Inspection on 24/08/09 for Arle House

This inspection was carried out on 24th August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Arle House 05/09/07

Arle House 13/12/06

Arle House 21/07/06

Arle House 04/10/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Arle House Village Road Arle Cheltenham Glos GL51 0BG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Wilcox     Date: 2 5 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 38 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Arle House Village Road Arle Cheltenham Glos GL51 0BG 01242514586 01242224259 manager.arle@osjctglos.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) The Orders of St John Care Trust Type of registration: Number of places registered: care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: To accommodate two (2) named Service Users under the age of 65 years. The home will revert to the original service user category when these service users reach the age of 65 or no longer reside at the home. Date of last inspection Brief description of the care home Arle House is a purpose built care home providing personal and nursing care. It is situated in a large housing estate close to local shops and other amenities. The Orders of St. John Care Trust is responsible for the management of the Home. The accommodation, consisting of forty-eight single rooms and one double room, is Care Homes for Older People Page 4 of 38 Over 65 50 0 Brief description of the care home arranged on two floors and has been equipped with a shaft lift to access the first floor. Although none of the rooms have en suite facilities, there are several assisted bathrooms and separate toilet facilities throughout the home. Some of the bedrooms at the front of the property have the benefit of a small balcony. There are three lounges within the home plus a large dining room and a number of smaller sitting areas where residents and their visitors may meet. The enclosed rear gardens are easily accessible and have attractive shaded areas where residents are able to sit when the weather permits. The provider supplies information about the home, including the most recent inspection report, in a file at the entrance of Arle House. Current fees range from 395 pounds basic local authority rate, to 830 pounds private nursing rate. Hairdressing, chiropody, optical services and any personal items are charged extra. Prices are available on request. 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One Regulatory Inspector carried out this inspection over two days in August 2009, and the support of an Expert by Experience was also used to further establish the daily experience of the residents from their perspective. The last Key Inspection of this service was carried out on the 5th and 6th September 2007. Care records were inspected, with the care of six residents being closely looked at in particular. The arrangements to manage residents medications were inspected. We met and spoke to a number of residents and visitors in order to gauge their views Care Homes for Older People Page 6 of 38 and experiences of the services and care provided at Arle House. Some of the staff were interviewed, as was a visiting healthcare professional from the Primary Care Trust. Survey forms were also issued to a number of residents, staff and visiting health care professionals to complete and return to us if they wished. Eight out of ten residents and four out of five staff to whom we sent surveys returned them to us, and some of their comments feature in this report. None of the visiting health care professionals responded to us. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service, and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, provision, training and supervision of staff were inspected, as was the overall management of the home. A tour of the premises took place with particular attention to the maintenance and cleanliness. We required an Annual Quality Assurance Assessment (AQAA) from the home, which was provided, the contents of which informed part of this inspection. What the care home does well: What has improved since the last inspection? What they could do better: The home must ensure that an information brochure is issued to all interested parties and prospective residents, and that letters are issued consistently to confirm a placement in the home further to an assessment. Shortfalls in documented care planning and medication management require attention and improvement if unecessary risks to residents health and welfare are to be avoided. Plans to improve how residents wishes and thoughts regarding their end of life care might be understood and catered for have yet to be fully implemented. We received generally favourable comments about the food, except that some residents thought that there should be greater menu choice, and that there should be more suitable intervals between meals, particularly breakfast and lunch. Care Homes for Older People Page 8 of 38 Despite a core group of care staff, there was a degree of instability amongst the team, particularly with qualified nurses. The manager was endeavouring to address this through the appointment of a deputy manager and a robust recruitment strategy. In many ways there was a sound recruitment procedure employed in the home, however there were two specific areas where the home must now make improvements in order to provide greater protection from unsuitable workers. Although we found evidence of good training opportunities for staff, the home should improve the way in which the training records are maintained. The arrangements for managing residents personal money and valuables placed with the home for safe-keeping were generally sound, however there were isolated aspects that should be improved to ensure complete transparency. