Inspection on 25/01/10 for Ashbourne House Nursing Home

This inspection was carried out on 25th January 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbourne House Nursing Home 12/05/10

Ashbourne House Nursing Home 29/10/09

Ashbourne House Nursing Home 01/05/08

Ashbourne House Nursing Home 21/05/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

Key inspection report Care homes for older people Name: Address: Ashbourne House Nursing Home 376-378 Rochdale Road Middleton Manchester Lancashire M24 2QQ     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: Lucy Burgess     Date: 2 5 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 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 39 Information about the care home Name of care home: Address: Ashbourne House Nursing Home 376-378 Rochdale Road Middleton Manchester Lancashire M24 2QQ 01616432060 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Silverdale Care Homes Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: 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: Old age, not falling within any other category - Code OP, Dementia - Code DE. The maximum number of service users who can be accommodated is: 29. Date of last inspection Brief description of the care home Ashbourne House Nursing Home is a converted and extended home located a short distance from the centre of Middleton, owned by Silverdale Care Homes Limited. The home is registered to care for up to 29 people with personal care needs, nursing Care Homes for Older People Page 4 of 39 Over 65 0 29 29 0 2 9 1 0 2 0 0 9 Brief description of the care home needs and those with dementia. Accommodation is provided over two floors, the majority of it on the ground floor. Part of the first floor of the building is not available to residents because of structural defects that are being repaired but repairs have not yet been completed. The range of fees at the time of our key inspection were 347.71 pounds to 460.32 pounds per week. Additional charges are made for Chiropody and Hairdressing Care Homes for Older People Page 5 of 39 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 was a key inspection visit, which included a site visit and took place over one day by an inspector and a pharmacy inspector. The service did not know that the inspectors were to visit. An Annual Service Review had been carried out on in May 2009, at that time our opinion had changed about the service. We had also been made aware of some concerns by the Local Authority. Due to this we conducted a Random Inspection in October 2009. A number of areas needing improvement were required. We also found concerns in relation to the safe management and administration of peoples medication. Following this visit we held a management review. It was agreed that a full key Care Homes for Older People Page 6 of 39 inspection would be undertaken as well as a referral to the CQC pharmacists so that a full audit of the homes system could be carried out. During this visit time was spent looking at records in relation to care files, staff recruitment, training and development, meals and health and safety. Time was also spent looking at the environment as well as observing peoples daily routines and interactions with staff. Our pharmacist completed a full audited of the medication system. Serious concerns were identified resulting in evidence being taken under a Code B. Two immediate requirements were also made with regards to people being provided with the medication they are prescribed and a satisfactory report regarding the electric circuit. Further issues have been detailed within the report. Following our visit a second management review would be held with our enforcement team to consider what further action was required. As part of our inspection process the manager was asked to complete an Annual Quality Assurance Assessment (AQAA), which was then forwarded to us prior to our Review. We also send out feedback surveys to people living at the home, their relatives and staff. We received a good response with 25 surveys returned. Comments have been added to the report. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? What they could do better: Initial assessments completed prior to people being admitted to the home need to include all relevant information as well as support currently being provided by health care services so that this is reflected in the care plan. This will ensure that all relevant support continues to be provided so that person care needs are fully met. Individual care plans should be available for each of the residents so that staff are provided with clear direction about how the people wishes to be supported ensuring their needs are met. Information detailed within the care files needs to reflects the current and changing needs of people. Where specific areas of concern have been identified a separate plan needs to be provided showing how the person is to be supported along with any intervention required. All areas of medication handling are unsafe. Effective procedures must be in place to help staff handle medicines safely. Medication must be stored securely at all times. Stock levels of medicines must be looked at to ensure good stock rotation. Medication which needs to be sent for destruction must be handled in a suitable manner. Records about all aspects of medication must be clear and accurate to show that medication is given properly and can all be accounted for. Details about how to give medication which is prescribed as when required or as a variable dose must be recorded so staff can give medicines safely and consistently. Full assessments of risk must be recorded when prescribed medication is kept in bedrooms or when people are looking after their own medication. Care Homes for Older People