opportunity for social activity and access to the community. We had seen some people playing Scrabble earlier in the day and we were told this was because a volunteer had supported them with this. People described how staff used to play cards with them in the afternoon and that quiz nights, film shows and bingo used to take place but viewed this no longer happens because of a reduction in staff. Three people said they either go out with their family or by the Ring and Ride service. One of these people described how staff supported them along with three other people to go to the pub last week, but viewed other than that there has been little organised by staff at Aldergrove. All of the people present during the discussion agreed there is little in the way of activity and that opportunity for a holiday has not been discussed or organised. One person described how residents meetings take place but views these do not give enough opportunity to promote discussion on what people want. The new manager told us she is planning to attend these meetings to see how they are run. The manager showed an activity action plan which has been produced by the unit manager for the younger persons unit which shows, as one of the key points, to access organisations such as colleges. The manager discussed her intentions in looking at the provision of activities throughout the home and our findings at this inspection show there is a need to ensure people are provided with varied activities to improve their social well-being. We observed the food served on the nursing and dementia care unit and people seemed to be enjoying their meals. People on the younger persons unit gave mainly negative feedback about their meals. One person commented some meals are okay but some are hit and miss and confirmed he is given a choice of what he would like to eat. Others told us the food is edible but not to standard. They described how they are given the menu to choose from for the following day, but all viewed that they are not asked what they would like on the menu commenting that managers write the menu without consulting with them. A staff member described how people are not being given what they order and that the food is not always cooked right, but thought the food will improve now another chef has started. Care Homes for Older People Page 21 of 38 Evidence: We visited the kitchen and spoke with the new head chef who appears enthusiastic and described how he wants to provide food generally associated with younger people, but time has been a limiting factor as he also needs to provide food from existing menus for people living on the other units. The chef was aware that the new manager has sourced additional chefs to help and another chef started the week of the inspection, which may alleviate some of the problems of insufficient food preparation time. The head chef was not aware of some of the conditions people may have which need additional nutritional requirements. This indicates the need for additional training, which was acknowledged by the chef and the manager. There were some gaps in written records to show that the temperature of hot food, fridge and freezer in the main kitchen had been taken on a few occasions. The chef was not on duty on those days and the manager knows there is a need to ensure all staff working in the kitchen keep accurate records. Care Homes for Older People Page 22 of 38 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 but it is not always made available to people, which means some people may not know how to raise concerns or complaints. People are not fully protected from the risk of harm and abuse because processes such as recruitment, care planning, risk assessment and administration of medication are not robust Evidence: We saw the complaints procedure is available within the service user guide. The procedure provides people with clear information on the process to follow and who to contact if people want to complain. However, whilst looking around the home we only saw one copy of the complaints procedure which was on a wall and was not easy to see. This means that for people who do not have a copy of the service user guide, they may not know the procedure to follow if they wish to complain. Two people who completed surveys for us indicated they did not know how to make a complaint. The people we case tracked and their relatives confirmed they know how to make a complaint and viewed their concerns and complaints would be dealt with. Six people on the younger persons unit told us they do complain and feel they are listened to and that some of their complaints are acted upon, but not all. Seven people we spoke with on this unit told us they feel safe. The AQAA completed by the previous deputy manager stated that there have been Care Homes for Older People Page 23 of 38 Evidence: three complaints in the past twelve months. We looked at where complaints are recorded which shows that additional complaints have been made since the AQAA was completed and sent to us. Some of these complaints have yet to be responded to by the home. We recently received a complaint indicating dissatisfaction with how concerns and complaints have been handled by the home over a period of time and part of the complaint is being looked at by the local safeguarding adults team. We made a referral to the safeguarding adults team recently following concerns raised to us about the care of a persons wounds. This is still being investigated and the outcome of the referral has not been concluded. We spoke with six staff who work in different parts of the home. All could confirm their role in safeguarding adults who live there from the risk of harm or abuse. A training plan completed by the manager identifies staff who need to do adult protection training and those staff who need to do an