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A pre-admission assessment allows the homes assessor to know that the home can meet peoples needs before admission takes place, however the failure to provide a confirmation letter and an information brochure to people in advance may hinder some in making an informed choice about the home. Evidence: Residents who responded to our survey confirmed that they had received information about the home prior to coming in here to assist them, although a small number were unable to remember if they had had one. We met at least two residents in the home who told us that they had never received an information brochure. When we discussed this with the manager it was fully acknowledged by him as an oversight. The AQAA stated that the information supplied relating to the home and its services could be provided in alternative formats if desired or needed. A full copy of the homes Statement of Purpose was displayed in the entrance hall, with a copy of the homes last inspection report. Care Homes for Older People Page 11 of 38 Evidence: All prospective residents were assessed prior to being given a place at the home. The AQAA stated that assessments involved the prospective residents family, and that in unplanned circumstances information was sought from other sources immediately. New residents were assigned a key carer when they were admitted to the home. We inspected five examples of pre-admission assessments, two of which were for residents more recently admitted to the home. Each assessment had been carried out prior to admission being agreed, and had been recorded on the homes designated tool for the purpose. The assessments had been signed and dated, with the location where it was conducted identified. The assessments took account of their personal details and their past medical history, their health and care needs, their medications, their socialisation and cultural needs, and their understanding. A section to record individuals legal status had not been consistently completed. There was also a moving and handling assessment, a pressure sore vulnerability and overall skin assessment, a nutritional and a falls risk assessment included for completion, but these had not consistently been recorded ahead of the admission taking place. Information and assessments from the placing authority and from other health and social care professionals previously involved in the persons care were also obtained. Confirmation letters of placements had not been issued as was required. Arle House does not provide intermediate care. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home can expect to have their care needs met, however failures within the care documentation and the medication systems are posing a degree of risk towards their health and safety. Evidence: Each resident had an individualised plan of care in place that had been drafted on the outcome of an overall assessment of needs and a range of risk assessments. It had been done in consultation with them and sometimes their family. Each was kept under regular review. We selected six care plans to inspect more closely. Some of the documented care plans had been drafted specifically for the resident, but we saw examples where standard drafted templates had been used, which were not person-centred at all. We were told about the homes forthcoming plans to rectify this situation that had evolved. In most cases the life history section had not been fully completed, and there were a Care Homes for Older People Page 13 of 38 Evidence: number of discrepancies in recording. We saw one lady who had sustained pressure sores to her heels, which were under the care of the community nurse. These were left exposed and were not being dressed; we asked that this strategy be reviewed with the community nurse involved. This persons pressure sore risk assessment was not accurate and showed a lower risk than we assessed she was actually at. This person was also at a high risk nutritionally. Staff were assisting her and were monitoring her food and fluid intake, however, information recorded on the monitoring chart was scant and did not actually record the amounts taken at each meal or drink. This person was in poor health and was being nursed in bed. We saw that she was clean, comfortable and reasonably peaceful, and she was able to confirm her comfort with us directly. In another case we were aware that the person had recently had a urinary tract infection that had given rise to some concerns in their mental health as well as their physical health. Despite there being a urinary continence care plan in place, neither this nor the review information on it mentioned this particular occurence. We also noted that this person had lost a significant amount of weight during the course of this year. Staff had been monitoring this to some degree, and as the person remained generally healthy with a reasonable weight overall no action had been taken in response. This person was sitting on a pressure relieving cushion due to the pressure sore risk, and she told us that she found it uncomfortable. We reported this to the manager for action. In a third case a risk assessment had identified the person was at high risk of developing a pressure sore. A care plan to address this risk was in place. However, the reviews of the assessment showed that a sore had developed but the plan of care had not been written in such a way as to demonstrate how this was being addressed. Residents told us that they received the care that they needed, with some saying that they were looked after well. One resident said that the home provided a good service. The residents with whom the Expert by Experience visitor spoke all confirmed to her that they liked living in the home. Three visitors told us that they were very happy with the home and the