Page 8 of 39 All medication must be given as prescribed; this includes having full knowledge of peoples current doses of medication and ensuring medicines are in date when administered. Prescribed medication must be available in sufficient quantities in the home and must not be allowed to run out. An overview of the ordering system needs to be undertaken so that medication is always available. The unsafe practice of secondary dispensing must stop immediately. Staff who handle medicines must be properly trained and must be assessed as competent to administer medication safely. The manager must make checks to ensure medication is handled safely. Unsafe medication practices put residents health and wellbeing at risk from harm. The home needs to provide residents with opportunities for social interaction and activities so that they have variety to their day enabling them to follow a lifestyle of their choosing. Arrangements in relation to meal times need to be improved so that people are able to sit and eat their meal comfortably with any necessary support they may need. Detailed policies and procedures in relation to safeguarding people need to be made available to staff along with relevant training so that they are aware of their responsibilities in ensuring people are kept safe. Following our last visit we requested a refurbishment plan however this was not provided. The registered person is again requested to provide us with a refurbishment plan along with timescales for completion so that people living at the home have a good standard of accommodation. This will be monitored to see what progress is being made. Recruitment practice needs to be improved. The registered person must ensure that anyone who is offered work for the organisation does not commence their employment until 2 satisfactory written references have been received, ensuring the safety and protection of people who live at the home. Records should also include a detailed employment history and any changes in their employment with the home. Sufficient staffing must be made available at all times so that people can be supported appropriately based on their individual needs providing a more positive experience for people. On going staff training must be provided to ensure their continuous personal and professional development. So that residents are confident they are being supported by competent staff who are able to met their needs. All new staff must complete a skills for care induction ensuring they are fully aware of the policies and procedures within the home so that they can carry out their duties safely. All staff must receive a minimum of six supervisions per year so that they are provided with clear direction and support in carrying out their role ensuring their continuous development. Care Homes for Older People Page 9 of 39 Evidence of the registered person monthly monitoring visits should also be provided to CQC to show that they are monitoring the service delivered. An effective system of monitoring the quality of service provided needs to be implemented so that outcomes for people living at the home are improved ensuring they receive a good service. Up to date policies and procedures need to be provided within the home so that all staff are clear about their responsibilities when carrying out their duties. The registered person has previously been asked to provide evidence of an up to date 5year electric circuits check. This again could not be provided. An immediate requirement was made requiring the Provider to provide us of evidence of this or make arrangements for a further check to be complete within 48 hours of our visit. 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 10 of 39 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 11 of 39 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. Comprehensive information needs to be gathered during the assessment process ensuring only those poeple whose needs can be met are admitted to the home. Evidence: The files of 3 people were examined, each were selected at random. One file included a new resident who had recently moved into the home. We looked at the assessment process undertaken to determine whether placement at the home was suitable. The manager had carried out the assessment the day prior to admission. The home has assessment document, which is used to gather information about the persons social, emotional and physical needs. Areas included; their personal details and those of their next of kin and relevant health and social care professionals involved, diagnosis, any history of falls, list of medication, personal care needs and level of support needed as well as their social interests. Care Homes for Older People Page 12 of 39 Evidence: This information was seen for the new resident however we were also made aware reading through the diary notes that this person was being treated by the district nurse team. However there was no information on the assessment to show why, what treatment was being provided or how often they would be visiting. It was further noted that this person did not have a care plan. Without comprehensive information about a persons care needs there is no assurance they will be supported in a way in which they would choose. Care Homes for Older People Page 13 of 39 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. Without detailed care plans there is no assurance continuinity of care will be offered ensuring people need are safely met. The management of medicines is unsafe and puts peoples health and wellbeing at risk of harm. Evidence: As already stated, we examined the care files for 3 people living at the home. One person had recently moved in, another had been admitted on respite and the third person had lived at the home for sometime. During our