update. We were informed that training is planned. The manager demonstrated a good knowledge of adult protection, the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards and is aware that all staff should have awareness training on the Act. One member of staff told us they had discussed the Act in a team meeting but could not describe it further. The Act oversees 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. At the last key inspection in 2007 we discussed with the previous manager at that time to review what was written in peoples care records about their mental capacity. The new manager assured us this will be acted upon, as a care record we saw indicated changes did not take place. The door to the dementia care unit is kept locked to help keep people safe. The unit manager confirmed that staff support people to go out in the garden or the community if they want to. Care Homes for Older People Page 24 of 38 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. On the whole the environment is safe and well-maintained, however more effort is needed to ensure it reflects individual tastes and preferences. Evidence: We looked at the bedrooms for the people we case tracked, which were clean and well-maintained. 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. People on the younger persons unit told us they are pleased with their bedrooms. When we looked around this unit we saw that the dining room needs to be redecorated, which the manager confirmed has been budgeted for. The dining room was not homely and would be difficult to have enough room for people who use wheelchairs to sit around the tables. We were informed that a lounge on this unit is not used and we saw the wallpaper and carpets appeared new and clean. The appearance of the lounge did not reflect the age group of the people who live on this unit. The dementia care unit was bright, colourful and well-decorated. The dining areas were attractively laid out with jugs of juice and flowers on tables. There was a very strong smell of urine in the corridor on this unit, the manager agreed and viewed this Care Homes for Older People Page 25 of 38 Evidence: as unusual and not an everyday occurrence. A survey we received before the inspection described the excessively hot temperature in this lounge and we saw that a complaint has also been made. We found the lounge to be very warm, and a staff member told us she turned a fan off in the room because someone was cold. This room continued to be very warm and an air-conditioning unit was found to be broken. We brought this to the attention of the manager and company operations manager for action as they were not aware the air-conditioning unit was broken. At the start of the inspection we were shown to a small lounge on the nursing unit and were told by the deputy manager the room is not used. The room was not appealing to spend time in, some of the chairs did not have cushions on, the carpet was stained and crumbs were over the floor. The main lounge appeared to be where some people spend their day. The decoration in here was satisfactory although there was a noticeable smell and we heard staff discussing that the room was due to be cleaned the day after the inspection. Whilst making observations around the home we saw that some carpets in peoples bedrooms looked new and clean, in other rooms carpets were stained and looked old. A survey we received commented that more cleaning was needed in peoples en-suites. Two visitors we spoke with on the nursing unit told us they thought cleaning in the home had recently improved. People are provided with a choice of washing and bathing facilities and there is equipment to help people get in and out of the bath. We were informed that a shower on the nursing unit, which we noticed was not working is waiting to be repaired. 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 and second floors. The AQAA described how peoples beds in the nursing unit have been replaced and we saw that people living on this unit have beds which can be adjusted to assist with both their moving and staff handling. 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. A staff member on the nursing unit identified that some people hadnt had special cushions put on their chairs and took action to put these in place. There is level access to a patio and rear garden, which is fully enclosed. One part of the garden is raised and may be difficult for people with mobility difficulties to get to, other parts of the garden are more easily accessible. Care Homes for Older People Page 26 of 38 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 manager knows there are gaps in the training programme and has plans to deal these gaps so that all staff receive the training they need. New staff are not always provided with an induction when they first start working at the home which means they may not have the knowledge and skills to meet peoples needs. The homes recruitment procedure is not robust, which means people cannot be confident that they are cared for by staff who have been fully checked for their suitability to work with vulnerable adults. Evidence: Recently there was a sudden change in staff and management at the home. A significant amount of staff left at the same time which has obviously caused some dilemmas with how the home is staffed and in particular on the nursing unit as most staff who left worked on this unit. One member of staff spoke told us how changes with staffing had been unsettling at first and could have been done better but after a staff meeting feels more positive about where the home is going. Another member of staff discussed his view that the new manager is trying to improve standards and that the staff team are supporting the managers quest for improvement. The staff we spoke with across the three units