level of care it provided for their relative. We spoke to a visiting health care professional from the Primary Care Trust, who was in the home conducting assessments. This person told us that the new manager was receptive and helpful, and that in their view the home was not great, but was not bad either. They were also able to tell us that they regularly observed staff being respectful with residents, and spoke nicely to them. Care Homes for Older People Page 14 of 38 Evidence: Staff who responded to our survey and those with whom we met personally confirmed that they got up to date information about the needs of the residents, although one person said that information sharing worked well only sometimes. Staff we spoke with generally appeared knowledgeable about the needs of the residents, and on the first day were witnessed working in an organised and calm way. Staff seemed sensitive towards the appropriate pace to use when attending to residents needs. This was slightly different on the second day of our visit, and due to a number of factors we could see that staff were working in a more chaotic manner, with obvious pressures affecting them. Despite this, we could also see that those whom we witnessed still managed to give residents the individual attention they required. We frequently saw a patient and friendly disposition displayed by staff towards residents. Residents wishes regarding the management of their medications was recorded on the pre-admission assessment tool. Residents were able to manage their own medications if they wished and were able, however there were no examples of this taking place at this time. Medications were stored safely and hygienically. Medication administration charts were clearly printed by the supplying pharmacist and were neat and orderly, with a record of administrations maintained. A computerised list of medications was checked when items were delivered into the home, and there was also a register of any unused items that had been returned to the pharmacy. A nurse told us that staff would normally record received items onto the Medication Administration Charts (MAR) as well, but that she had been too busy to do this on this occasion. The arrangements for analgesia, external preparations, and any medications prescribed for use when needed were checked for each person that we case tracked and these were largely in order. In one case a plan of care for managing pressure sore vulnerability had directed staff to use a particular barrier cream, however this item had not been prescribed and was not in use on the MAR for this person at all. In another case the MAR showed the use of two particular external creams that did not feature in the planned care. We found at least two cases where staff had not signed to confirm administration of a medication. When we audited these cases it was clear the tablets had been given as prescribed and that the nurse concerned had failed to sign the chart. There were isolated examples of handwritten entries and amendments on the printed charts. Although doctors notes confirmed certain dosage changes there were no Care Homes for Older People Page 15 of 38 Evidence: signatures or dates recorded on the MAR to confirm when or by whom the changes had been authorised. Controlled drugs were in order, except that in one case where the dosage instructions were confusing, the previous nights nurse had decided to omit the dosage altogether. Fortunately this resident had not suffered any ill effects, and had remained comfortable with the use of other prescribed analgesia. However this had further illustrated our point that directions must be made absolutely clear on medication charts. When we audited controlled medications we found an example where a medication had been given on the correct days as prescribed ie: every third day, with stocks and balances in order. However a nurse had signed for administration on a day when it was not due to be given. She reported that she had automatically done this, and conceded that it was an error on her part. Despite these identified shortfalls, it transpired that the nurses had attended safe medication management training, and we saw examples of competency assessments having been conducted with them. We observed a medication round taking place, and this was done in a calm way, with unhurried attention given to the residents. The AQAA told us that the manager and one of the care leaders had attended a conference on End of Life Care, and that information from this was being cascaded to the care team. Assessment tools provided staff with the opportunity to discuss individuals wishes regarding arrangements for their end of life care when they came into the home, however this was rarely taking place, with most that we saw not having been discussed or recorded. A specific Advanced Wishes plan of care was being developed for introduction into the home in the near future so that this could be dealt with on an individual basis more consistently. The AQAA acknowledged that the home needed to implement a more detailed End of Life Care Pathway, and that staff needed more training. Care Homes for Older People Page 16 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. People living in this home have the opportunity to remain socially active and exercise choices, however certain restrictions over preparation for and during mealtimes is affecting enjoyment of meals for some. Evidence: The designated activity coordinator helped to plan and implement an activity programme to suit residents needs and preferences, and a bright and eye-catching illustrated plan of events was displayed in the home. The home aimed to provide social opportunities for residents twice each day. The programme included, games, crafts, discussion and reminiscence groups, exercise and fitness sessions, quizzes, musical