random inspection in October 2009 the manager advised us that new care plan documentation was being introduced. During this visit we found that this had not been carried out on all files, therefore some of the documentation varied. The first file examined was for a new resident. It was acknowledged that this person had only moved into the home several days before our visit and therefore the completion of a comprehensive care plan had yet to be carried out. However we found that information gathered at assessment had not been outline in the file. We would Care Homes for Older People Page 14 of 39 Evidence: expect that an interim plan be put in place outlining the support needs of the person, so that staff are aware of how they are to assist the person. Risk assessment documents were also on file, however these too were incomplete. We were aware that the district nurse was visiting the home to tend to the person however there was no reference of this on file. On the second file, risk assessment documentation had been put in place however again their was no care plan about how this person was to be supported. The third file was more detailed. A care plan and risk assessments had been completed. Information had been reviewed on a monthly basis. It was noted however that the plan only referred to areas of concern and did not provide details about the persons care needs. The registered person must ensure that a detailed care plan covering the social, emotional and personal care needs of people are provided. Without such information their is no assurance people will be supported in a way they wish or need. Other records were also held. These include daily reports, professional visits, weight records and other correspondence. On one file we also saw a monthly audit sheet, which had been completed by the named nurse. Some of the comments received from people in the surveys showed that improvements could be made in relation to the care provided. People said; they need to ensure adequate staff cover is available to enable all planned care to be met adequately and sometimes care needs cannot be given as documented and therefore aims of care are not always met. Other comments were more positive. They included; I feel that Ashbourne House takes the needs and wishes of all residents into account when planning the day to day running of the home and Ashbourne is trying to give the best possible care. This needs to be explored by the registered person ensuring people receive a quality service which meets their needs. Two areas of good practice were noted. One file contained My Life Story Book, this included a photograph of the person with details about their family life, holidays, hobbies, family tree, memories of the war, routine and preferences and birthdays and anniversaries. This information was written in a sensitive way and provided good information about the person and things that are important to them. One staff member commented in the surveys; The new documentation life story books help all staff to understand more about each resident. These should be developed for each of Care Homes for Older People Page 15 of 39 Evidence: the residents. A further file contained documentation in relation to the Deprivation of Liberty Safeguards. A referral had been made to the local authority for authorisation with regards to the use of restraint with a resident. Prompt action had been taken to ensure that the safeguards in place were agreed with the local authority. During the inspection the specialist pharmacist inspector looked at how well medicines were handled to make sure that residents were being given their medicines properly. This was because at the previous inspection we identified that some areas of concern about how medicines were handled. Since the last inspection we found little or no improvements had been made in the medication systems to address the concerns found. At the last inspection we found that there were a large number of medicines stored in a stock cupboard. Some stock had not been rotated or sent for destruction. We found this was still happening at this inspection. As at the last inspection, we found that some items of medication were unlabelled so it was unclear who medication was prescribed for. The storage arrangements for medicines were generally suitable; however as at the last inspection we found that creams were being stored in peoples bedrooms without any assessments made to show it was safe to do so. Items which are not stored securely could be accessed by anyone in the home which may put their health at risk from harm. We also found that some eye drops, which should have been stored in a fridge, had not been kept cool. If medication is not stored according to manufacturers directions then it may not work properly. Records about medication administration were poor and did not always show exactly what medication had been given residents or that it could be accounted for. We found little or no improvement had been made to them since our last inspection. Nurses did not always record the quantity of medication that arrived in the home for people, or the current amount of medication held for each person. There were some records about medication that had been refused or was no longer needed, but it was not possible to tell if they were accurate. This was because nurses had popped out all the tablets into a special container for medicines waste. Tablets must be returned for destruction in their original blister packs to comply with current legislation. There were gaps on the medication administration record sheets (MARs) where staff had failed to sign to show if they had given or omitted medication. There also symbols Care Homes for Older People Page 16 of 39 Evidence: were used on the MARs such as O meaning other