Inspection on 28/05/09 for Ashfield House

This inspection was carried out on 28th May 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashfield House 03/11/09

Ashfield House 07/06/07

Ashfield House 03/08/06

Ashfield House 07/12/05

Ashfield House 19/07/05

Ashfield House 14/02/05

Ashfield House 03/08/04

Ashfield House 04/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ashfield House Ashfield House Bargates Leominster Herefordshire HR6 8QX     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: Jean Littler     Date: 1 6 0 6 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 36 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 36 Information about the care home Name of care home: Address: Ashfield House Ashfield House Bargates Leominster Herefordshire HR6 8QX 01568614662 F/P01568614662 margaret@wenlock8457.fsnet.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Margaret Mary Wenlock care home 14 Number of places (if applicable): Under 65 Over 65 0 14 dementia old age, not falling within any other category Additional conditions: 14 0 1.The registered person may provide the following categories of service only: Care Home only PC 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 OP 14 Dementia DE 14 Age: Dementia - Code DE age 55 and above. The maximum number of service users who can be accommodated is: 13 The maximum numbers of service users who can be accommodated is:14 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 13 Old age, not falling within any other category (OP) 13 Date of last inspection Care Homes for Older People Page 4 of 36 Brief description of the care home Ashfield House is a Victorian three-storey detached house, set in large, mature gardens and situated on a main road through Leominster. The service is registered to accommodate 14 older people, male or female, who may have needs arising from the normal ageing process or from dementia related conditions. The Statement of Purpose confirms that the home cannot accommodate residents who may have behaviours that significantly impact on other residents in a negative way. Care Homes for Older People Page 5 of 36 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: We, the Commission, carried out this inspection over two days. The first was unannounced on May 28th and the second was announced on June 16th. The second day was needed as the owner did not have keys avaiable to open her office on the first day and she was going on a two week holiday. At the last inspection in June 2007 the service was rated as providing good outcomes for people, therefore an inspection was not carried out for two years. An Annual Service Review was carried out in 2008. The information received from the owner manager Mrs Wenlock and from surveys indicated that good outcomes were still being achieved. Mrs Wenlock provided the annual quality assurance assessment (AQAA) that registered people are asked to complete each year. A sample of survey forms was sent out to Care Homes for Older People Page 6 of 36 obtain feedback on the service. During the visits to the home the building was toured, records such as medication, care plans, training and staff rotas were sampled. Staff were interviewed and residents and relatives spoken with. What the care home does well: What has improved since the last inspection? What they could do better: Information about the home could be made clearer for people considering moving in. Care plans could be reviewed more often to make sure they contain peoples current needs. When peoples health needs increase a reassessment needs to be requested more quickly to ensure they get continuing health care funding at the right time. The way medication is administered and recorded needs to be improved to make sure people in the home get the right medicines. Staffing arrangements could be changed to provide more opportunity for local outings and to ensure care staff can supervise people at all times. Infection control arrangements and waste disposal in the home can be improved. The security of the home can be further improved to help protect and reassure people Care Homes for Older People Page 8 of 36 in the home. The two bathing rooms out of use should be made available again to offer people a choice of which facility to use. New staff should be provided with a comprehensive induction that ensures they are fully aware of their role and the homes procedures. Staff could be better supported to do a good job through formal supervision sessions and appraisals and regular staff meetings. More robust recruitment checks need to be carried out on people applying to work in the home. Fire drills need to be held regularly to ensure all staff are able to carry out the fire evacuation procedure if required to in an emergency. The owner needs to make sure she is up to date with changes that affect her responsibilities. She needs to complete work on policies and procedures and make sure these are implemented consistently by everyone working in the home. She needs to set up systems to help ensure standards in the home do not drop below an acceptable level. Significant events in the home need to be reported to us, the Commission, to help protect people in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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 36 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 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given information about the service. They have their needs assessed and are encouraged to visit and try out the service before making a decision whether to move in permanently. Evidence: There is a Statement of Purpose that is available at the entrance. This will need to be amended now there is an additional bedroom. There is a brochure but a copy of this was not seen. Mrs Wenlock said in the