activities and entertainments, religious services and trips out. Pieces of the residents craft work were on display in the home, and there were also photographic displays of past events. During the last review of this service some residents who responded to our survey told us that they could sometimes feel excluded from social activity. At the time we were told that the social activity coordinator was meeting with residents to discuss this, and the latest AQAA acknowledged that this was an area for further improvement. During this visit we saw a member of staff sitting with residents devising a social activity Care Homes for Older People Page 17 of 38 Evidence: programme that would be suitable for their particular needs. The coordinator made efforts to provide those residents who remained in their own rooms with quality oneto-one social time whenever possible. On this occasion residents who responded to our survey told us that there were activities for them, although some said that these were only sometimes. One person told us they would like to see a piano in the home, whilst another told us that, although they enjoyed the activities and outings, they would like to have activities that were more stimulating mentally. There were no restrictions upon residents receiving their visitors, and the AQAA stated that visitors were welcome to stay for a meal with their relative. One of the visitors to whom we spoke directly told us that she felt very welcome in the home, and that she was always offered refreshments by staff. She also said that information was shared with her appropriately by staff, and that she was always kept in touch. She said it was a beautiful home, and that her relative loved it here. The AQAA stated that residents were given choice at every opportunity, and that their preferences were recorded in their plans of care. One resident who responded to our survey told us that they would like to get up earlier in the morning. Another we met in person said the same, saying that she often had to wait before staff were ready to help her get up in the morning. We saw residents who were able, moving freely around the home, with at least two speaking of their appreciation of retaining a lot of independence and managing to do their own chores in their rooms. Residents bedrooms, although not large, had been personalised by the current occupants and their families to a degree, with the introduction of personal items and treasures. There was a choice of food available to the residents, and we saw each being helped to select from a menu of at least two main courses and puddings. There were also choices at breakfast and teatime. The lunchtime meals were reasonably presented, with portion choices and control evidently observed. The fish pie and the chicken curry choices looked appetising, however mashed potato was one of the accompaniments to the curry, with the other being boiled rice, which would be more suited to curry. However, the boiled rice was very sticky and in clumps, and did not look appetising. Residents who responded to our survey indicated general satisfaction with the food, Care Homes for Older People Page 18 of 38 Evidence: although one told us that they would like greater choice, whilst another told us they would like peace and quiet in the dining room, which was often very noisy. We did not witness this on this occasion however, with the room being reasonably quiet. A member of staff told us that the menus were the same week in and week out. Residents we met in person mainly seemed to enjoy their food, although one person said that they could do with more selection. One resident told us that there were times that she did not feel ready for her lunch, as breakfast had not been served to her until after 10 o clock in the morning. The AQAA stated that the home had plans to carry out a full review of menus over the coming months in order to offer more variety and choice. Some of the residents had been helped into the spacious dining room well in advance of the meal, and mentioned that it was not unusual for them to have to sit and wait like this. The dining room was laid reasonably attractively for the meal, with tablecloths and drinks, however there were dead floral arrangements and dirty condiments on some of the tables. We observed several residents being assisted to eat their meals. This was done with dignity and sensitivity, allowing the residents to eat at their own pace without feeling hurried in any way. On the second morning of our visit, whilst there were obvious pressures upon staff as previously reported, we noted that one resident was assisted by three different carers during the course of his breakfast cereals, which was not ideal. We had previously received a complaint that incorporated concerns about the quality of the food and general catering arrangements here. At the time the home reviewed menus and nutritional arangements for people, and hygiene standards in the kitchen were also reviewed. Guidelines were issued to staff regarding specific actions to meet particular nutritional needs of residents. Another audit of the standards in the kitchen had been carried out recently, with areas for improvement identified again. We visited the kitchen during the lunchtime preparations. The cook was evidently too busy to spend much time with us, but was able to briefly confirm her knowledge of special diets, and that she would do what she could to offer residents choice other than that which was on the menu on any given day. Catering records were being maintained, with appropriate safety checks carried out. The dry food stores appeared minimal at the time that we saw them. Care Homes for Older People Page 19 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. People living in this home can be more reassured by the latest approaches being