but staff failed to record an explanation as to what other meant. We also found that nurses had changed the dates on the MARs so it was very difficult to tell which day medication had been given to certain people. During the inspection we compared the medication held in the home for people with the records about medicines. We found that the records showed that some medication had been given but had not been signed for. We observed the nurse on duty signed that she had given medication but did not administer it. The medication was not available in the home to give. We found that some medicines were in the home but there was no record of them being there. In some cases this meant that people missed doses of their medication because nurses did not know exactly what medicines people were currently prescribed. We also saw that nurses did not always sign for medication they had given at the time they gave it; this is poor practice which could lead to people being given too many or too few doses of medication. Other records about medication were also poor. No information was recorded in the care plan for nurses or care staff to follow about how to give medicines which were prescribed as a variable dose or when medication was prescribed when required. If staff do not have enough information to follow to give medication safely and consistently then peoples health could be at risk. Records showed some people looked after some of their medication, such as inhalers, but there was no information recorded that checks had been made to ensure it was safe for them to do so. We had serious concerns that nurses had adopted some unsafe practices in administering medication. Nurses sometimes gave medication by secondary dispensing. A type of administration that is recognised as high risk and potentially dangerous. Secondary dispensing involves the removal of tablets from their original containers supplied by the pharmacy and placing it in unlabeled containers well in advance of it being given to the people for whom it was prescribed. The nurses were placing the medication in small medication cups and placing a scrap of card in each cup to show who the medication was for. There is a high risk that these little scraps of paper could get muddled up and the wrong medication would be given to the wrong person. We found that there were names on scarps of card for 18 people indicating that this may be done for as many as 18 people at any one time. We told the manager at the inspection that this practice must stop immediately and she assured us it would. We also found that people who were prescribed eye drops were at high risk of having out of date drops given to them. This was due to a combination of things such as poor Care Homes for Older People Page 17 of 39 Evidence: stock rotation and a failure to always date drops which have a limited life once open, on opening. One person was given eye drops which were 3 weeks beyond the expiry date. We found that people were not given medication as prescribed and their health may have been placed at significant risk from harm. Our visit coincided with the first day of the new medication cycle. The nurse on duty told us that three people could not have their medication that day, because the home had not realized they had not received their monthly medicines. This was due to very poor ordering systems and a failure to check medication when it arrived in the home. We looked in detail at the MARs for 9 people and found that 7 of them had run out of some or all of their medication during the previous 2 months for time up to 5 days at a time. We also found that other people did not have medication available for administration on the day of our inspection, but this was not mentioned to us by the nurse or manager. Records also showed that some times people had been given double the dose of their medication. One gentleman was given a double dose of some medication over a period of 9 days and a lady was given a double dose of her sleeping tablets over a period of 3 days. We found that one person was given another persons medication because theirs had run out. This is very poor practice as nurses should only be give medication to the person for whom it was supplied. One gentleman was not given one of his tablets properly for two weeks. The consultant at the hospital had doubled the dose of his tablets, but he had not been given the increased dose. For two days he did not have any tablets because nurses thought his medication was out of stock. During the visit the inspector found his new supply of tablets in the back of the stock cupboard, the dispensing label showed they had been dispensed two weeks previously. One person was prescribed very strong pain relief in the form of a patch which must be changed every 3 days, 72 hours. We noted that last application of the patch was 18 hours later than it should have been. This person may have been without adequate pain relief for this period. We talked to the manager and nurse on duty about the exact medication three people living in the home should be taking. Neither could tell us the dose of a tablet one Care Homes for Older People Page 18 of 39 Evidence: person was currently prescribed nor could they tell us if one persons tablets had been stopped by the doctor. The manager could tell us what the third person was meant to be taking but the nurse had signed for medication which the resident was not currently prescribed and was not in stock in the home but was listed on the MARs. The manager told us she did not do any formal audits to check that medicines were handled safely. It is important that these checks are made. It is also vital in light of our findings that nurses have training in medicines handling and are assessed as competent to handle medicines safely. During