viewed that there are enough staff during the day Care Homes for Older People Page 27 of 38 Evidence: and evening to attend to peoples care and nursing needs. One member of staff told us how they manage alright with the staffing levels unless someone needs a member of staff to accompany them to an appointment. People living on the younger persons unit told us that they do not think there is enough staff and gave examples of days when they thought there werent enough staff. They told us there used to be four staff on duty in the mornings and evenings and this has reduced to four in the morning and three staff in the afternoon, and view this has recently been reduced further. We discussed this with the manager and looked at written records of staffing levels, which showed for August 2009 there had been a reduction of staff although the manager felt this did not happen and the shortfall would have been covered. The manager gave examples when staff are not telling her when people have appointments which means she is unable to plan in advance so that staff are available to accompany them. On the day of inspection a staff member from the younger persons unit went to help on another unit to relieve a member of staff so they could accompany someone to an appointment. This indicates a need for improved communication between staff and the manager. The manager is also advised to keep staffing levels under review as findings at this inspection indicate that peoples care needs are being met but a lack of additional staff time means peoples social needs are not always met. A person commented within their survey to us that the home could do better by having more staff-they have no time to chat and spend time with us. During the inspection we saw that a member of staff stayed in the larger lounge on the nursing unit to supervise and assist people. We were informed that this lounge is always supervised by a member of staff. However, after the inspection a person contacted us to inform us that on the evening of the inspection the lounge was not supervised. We contacted the manager to inform her of this concern and to take action. The home has recruited new staff to vacancies. We looked at three staff files to see how the home had recruited these people. We found the home had not ensured these staff had all the necessary pre-employment checks undertaken to ensure they are suitable to work with vulnerable people. One member of staff had started work at the home with only one reference and for another member of staff a reference had not been sought from their last employer. Two nurses had a photocopy of their membership card to their professional register (Nursing and Midwifery Council NMC), yet evidence of their registration should also have been sought direct from the NMC and not based on the production of the registration card alone. When we made the manager aware of this, action was taken to get this verification from the NMC and to Care Homes for Older People Page 28 of 38 Evidence: obtain references, but this highlights an urgent need for the home to review all staff recruitment to ensure it complies with our regulations, so that people are not placed at risk of being cared for by staff who are not suitable to work with vulnerable adults. The operations manager told us the home has a contract with an agency to say that any staff supplied by the agency have gone through all pre-employment checks. The manager assured us she would ensure evidence of this information is kept at the home so that it is readily available. There was no evidence to show that a new member of care staff had an induction into their role and for a new member of the nursing team a checklist had not been signed by them to show when their induction had been completed, but had been signed by the deputy manager only. Therefore it is not known whether the new employee agreed they felt competent in their new role. When the AQAA was completed by the previous deputy manager it indicated that most of the care staff had a recognised qualification in care (National Vocational Qualification NVQ). However as some of these staff are no longer working at the home and new staff have started, the new manager was not able to give us a ratio of staff with NVQ level 2 but showed us the homes training planner which shows that some staff have achieved NVQ 2 and others are in the process of studying for this qualification. A staff training planner shows the home has identified which staff need initial training or updates in safe working practice topics such as fire safety, moving and handling and more specific training in topics such as pressure area care and dementia awareness. The planner shows that some staff are up to date with all their training, which should contribute to ensuring they have an effective knowledge of social care and meet peoples needs. Care Homes for Older People Page 29 of 38 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 that action 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, this inspection identifies that the service is currently not fully protecting peoples health and welfare which puts people at risk of not receiving the care they need. Evidence: The new manager Ms Geanette Pinches started work at the home very recently, at a time when there had been significant changes at the home. A number of staff who had worked at the home for some time had left and new staff had started. Our discussions with Ms Pinches have been positive. She seems aware of what needs to be done to improve outcomes for people, provide stability and manage the home. Ms Pinches gave us an overview of her previous employment and experience and she appears to have the knowledge and skills for the role of manager. Ms Pinches is aware that an application for consideration for registration with us is needed as well as pursuing a management qualification to supplement experience. Care Homes for Older People Page 30 of 38 Evidence: We looked at a selection of documentation which shows that regular checks are undertaken of equipment to ensure it is well maintained. Records show that staff test the temperature of the water to ensure it is not too hot. We saw a fire drill had recently taken place, so staff should be aware of the procedures to follow in the event of a fire. A representative of the company monitors quality at regular intervals with monthly unannounced visits. The company operations manager attended during inspection to complete one of these visits. We observed the reports produced as a result of a visit in June and July 2009. This showed that a wide range of matters are looked at to see how the service is operating and identifies when action is needed. 