adopted in the home towards managing complaints and protecting their interests and rights, and protecting them from abuse. Evidence: The home had a clear complaints policy which, although was reported as usually being displayed in the entrance hall, was not on this occasion. This had been addressed by the second day of our visit. Half of residents who responded to our survey told us that they did not know how to make a complaint, although acknowledged that there was someone to talk to if they were unhappy about anything. We inspected the numerous records of complaints that had been received by the home. Copies of associated investigations and correspondence were included and, with the exception of one complainant for whom a resolution appeared to have been delayed, each had been addressed robustly with the necessary actions taken in response. A visitor we spoke to had no concerns at all, and expressed their complete confidence in the home to address them should any arise. Residents told us that staff usually listened and acted on what they said, whilst one person said that they sometimes did. Some of the residents told the Expert by Experience that they would have no problem in approaching a staff member or the manager, who would put things right. Care Homes for Older People Page 20 of 38 Evidence: One particular resident told us that staff did not always listen when they raised an issue. Within the past year two complaints were raised with us about Arle House. These related to aspects of care, staffing and deployment, and food and hygiene standards. At the time these were raised there appeared to be little confidence amongst informants that the issues would be fully addressed and resolved by the existing management arrangements that were in place at that time. However, the latest management declared in the AQAA that the home made use of complaints to inform the service development, and the new manager demonstrated his clear intention to remain open and accessible to any issues of concern that people wanted to raise. The home had policies and procedures for the protection of the vulnerable residents. An incident reported to us recently highlighted that these required a degree of review, to ensure the correct telephone contact details were included for expediting referrals to the Safeguarding Team at the Local Authority. The homes AQAA indicated that the level of staff training to prevent and deal with abusive practice had been increased due to some concerns about poor attitude from isolated staff, showing a lack of respect towards residents. This training was reported during the inspection as being a person-centred care session. The new manager was not aware of anything else specific at this stage, although went on to say that he was intent on providing a very positive role model to staff in terms of respect for residents and upholding their rights. Recognition and prevention of abuse training was delivered during the staff induction training period, as well as part of the ongoing staff development programme. Some of the staff to whom we spoke were conversant in the areas that the training had covered, including people to contact and multi agency involvement for when concerns arose. A decision-making flow chart had been produced to address the residents rights under The Mental Capacity Act 2005 (MCA), and MCA assessment forms were reported by the Assistant Operations Manager as being due for phasing into full use during September. In recent weeks a number of concerns have arisen around the unacceptable practices of particular staff. There has been an obvious move amongst more recent management to address these issues in a more robust manner, and the necessary staff disciplinary procedures had been implemented for the protection of the residents. Care Homes for Older People Page 21 of 38 Evidence: A visitor told us that they had faith in this home, unlike where their relative had previously been, and trusted staff completely. Care Homes for Older People Page 22 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. People living in this home are generally provided with accommodation that is suitable and safe to meet their needs, despite the evident constraints of the long-standing existing building. Evidence: A committed and regular maintenance person was employed, and there was an ongoing maintenance and redecoration programme in place. The dining room had been redecorated and new flooring had been provided. Corridors had also been repainted. A number of additional profiling beds had been provided to meet residents health needs. Certain parts of the home appeared fatigued and worn, but these were generally not in areas that were accessible to residents, such as the laundry rooms and sluice rooms. The garden was well tended and was safe and accessible to residents. One resident told us that Arle House was a comfortable home, was warm and had all the comforts. The home was clean and free of unpleasant odours in the main, and the cleaning staff were seen shampooing carpets. One of the sluice rooms was not particularly well kept when we saw it, with a clinical waste bag having been left on the floor where it had fallen from its holder, and a spillage of water on the floor being left. We saw at least Care Homes for Older People Page 23 of 38 Evidence: two residents bedrooms that remained untidy with unmade beds by the time lunchtime had arrived. Laundry was segregated appropriately before washing, and machines had sluicing and disinfection cycles as part of the infection control procedures. We saw good supplies of liquid soaps, sanitising hand gels, disposable aprons and paper towels around the home. The Expert by Experience spoke with the laundry assistant who said that every effort was made to ensure each resident had their own clothes returned to them, with