the inspection we asked for the medication doses to be confirmed and we expected that steps would have been taken to obtain medication which was not available for people. This had not happened by the end of our inspection so we issued an immediate requirement form which required the home to make sure everyone had enough medication and to tell us exactly what had been obtained also to confirm the doses of medication one person by the following day. We received a fax the following day which confirmed the dose of medication for that person. We also received information that two peoples medication had been obtained and the supply for a third person would arrive the following day, but they failed to detail exactly what medicine had been obtained. Care Homes for Older People Page 19 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Routines do not afford people independence or opportunity in making the most of their abilities so that they are able to live a lifestyle of their choosing Evidence: During our visit we looked at the daily routines of people. We were told that the home employs an activity worker, who works 3 afternoons a week. Time was spent observing what takes place during the day as well as speaking with a group of people in the lounge and 3 people in their own rooms. From our observations we found that there was little stimulation provided and at times little interaction with staff. For a period of time there was no member of staff present in the lounge. One carer had escorted a resident to an appointment, the 2 remaining carers were assisting individuals with personal care and the nurse was updating care records. We asked people what activities were made available and how they spent their time. They said that there was generally little offered, with much of their time spent watching television. One person said that at times, they were bored. Four people Care Homes for Older People Page 20 of 39 Evidence: spoken with said that there was nothing going on throughout the day. Other people commented on the surveys; activities could be improved and I would like to go out more. Again this is an area the registered person needs to explore so the people are offered a choice in their daily routine enabling them to maintain some quality of life. Visits were made by a visiting hairdresser. Several people confirmed that they enjoyed this and had their hair done each week. The home has an open visiting policy. People are able to meet with their visitors in the privacy of their own rooms or in one of the communal areas. We spoke with the cook with regards to meal arrangements. Weekly menus are available. Residents are offered a choice, with the main meal being served at lunch time. The cook was aware of those people who had specific dietary needs. Sufficient food stocks were available with shopping being purchased on weekly basis to ensure items were rotated. Feedback from 2 residents spoken with was very positive about the quality and choice of food provided. They said; always plenty and the cook knows what people like or dont like. Further observations were made during the evening mealtime. People were able to have their meal either in the dining room, the lounge or in their own room. The cook was serving the meal with support being offered by the 2 carers. One carer was taking meals to those people in their own rooms, trays were not used. The second carer was helping to feed a resident. A number of other residents would have benefited with some assistance. Two residents were seen to use their hands to eat their meal as they had the wrong cutlery, another persons meal went cold as they needed to be prompted to eat, a further person commented, only beans, better than nothing I suppose. One person who was eating their meal in their room was seen balancing their meal in their hand as they did not have a table. Another person in the lounge was unable to sit close enough to their meal and therefore spilt it on their clothing. We discussed all our observations with the manager. She acknowledged that this was poor and that further improvements were needed so that people were afforded a more positive experience and enjoyed their meal times. We were told that small tables were being purchased as well as new crockery so that mealtimes would be more comfortable. Care Homes for Older People Page 21 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst information is available with regards to complaints and protection, practice found does not ensure that people are being protected from risk of harm. Evidence: We had received an up to date copy of the homes statement of purpose and service user guide. This includes a copy of the homes complaints procedure. The manager advised us that other policies and procedures need to be drawn up and implemented. This must include a comprehensive policies and procedure in relation to Safeguarding Adults (including reference to the Local Authority procedure), Whistle Blowing, Mental Capacity Act and Deprivation of Liberty Safeguards. Staff must also be made aware of their responsibilities in these areas so that people are protected. Information provided on the training matrix showed that little recent staff training had been provided in relation safeguarding. The manager must make arrangements for this to be provided so that staff are aware of their responsibilities in this area and know what to do should an incident arise. We discussed with the manager arrangements in relation to the management of residents finances. Only a small number of people are supported with their money. Others were generally assisted by their relatives or an appointed representative. For those where money is held, the manager explained that records were maintained along with receipts for any items purchased. Care