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 and one persons sore had healed. The manager also showed us written records she keeps when she visits the units in the morning and identifies the numbers of staff on duty. Since starting work at the home the manager has kept us informed of the occurrence of accidents and incidents and has demonstrated that she knows when to refer to other agencies. The unit manager on the dementia care unit described the process used to manage peoples money which appeared robust and should ensure peoples money is held safely. People on the younger persons unit told us there had been some problems with knowing how much money was in their accounts but that this has now resolved. We saw a summary of feedback from questionnaires was included with the service user guide, however as the summary was not dated we were not aware when the questionnaires had been sent out and returned. Throughout our inspection we found shortfalls, for example with care planning, medication, activities, recruitment and staff induction. The manager and operations manager agreed that action will be taken to ensure these shortfalls are dealt with and the service improved. Care Homes for Older People Page 31 of 38 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 32 of 38 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 8 13 People who need bed rails 13/10/2009 must be assessed for the risks associated with the use of bed rails. This is to ensure bed rails are used appropriately, safely and in accordance with guidance provided by the HSE and MHRA. 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 13 To make arrangements to ensure that controlled drugs are stored securely. This is to ensure they are 13/10/2009 Care Homes for Older People Page 33 of 38 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 stored in accordance with the requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations Amended 2007 and the guidelines from the Royal Pharmaceutical Society of Great Britain. 4 9 13 Medication must be stored securely and at the correct temperature, recommended by the manufacturer. This is to ensure that medication is stored correctly to prevent people being placed at risk of harm and from receiving ineffective medication. 5 9 18 Staff must be suitably 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. 6 9 13 Appropriate information 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 13/10/2009 13/10/2009 13/10/2009 Care Homes for Older People Page 34 of 38 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 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 7 9 13 Accurate, complete and up 13/10/2009 to 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. 8 29 19 Staff recruited by the home must have all required preemployment checks undertaken. This is to protect people from being cared for by staff who may be unsuitable to work with vulnerable adults 9 30 18 All staff must receive an 03/11/2009 induction programme appropriate to the work they are to perform 13/10/2009 Care Homes for Older People Page 35 of 38 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 will ensure staff have the skills and knowledge to meet the needs of the people living at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The Service User Guide should be amended to show the fees charged by the home. This is to ensure people are provided with clear and up to date information on fees and to assist them in their decision making. People should have care plans which are current and clearly show how their needs are to be met 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. People living at the home should be involved in developing menus so they have meals which meet their preferences. 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. Consideration should be given to providing copies of the complaints procedure in different locations of the home. This is to ensure that the complaints procedure is accessible to all. 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. 2 3 7 12 4 5 15 15 6 16 7 25 Care Homes for Older People Page 36 of 38 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 8 27 Sufficient staff should always be available to meet the needs of people who are assessed as needing constant supervision and observation. Staffing levels should be kept under review to ensure that sufficient staff are available at all times to meet peoples care, health and social care needs. Staff files should be audited, to ensure that all required pre-employment checks have been completed, to meet legislation and protect people living at the home. An effective system should be introduced to ensure verification for nurses registration is sought direct from the NMC. This is to ensure nurses have current registration with the NMC 9 27 10 29 11 29 Care Homes for Older People Page 37 of 38 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). 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