AQAA that it contained all the information people need including the complaints procedure. She said she is working on a separate Guide, but she does send the fees out with the brochure when people are interested. It would be positive if the Guide had large print to help people with poor sight to read it. As there are still shared bedrooms in this home, it would also be good practice to provide details of what rights people have when they share and how any vacancies in shared rooms will be managed. Mrs Wenlock said she does consult people about who Care Homes for Older People Page 11 of 36 Evidence: they share with. Mrs Wenlock said in the AQAA that the assessment tool has been improved and the interested persons family are now asked to complete an information sheet. This was however reported as already being in place at the last inspection. Mrs Wenlock reported that she gathers information and obtains a social work assessment where possible. She encourages visits along with an initial trial stay. One resident and her relatives said they had been given information about the service. The resident had stayed for respite care on two occasions before having to move in quickly when her situation changed. All residents seemed to be appropriately placed and those spoken with were positive about the service. The care plans seen showed that assessment information had been gathered about the peoples needs before their admission. Care Homes for Older People Page 12 of 36 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 have the majority of the care and health needs detailed in their care plans, although to ensure this these should be reviewed more frequently. People are happy with the way the staff support them on a day to day basis with their care needs and they feel they are treated with respect. Medication is not being safely administered and therefore people are at risk of not receiving the correct medication. Evidence: A sample of care records were seen. Mrs Wenlock has introduced a new care plan format so this had been completed for people who had moved in more recently. This gives space to record staffs role in meeting each need and any potential problems that may arise. Some folders were well organised with the current information for staff at the start and clearly indicated, in others this information would be harder for staff to locate. The plans contained helpful information about peoples main needs and their preferred routines. Some plans were nicely personalised, such as describing how one person Care Homes for Older People Page 13 of 36 Evidence: likes help to get her legs into bed, food preferences and when people want to be independent but need help with zips and buttons. There was no sign that each care plan is being reviewed monthly as recommended, however, changes had been noted in some care areas such as when sleep patterns changed. Some gaps in information were noted. For example, there was no falls assessment for one woman even through she had a history of skin tears, has an unsteady gait and uses a walking frame. Mrs Wenlock has taken action to help prevent falls and promotes good fitting footwear. One care plan said the person baths in the Medi-bath with the help of one carer, but this bath is not being used anymore. One person self harms but there are no specific monitoring charts in place for this. Staff were, however, aware of triggers and the need to act quickly if she became upset, and a psychiatrist and psychiatric nurse were involved. Mrs Wenlock said the seniors have responsibility for keeping the plans under review and updated. Staff feedback indicated that seniors felt because there is often only two staff on duty they do not have time for administrative duties. Mrs Wenlock needs to check the care plans as part of the quality assurance process and ensure the updating system is effective. Care planning for people with dementia could be further developed. For one person an orientation assessment had been completed and dementia was noted in places in relation to other care needs. An assessment about the risk of wandering said control measures are in place but gave no details. There were no baseline assessments from dementia nurses, detailed guidance for staff or monitoring tools to map development of the condition. Mrs Wenlock had called a care review for one person and attended a mental health review with their family when after moving in some behaviours started to affect others in the home. The initial assessment she completed had not identified any behavioural needs. Mrs Wenlock reported in the AQAA that the service had supported a person in their sixties, with Alzheimers disease, to return home. Staff were observed approaching residents in a respectful manner and those residents who were spoken with said they liked the staff and they had confidence in them. Hospital transfer information has been completed for each person in case of emergency admission. Mrs Wenlock said the ambulance service have praised the arrangements. She takes people to hospital appointments if they do not have family or friends to accompany them. Health records showed peoples weight is being monitored and that annual eye tests are being carried out. Community nurse support had been arranged when needed, for example, when one person had a skin tear. Records showed when this had healed successfully. A pain assessment and monitoring chart Care Homes for Older People Page 14 of 36 Evidence: had been used with one person while they had a frozen shoulder. Mrs Wenlock said in the AQAA that a mobility therapist visits weekly and that a chiropodist visits regularly. She hopes to arrange in house dental checks in the future. One nurse provided feedback and said, Peoples health needs are sometimes properly monitored and reviewed. Residential