loss of clothing kept to a minimum. Care Homes for Older People Page 24 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home receive care from a staff team that currently possesses a degree of inconsistency in terms of its overall stability, recruitment and development. Evidence: The AQAA demonstrated that there had been a significant use of agency staff in recent months, both among nurses and care staff, although from talking to staff there were a core group of carers who had been at the home for some time. The home intended to increase its own bank of staff if possible in order to avoid this agency usage in the future. The home did not currently have a deputy manager in post, and there was a lack of regularly contracted trained nurses. The new manager was making all efforts to address this through a robust recruitment strategy. In addition to this, he also had a number of carer applications to consider. The staff rotas included the provision of two nurses each morning, with ten care staff; two nurses if possible, and up to eight carers during the afternoon and evening, and one nurse and three care staff overnight. The rota showed occasions when there were less than these numbers on the late shift, but it was evident that all efforts were made to provide adequate numbers of care staff, sometimes with the use of agency staff. Staff were divided into teams of care leaders and carers, and deployed to work in specific areas of the home. A very experienced senior care leader from another care Care Homes for Older People Page 25 of 38 Evidence: home in the Trust group was seconded to Arle House for one month in order to overview systems and identify any weaknesses in the homes existing working practices that had evolved over time, and which were not necessarily meeting the needs of the home. There was an ancillary team of cooks, cleaners, a laundry assistant, maintenance and administrative staff to support the care team. A laundry assistant was not provided every day of the week, meaning that care staff had to undertake a degree of laundry duties in addition to their care duties. In our view this arrangement was not ideal and presented a slight risk to care staff being readily available to residents at times. Some of the staff who responded to our survey told us that there needed to be better organisation on the floor, with better team work, and that this included the nurses as well. Residents generally spoke positively about the staff, although one person told us that the home needed more of them. We spoke to a visiting health care professional who told us that the home really needed a more stable team, particularly among nurses. We witnessed at least two significant periods when residents call bells rang for a prolonged time before staff responded due to pressure of work and demands upon their time. We had previously received a complaint that incorporated concerns about the levels of staffing in relation to the high dependency needs of some of the residents. As a consequence of this, staff rotas and allocations were reviewed at the time, with a small increase in numbers of care staff provided. The Trusts Professional Development Nurse provided support to the nursing team also at the time. There was an expectation that care staff started a National Vocational Qualification in Care (NVQ). There were currently thirteen care staff qualified to a level two standard, with the care leaders qualified to level three. The NVQ training programme was in progress for one member of staff, and we were told that three staff names had been submitted to start this training as soon as possible. We inspected recruitment files for two nurses. Application forms provided a full and detailed employment history. Two references, one of which was from the previous employer had been obtained and proof of identity had been confirmed. Verification of why the worker had left their last place of work had been sought on applying for references, and in one case the referee had identified a reason of possible concern as to why the person had left their employ, but there was no evidence that this had been Care Homes for Older People Page 26 of 38 Evidence: further explored or risk assessed before offering employment. The correct Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks had been carried out. Proof of qualifications had been confirmed in one of the cases, but in the other the persons eligibility to practice as a nurse had not been confirmed with the National Midwifery Council until one month of employment had elapsed. Equal opportunities monitoring was being carried out, and offer letters and terms and conditions of employment had been issued. Staff told us that they had received induction training when they had started working here. We saw certificated evidence of new care staff undergoing induction training that covered the national Common Induction Standards (CIS) for care workers. The care leader confirmed that new staff worked under supervision of an experienced worker when they first started in the home, and also had some supernumerary time in which to observe and learn. There was a designated training coordinator in the home, however the monitoring and planning of the training programme was disorganised, with a sporadically maintained and unreliable paper matrix in place. We were told that the computerised training records were not available due to some unresolved Information Technology (IT) issues. There was an auditing system currently in operation however, so that shorfalls in the training programme could be identified and addressed. Staff had individual training and development portfolios, and these contained evidence of any training that had been undertaken. The homes AQAA told us about training in the use of syringe drivers, but we could not evidence this further from