Homes for Older People Page 22 of 39 Evidence: Due to some of the concerns found with regards to unsafe medication practice, we have raised these with the local authority in line with their safeguarding procedures. Care Homes for Older People Page 23 of 39 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. Improvements are need to enhance the appearance of the home so that people are provided with comfortable accommodation, which is well maintained. Evidence: During our visit in October 2009 we found that requirements had been addressed with regards to the sluice area. However further work to improve the standard of accommodation throughout the home had not. The registered person had again been asked for a refurbishment and redecoration plan however this was not provided. During this visit we found that residents were sharing the communal areas on the dementia unit as work had commenced in other areas. We were told that this had started before the Christmas holidays however progress had been very slow. We were pleased to note that the initial changes would include a new office space for the manager, allowing more space for the staff and the safe and confidential storage of records. The manager advised that she does not have a formal record of work required or planned to be carried out within the home. We were told that the registered person had agreed to draw this up. This must be addressed and include the redecoration and refurbish of each room, replacement furniture, rooms being used for storage need emptying and bathrooms need updating so that they meet the physical needs of Care Homes for Older People Page 24 of 39 Evidence: people. A copy of this must be provided and progress will be monitored. The standard of accommodation must be improved so that people are provided with a good standard of accommodation. Whilst looking round the home, areas were found to be generally clean and tidy. The home employs 2 domestic staff and a laundry assistant. There is also a part time handy man who deals with any general repairs within the home. Staff had been provided with protective clothing and were seen to be wearing aprons and gloves when supporting people with specific tasks. Hand washing provisions were also available in areas where personal care is provided. Relatives commented in the surveys about the environment. They said; they could do with more staff including cleaners and handyman and home could do with being updated such as heating, windows and doors etc. Care Homes for Older People Page 25 of 39 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. Without sifficent competent trained staff that have robustly recruited, there is no assurance people will be cared for safely. Evidence: Staffing levels were reviewed. We looked at staffing rotas for the week of our visit. At present the manager spending the majority of her time covering as the nurse on duty with little time allocated for office work. Days shifts are from 8am to 2pm and 2pm to 8pm and night shifts 8pm to 8am. Cover provided each day includes a nurse and 3 carers and at night 1 nurse and 2 carers. There are 6 hours each day provided by an registered mental health nurse (RMN). The care team is supported by domestic, laundry and catering staff as well as a part time handyman. Whilst the rota shows that sufficient staff are on duty for the current number of residents. We found through our observations that this was not the case. Due to staff escorting for appointments and considering the needs of people there were not sufficient staff available throughout the day. The recruitment files for 4 staff were looked at. Information included an application form, health declaration, written references, Independent Safeguarding check (previously POVA) and criminal record checks (CRB). Further information was on file with regards to checks carried out for nursing staff. This including details of the Care Homes for Older People Page 26 of 39 Evidence: Personal Identification Number (PIN) held by the Nursing and Midwifery Council (NMC). These showed that staff were currently registered to work. Shortfalls were found. The registered person must ensure that gaps in employment are explained, where staff has terminated their employment then been reinstated that this is clearly recorded and where necessary relevant checks are made and the 2 written references are provided. Without robust recruitment procedures there is no assurance people are being kept safe. Information was provided with regards to staff training. The training matrix showed that some staff had received recent training in moving and handling, first aid and food hygiene. In house fire training was planned for the day following our visit. Further up dates were required in relation to infection control, safeguarding, health and safety, dementia care, nutrition etc. There was not evidence to show if nursing staff had undertaken any training to up date their clinical knowledge. On going staff training must be provided to ensure their continuous personal and professional development. So that residents are confident that they are being supported by competent staff who are able to met their needs. Staff also commented; more availability of courses could be better. Induction and supervision of staff is also an outstanding areas of development. The manager has accessed the skills for care induction workbooks. These need to be completed with new staff. Supervision session have also commenced however sessions have not always been recorded to evidence what has been discussed. During our visit we became aware that a new staff member who had transferred from one of the other homes within the group at the request of the registered person, was living in one of the residents empty bedrooms, sharing the bathing and kitchen