clients are well cared for and all meals and drinks are superb. The owner has a tendency to keep people too long especially when their condition deteriorates to borderline nursing. She has needed to be prompted to request a continuing care assessment to see if the individuals are eligible for free nursing care. Relatives gave comments, People are treated as individuals by caring and competent staff, They give appropriate care for individuals needs. Staff feedback included comments, It is a comfortable home for the residents and all staff are friendly and give the best care. I am comfortable working here as a senior because I can contact Mrs Wenlock if I am worried about one of the residents and she will give advice or come in. Medication is being stored in a suitable cabinet. The charts had not been signed for the morning doses at the start of the inspection at 10.30am. Staff said they give medication from memory and sign records afterwards. The records confirmed this practice as there were several examples of doses being signed for incorrectly, such as, when doses were still in the Monitored Dose System MDS as they had not been wanted or needed by the resident. Mrs Wenlock confirmed this practice and said that she also did this. This practice puts people at significant risk of not being given the correct medication. An urgent action letter was send to Mrs Wenlock and on the second day of the inspection she said she had met with the seniors that morning and agreed a new procedure for administering the medication whereby each person has their meds after staff have checked the charts. The codes on the administration charts are not being used correctly or the space for notes on the reverse to indicate why medication in the MDS system has not been administered. This meant staff did not know why their colleagues had not given doses to people on previous shifts even though discussions showed these were for legitimate reasons. Controlled drugs are being stored in a suitable cabinet but the key is inside the main cabinet which defeats the aim of the CD storage being extra secure. A separate CD record is being kept and this balanced against the stocks held. This should be a bound register rather than a loose leaf folder. One persons care plan indicated they had an allergy but this was not shown on their medication charts in the box provided for this. Care Homes for Older People Page 15 of 36 Care Homes for Older People Page 16 of 36 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to live in the way they prefer but within a safe environment. Relatives are encouraged to visit and made to feel welcome. Activities are provided but increased staffing could provide the opportunity for people to go out into the local community. People enjoy the food and the mealtimes are sociable and relaxed. The meals provided are varied and offer a balanced diet. Evidence: People spoken with said they felt comfortable in the home and could move around freely. One person said she likes to smoke and no restrictions are placed on her. People were seen to take themselves outside unprompted to enjoy the sunshine on the patio. One person choose to read a large print book in the conservatory where there are lots of books and games available. One person said she prefers to spend time in her bedroom where she had a television, radio and the daily papers. There is a programme of social activities that includes exercises and music. Mrs Wenlock said in the AQAA that an activities person visits every second week and provides model making, flower arranging, painting or drawing. Staff said they would like to be able to offer people more opportunities to go into town but this is only Care Homes for Older People Page 17 of 36 Evidence: possible when there are three staff on duty. Mrs Wenlock said this was happening last summer but had stopped because of the winter and had not restarted again. Other staff survey feedback included, There is a very good meal choice, good entertainment and an exercise programme. The television was left on in the lounge throughout the day. A resident said there is no discussion about what to watch and she had no interest in the American weight loss show that was on at that time. Staff were seen to try and occupy and settle one person who was restless and confused. One put her favourite music on in the dining area but she walked away. Her behaviour bothered some of the other residents in the lounge and one was very unpleasant to her at times. Staff did not witness this as they were busy elsewhere. Mrs Wenlock needs to ensure staffing arrangements enable one worker to have a presence around the communal areas to intervene when needed to prevent any bullying and to help people make decisions about how to spend their time. Feedback from relatives was positive. One commented, The service provides comfortable accommodation, tasty well cooked food, excellent carers who are well aware of each persons needs likes and preferences. Mum is very content there. She is very active and however many interests are on offer she would like more. We are very pleased with the service Mum is given. She is always treated with respect and care. Staff were seen to welcome visitors and offer them a choice of where to spend time so they could have some privacy. Visitors spoken with said they felt free to visit anytime and found the atmosphere pleasant. People were observed to enjoy their lunch and evening meal. Staff were attentive and offered people a choice of where to sit. The atmosphere was congenial and people were not rushed. Mrs Wenlocks husband cut the grass outside the dining room right through the lunch meal which must have detracted from peoples enjoyment. Consideration should be given to the best time to do this. Two cooks are employed who prepare the main