the records. The Assistant Operations Manager was able to confirm to us that it had taken place however. We could not directly evidence from records that the nutritional training reportedly delivered in the AQAA had taken place. Dementia care, and Care of the Dying Person training had been delivered. Moving and Handling training had reportedly taken place but the records to support this were not available. Staff spoke to us of good training and development opportunities being available to them. Care Homes for Older People Page 27 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. There have been some changes to the management systems in place here, however these need time for further development if the interests of the residents living in the home are to be safeguarded more consistently. Evidence: There have been some changes to the management of this home during this year. Issues relating to the management have been under some scrutiny by CQC and also the care provider, The Orders of St John Care Trust. There has been an acting manager for a short time since the departure of the previous one, and a new and permanent manager was appointed some weeks ago. This person is experienced and qualified for the role, and is now required to submit an application to register with us. He confirmed that he had already begun this process. A staff member who responded to our survey told us we need more consistent management, whilst another said give us a manager who is willing to stay; the changes bring unrest to residents and staff. Staff and residents spoke positively about the new management, saying that he was Care Homes for Older People Page 28 of 38 Evidence: much more evident and accessible around the home. We observed that he enjoyed a good deal of contact with the residents and was getting to know them. He was not averse to helping residents with their personal care needs as well as managing the home overall. One member of staff told us that he tackled issues quickly, particularly those affecting residents. The AQAA was completed by the acting manager prior to her departure to another home in the care group. It provided us with a lot of positive information about the home and its services, however aspects of the information could not be directly evidenced and supported during the course of our visit. Information showed the home had a range of documented policies and procedures that had been kept under review. The new management at Arle House had commenced a more robust approach towards quality assessment to ensure that standards in the home could be monitored more closely and, where needed, improvements made. A range of internal quality auditing tools had been developed to look into care planning and medication management, and a major internal audit had been undertaken some weeks ago and an action plan devised to address the numerously identified shortfalls. Annual quality assurance surveys were carried out in order to obtain views and experience of the service from residents and their relatives, with the latest survey currently in progress. The AQAA told us that six monthly reviews were also carried out with residents, and a member of their family if they wished, as another method of ensuring that residents could influence their care and any changes and improvements in the home, however these did not appear to have been carried out consistently. A residents meeting was planned, with relatives also welcome to attend. There were no residents currently subject to the Deprivation of Liberty Safeguards (DoLS). The manager had undergone training in this area, and plans to ensure that staff received the necessary training also, using a County Council Website training programme were reported to us. Some residents had chosen to place personal money in the homes main safe for safekeeping. Records were maintained in each individual case, which contained evidence of running balances and transactions. Receipts were available to confirm any transactions that had taken place. We carried out a number of random checks on arrangements and each was in order. It was the policy of the home that two members of staff signed records in the absence of a resident being able to sign to acknowledge transactions for themselves, however there were a number of entries that only displayed the administrators signature. She told us that she was aware that she had Care Homes for Older People Page 29 of 38 Evidence: to follow up on this with the other person involved. There were a number of incorrect entries that had been rectified using white erasing fluid. This method served to mask the entry, and we strongly advised against this, recommending that a written strikethrough principle be used instead so that records remained completely transparent. We saw one example of a resident signing their own financial record. The AQAA told us that there was a staff supervision programme in place. However we found that the delivery of this had been inconsistent to date. Carers were certainly aware of a more structured approach to this being planned, and a tiered responsibility amongst senior staff for the programmes delivery had been devised. There were some supervision records in place, but the recent management changes and inconsistency had not helped towards consolidating any plans at this stage. Previous concerns raised in relation to this home had identified that the staff team needed closer supervision in practice, with stronger leadership and guidance being an important factor in this. One member of staff told us that there needed to be much better communication between the care team and the nurses, whilst others indicated that they received good levels of support. One person told us that the home desperately needed reliable and consistent nurses. The home had written policies and procedures in