facilities with residents. We were told that this was a temporary arrangement whilst accommodation was found. This is not acceptable and must be addressed without further delay. Care Homes for Older People Page 27 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems in relation to the management and organisation of the service need to be improved so that people receive a quality service. Evidence: A Random Inspection was carried out at the home in October 2009. At that time we made a number of requirements in relation to the care and support received by residents as well staff recruitment and conduct of the service. We did not receive a response to this report from the registered person or the manager. During this inspection we found that no improvements had been made to safeguard the well being of residents, particularly in relation to medication practice. As detailed earlier in the report further issues were identified with regards to the daily routines of people, sufficient staffing, training and development as well improvements needed to the environment. Some improvements were noted with regards to recruitment procedures however this too needs further improvement. Overall, this does not demonstrate that the home is providing a good quality service for the people who live Care Homes for Older People Page 28 of 39 Evidence: there ensuring their needs are safely met. The manager has worked at the home for some time. She has considerable experience working within the health and social care sector. We wrote to the manager and provider at the end of 2009 requesting that action was taken with regards to the managers registration. We were informed during this visit that the manager has now submitted her application to register and a date has been set for interview. The day to day running of the home is carried out by the manager with additional support from the nursing team. Each have delegated responsibilities however it was unclear what steps were taken by the manager to ensure that tasks had been completed appropriately, demonstrating that she was confident practice within the home was safe. Systems in relation to quality monitoring need further improvement. Audits of care plans had been introduced, however these had not been completed for everyone. The manager advised us that the monthly monitoring visits on behalf of the provider were also being completed by the area manager. We have previously requested that copies of these are forwarded to us so that we are able to monitor the home. This has not been done. Further information has been requested as detailed within this report following our previous visits. However these have not been provided. This does not demonstrate effective open management of the service. The registered person needs to evidence that they are monitoring the quality of the service provided. Where areas of improvement are needed, these should be detailed within the homes business plan and reviewed periodically. Without this there is no assurance people are receiving a quality service. A random check was carried out with regards to servicing. Up to date checks were in place with regards to small appliances, call bells, gas safety, passenger lift and hoist. Further checks were due in relation to the fire alarm, equipment and emergency lighting. A previous requirement with regards to the 5 year electric circuit certificate could still not be provided. An immediate requirement was made requiring the registered person to make urgent arrangements for this check to be carried out or provide evidence of an existing up to date satisfactory check ensuring the safety and protection of people living and working at the home. Care Homes for Older People Page 29 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 12 Information detailed within the care files must be expanded upon so that information reflects the current and changing needs of people so that the health and well being of people is not affected. 30/12/2009 2 9 13 Items of medication which 30/12/2009 are not labelled for the person they are intended for must be returned to the supplying pharmacy ensuring people are only given items which are clearly prescribed for them. 3 9 13 The manager must ensure that medication which is currently required is kept at the home. Unwanted items should be returned to the supplying pharmacy ensuring good stock rotation so that people only receive medication for which they have been prescribed. 30/12/2009 4 19 23 (2) A programme to detail the 30/06/2008 maintenance and the renewal or replacement of fabrics and the timescale for completing the decoration of the home Page 30 of 39 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action must be forwarded to the Commission of Social Care Inspection. 5 19 23 A refurbishment plan must 30/12/2009 be provided detailing all areas of work required within the home along with timescales for completion. This is to ensure that people are provided with a good standard of accommodation in which to live. 6 29 19 (1)(c) Schedule 2 The registered person must 12/06/2008 obtain two written references for new staff employed to protect the residents The Registered Provider must 30/06/2008 provide a written report of an unannounced visit to the home each month and forward a copy of the report to the Commission of Social Care Inspection 7 33 26 Care Homes for Older People Page 31 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 9 13 The practice of secondary 27/01/2010 dispensing must cease with immediate effect. To protect the health and wellbeing of people who live in the home. To protect the health and wellbeing of people who live in the home. 2 9 13 To ensure that all people 27/01/2010 living at Ashbourne House had medication available for administration and to tell the commission the details of exactly what medication had been obtained or confirmed. so that their health and well being was not affected. 