meals and bake cakes ready for the evening tea. There is a four week menu of quite traditional British meals. There is a roast dinner twice a week and the cook on duty, who has been in post for many years, had baked meat pie for lunch. She said she considers the weather and is aware of individual preferences. One resident confirmed that as she does not like fish she has eggs instead. There is currently one person with diabetes, she is catering for and she said Mrs Wenlock buys low sugar pudding options. No one was currently on softened food but there is a liquidiser in case this is needed. The cook said in the past she has liquidised the whole meal together but she would consider for the future that it would be more enjoyable and palatable if each component was softened separately. Care Homes for Older People Page 18 of 36 Evidence: Environmental health gave a three star rating in January 2008. Both cooks completed the advanced food hygiene certificate in 2008. Care Homes for Older People Page 19 of 36 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 are able to express their views and any complaints will be taken seriously. Arrangements are in place to help protect people from abuse, but these can be made more robust through better staff management and recruitment practices. Evidence: The Commission has not received any complaints about the service since the last inspection. Mrs Wenlock reported in the AQAA that none have been received by the service either. In the past Mrs Wenlock has been open with us about complaints received and addressed them appropriately. Feedback in surveys showed that people felt able to raise concerns with Mrs Wenlock or staff. There is a written complaints procedure and Mrs Wenlock reported that a copy is on the notice board. This needs to be updated to include our new title, CQC, and the new central address in Newcastle. She said she plans to develop a version that is easier for residents to understand and then laminate copies of this. She has ordered a suggestion box that is going to be located by the entrance for all to use. Information is available to staff in the office about the local multi agency adult protection procedure. Mrs Wenlock reported in the AQAA that the home has written guidance and staff have received training in abuse awareness. In the AQAA she said she plans to arrange a refresher course. The staff spoken with said they found Mrs Care Homes for Older People Page 20 of 36 Evidence: Wenlock approachable and would report any abuse to her. Mrs Wenlock had attended a briefing on the new Deprivation of Liberty Safeguard legislation. However, she was not informed about the Independent Safeguarding Authority set up from April 1st 09. This will have an impact on staff recruitment in the near future and on the process providers follow when referring people unsuitable to work in care. More detail is under other sections of the report about how people have been put at potential risk of harm because of a lack of routine fire drills, poor recruitment procedures and unsafe medication administration practices. Care Homes for Older People Page 21 of 36 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 have a comfortable and clean home with pleasant gardens. Some areas for improvement were found particularly around infection control. Evidence: The home has a large dining room and conservatory that overlook the gardens. There is also a separate television lounge. The communal areas are homely and comfortably furnished. There is lots of seating in the conservatory if people wish to have some quiet time away from the television. There is a patio area with seating and several people were seen using this area to enjoy the sunshine. Seven single bedrooms and two double bedrooms are upstairs. Three of these rooms have en-suite facilities. A stair lift is installed on each stair case to enable people with limited mobility to access these areas. The library on the ground floor has recently been converted into a 14th bedroom with en-suite facilities. There are now three bedrooms on the ground floor, two of which have en-suites. The bedrooms seen had a sink and had been nicely personalised. Two residents spoken with in depth were both satisfied with their private space. Staff told us that there was a privacy screen in one shared room, but this was not always used. The other shared room does not have a screen. Care Homes for Older People Page 22 of 36 Evidence: The en-suites include toilets and sinks but not baths. There are three communal bathrooms. However, the walk in medi-bath and a disabled access shower on the ground floor were both full of storage items and were obviously not in use. Staff confirmed that all current residents are using the bath with a chair hoist. The other rooms should be kept clear and ready for use so staff can offer a genuine choice to people. As well as the bath aides and stair lifts there is a portable hoist. Mrs Wenlock did not put servicing dates into the AQAA for these but told us that maintenance contracts are in place. Mrs Wenlock did not report in the AQAA any improvements to the premises in the last two years. The only plan for the future noted was to provide visitors with hand gel cleanser. Staff feedback raised concerns about the security of the premises. Mrs Wenlock told us that there had been two incidents of intruders and one was successful at getting into the ground floor before being disturbed and fleeing. She has had advice from the police and said she has taken action to improve arrangements. Further plans are in hand, such as a new more solid back door being fitted. One worker gave feedback that there have been several maintenance tasks outstanding for a long time but that these have been dealt with recently. Mrs Wenlock said the maintenance log book is