relation to the promotion of the health and safety of the residents, visitors and staff, and associated training was provided for staff. Records showed us that regular safety checks and planned maintenance visits had been carried out on the fire safety systems. Residents had an individual fire safety risk assessment in their care plan. Fire safety training had been delivered to staff, and this had incorporated theoretical and practical training, with instruction in evacuation procedures in the event of a fire. Hot water temperatures were being monitored for safe levels, and a Legionella risk assessment and appropriate control measures were in place. Timely safety checks and maintenance had been carried out on utilities and equipment. First aid facilities were available and staff had received First Aid training from an accredited training provider. A number of doors to restricted areas, such as the laundry, sluice, stores and staff room were fitted with secure coded key-pads. However these had been left open by Care Homes for Older People Page 30 of 38 Evidence: staff during the afternoon of the first day of our visit. Not only did this give vulnerable residents access to areas of greater risk, but one of the sluice windows on the first floor had an unrestricted opening. This was addressed immediately and made safe, and the manager made arrangements to ensure that staff did not leave doors to these rooms open. We were notified about an intruder in the home last year, who had entered in daylight through an open door. Nothing was taken from residents, although a staff purse was stolen. The home took the appropriate actions in repsonse to this incident at the time. 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 1 5 The registered person must ensure that a copy of the Service User Guide (home information brochure) is issued to each resident. This is so that all residents have enough information about services in the home, and that they are helped to make informed choices. 31/10/2009 2 3 14 The registered person must ensure that written confirmation is provided to prospective residents following an assessment of their needs. This is so that the person can be assured that the home will be able to meet their needs in respect of their health and welfare. 31/10/2009 3 7 15 The registered person must ensure that staff devise detailed written care plans which clearly show how 31/10/2009 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 residents health and personal needs are to be met. This is so that all identified needs, including pressure area vulnerability and acute illness can be fully addressed. 4 8 12 The registered person must ensure that staff review pressure area risk assessments fully and appropriately. This is so that the correct risk factor can be identified and the most suitable care provided. 5 9 13 The registered person must ensure that medication charts contain clearly recorded instructions for the use of all medications, including for external preparations. This is so that residents can receive their prescribed medications in accordance with prescribed instructions to meet their health needs. 6 9 13 The registered person must ensure that changes to dosage instructions of medications are clearly identified on the medication 31/10/2009 31/10/2009 31/10/2009 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 charts, including the date of the change and by whom it was authorised. This is so that residents can receive their medications as prescribed. 7 9 13 The registered person must 31/10/2009 ensure that a clear record of medication administration signatures is maintained on the medication charts. This is to ensure residents receive their medications as prescribed and avoid possible errors in administration. 8 29 19 The registered person must 31/10/2009 ensure that documentary evidence of a prospective workers qualifications and training, and that evidence of registration with a professional body is obtained before employment is offered. This is so that vulnerable residents can be protected from unsuitable workers. 9 29 19 The registered person must 31/10/2009 ensure that any reasons for prospective new staff leaving their previous employment, which involved the care of vulnerable 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 adults, are sought before offering employment. This is so that vulnerable residents can be protected from unsuitable workers. 10 31 8 An application for the manager of the home must be submitted to CQC for consideration. This is to ensure that a suitable manager for the service can be considered for registration by CQC. 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 31/12/2009 1 2 7 8 Staff should complete the life history section in care plans in full. Staff should record the actual amount of food eaten on dietary monitoring charts so that nutritional intake can be more accurately determined in cases where nutritional risks are identified. The registered person should ensure that residents mealtime arrangements are reviewed to ensure that there are suitable intervals between meals, and that residents are not brought into the dining room to be left waiting unattended for an unacceptable time before their meal is served. A laundry assistant should be provided each day, so as to avoid care staff having to undertake laundry duties. Two staff signatures should be recorded on residents financial records to confirm and witness any transactions 3 15 4 5 29 35 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 carried out on their behalf. Staff should not use white erasing fluid to mask incorrect entries on these records. 6 36 Staff should receive formal supervision at least six times in a twelve month period. Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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