3 9 13 To confirm the exact dose of 27/01/2010 Citalopram that should be received by the identified person so that they are not place at risk of harm. 4 38 23 The Provider must provide us 27/01/2010 with evidence of an up to date 5year electrical check or make arrangements for a further check to be complete within 48 hours of our visit. So that people living and working at the home are not place at risk. Care Homes for Older People Page 32 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Initial assessments 30/03/2010 completed prior to people being admitted to the home must include all relevant information as well as support currently being from health care services so that this is reflected in the care plan. This will ensure that all relevant support continues to be provided so that person care needs are fully met. 2 7 15 Individual care plans must be available for each of the residents so that staff are provided with clear direction about the people wishes to be supported ensuring their needs are met. 30/03/2010 3 9 13 Effective arrangements must 25/03/2010 be put in place at the home to ensure that all medication is administered to peoples in exact accordance with the prescribers directions. Because receiving medicines at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. Because receiving medicines Care Homes for Older People Page 33 of 39 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 at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. 4 9 13 Effective arrangements must 25/03/2010 be put in place at the home to ensure that all medication records regarding receipt, administration and disposal are completed accurately. So that medicines can be fully accounted for to prevent mishandling. Records must also show that medicines are being given correctly and peoples health is not at risk form harm. So that medicines can be fully accounted for to prevent mishandling. Records must also show that medicines are being given correctly and peoples health is not at risk form harm. 5 9 13 There must be effective 25/03/2010 information recorded to enable staff to administer medication safely and know how to store medication safely. To prevent peoples health from being harmed by the misuse of medication. To prevent peoples health from being harmed by the misuse of medication. Care Homes for Older People Page 34 of 39 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 6 9 13 Effective arrangements must 25/03/2010 be put in place at the home to ensure that an adequate stock of medication is available for each person at all times so that people receive their prescribed medication when requried. 7 9 13 There must be an effective 25/03/2010 auditing processes are in place to ensure that managers are confident that medicines are being handled safely. To help make sure that people who live in the home are kept safe. To help make sure that people who live in the home are kept safe. 8 9 13 There must be effective systems in place to ensure staff that handle medicines are trained in medicines handling and are competent to do so safely. To help make sure that people who live in the home are kept safe. To help make sure that people who live in the home are kept safe. 25/03/2010 9 9 13 All medicines must be stored 25/03/2010 securely. Care Homes for Older People Page 35 of 39 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 Medicines must be stored safely to make sure they can not be mishandled and put peoples health at risk. 10 12 16 The home must provide 30/03/2010 people with opportunities for social interaction and activities so that people have variety to their day enabling them to follow a lifestyle of their choosing. 11 15 16 Arrangements in relation to meal times need to be improved ensuring residents have approapriate supervision, utensils and support so that they are able to enjoy their meal in comfort. 30/03/2010 12 18 13 Detailed policies and 30/03/2010 procedures in relation to safeguarding people must be made available to staff along with relevant training so that they are aware of their responsibilities in ensuring people are kept safe. 13 27 18 Sufficient staffing must be made available at all times so that people can be 30/03/2010 Care Homes for Older People Page 36 of 39 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 supported appropriately based on their individual needs providing a more positive experience for people. 14 30 18 On going staff training must 30/05/2010 be provided to ensure their continuous personal and professional development. This should include infection control, safeguarding, health and safety, dementia care, nutrition etc as well as courses relevant to the clinical support provided by nurses. So that residents are confident that they are being supported by competent staff who are able to met their needs. 15 33 24 An effective system of monitoring the quality of service provided must be implemented so that outcomes for people living at the home are improved ensuring they receive a good service. 16 36 17 All staff must receive a 30/03/2010 minimum of six supervisions per year so that they are provided with clear direction and 30/04/2010 Care Homes for Older People Page 37 of 39 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 support in carrying out their role ensuring their continuous development. 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 28 All new staff must complete a skills for care induction ensuring they are fully aware of the policies and procedures within the home so that they can carry out their duties safely. Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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