no longer used so she could not evidence how quickly work was carried out by her husband or a contractor. There is a call system in place and bells were seen to be appropriately placed in peoples bedrooms and in the toilets. A resident who smokes said she takes one with her when she goes outside in case she needs to call for assistance. The garden is accessible so the residents can enjoy it. It has a secured area so people can safely spend time outside. The front door is fitted with a coded lock to ensure people who have dementia do not leave without staff knowing. There is a staff pager system, including direct link to the sleeping in room, so that they can respond to the residents call bell. Staff said they would also like a phone in the sleep in room because of the security concerns. The fire escape door upstairs can be pushed open from inside. Staff raised concerns about people with dementia leaving by this route and being at risk. Mrs Wenlock said there is an alarm but this is not in use as it is too sensitive and will go off if people walk past. She only plans to use it when someone is resident who she feels is at risk. As the service is meant to be designed for people with dementia it would be reassuring for all if an effective alarm were permanently fitted. Mrs Wenlock reported that there is an infection control policy. Since the last inspection a cleaners post has been created. This is proving effective as the home was clean and Care Homes for Older People Page 23 of 36 Evidence: fresh. It will have also relieved care staff of some domestic tasks. The laundry is large and the equipment was in working order. There is no sluice facility on the washing machine and staff said when there is soiled items they have to sluice them in a bucket. Mrs Wenlock said she plans to fit an industrial machine the next time the washing machine needs replacing, but as the plumbing will have to be altered this is a major job. Gloves and other protective clothing were seen around the home, but no gloves and no soap were in sight in the laundry. There is no storage for rubbish bags while they are waiting for the weekly collection. Several were laid out along the back of the patio in the sun. Several clinical waste bags were also on show as the contracting company have not been asked to provide an outside bin. This is unpleasant to look at for the residents who were using the garden. A worker reported this issue in their survey and said that the bins smell. Mrs Wenlock said she had never considered the matter and would look into alternative arrangements. Care Homes for Older People Page 24 of 36 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 are being supported by staff they like and know well. There are enough staff to meet peoples general needs, although more staff at specific times could improve supervision and support for those no longer able to occupy themselves constructively. Staff are being trained but there are gaps and refresher courses needed. The current recruitment practices could put people at risk. Evidence: There is a reasonably stable staff team and some workers have been in post for several years. This is a benefit to the residents as staff get to know them well. Four staff have left in the last year. The feedback from residents and relatives, about the staff, was positive. Residents spoken with said they do not have to wait long if the call for assistance. They described the staff as patient and caring. The base staffing level is two. A third carer usually works 8am to 11am and 7pm to 9pm to help during the busiest times. The residents appeared well attended to and the home was clean and tidy. Some conflict was observed between residents when people became frustrated with one person who was quite confused and restless due to dementia. These incidents were unseen by staff who were not in the communal areas at the time. Mrs Wenlock said she felt the staffing level are adequate for the current resident group and that staff do hear if there are problems between residents. She Care Homes for Older People Page 25 of 36 Evidence: said she would provide three staff all day if the three vacant rooms were taken by people with dementia or other high care needs. As mentioned under Lifestyle, some staff felt three staff are needed to enable people to go out into town more often and to occupy the people during the day who have lost the ability to follow constructive pastimes due to dementia. The care staff are supported by a cleaner and cook, but the senior on duty is responsible for preparing the early evening meal when the cook has gone. Consideration should be given to increasing the care staffing to three throughout the day or at least to provide kitchen support for the evening meal. Recruitment records were seen. Mrs Wenlock said that she used to record interviews but does not do this anymore. Applicants had completed an application form and proof of their identity had been kept. One file contained two references, but one had no date on it to show if it was received before the worker started. This contained some negative information but no record had been made of why Mrs Wenlock decided this was not relevant. The worker had started five weeks before a clear CRB was returned. Mrs Wenlock had not obtained a POVA First check. The risk level was relatively low as the worker and her family are known to Mrs Wenlock and she had moved from another care home where a CRB would have been carried out. A second file showed that two references had been obtained before the worker started but the CRB was issued the following day. Mrs Wenlock accepted that she had not followed the regulations and said she understood that poor recruitment practice could potentially put people at risk. Mrs Wenlock said she provides an informal in house induction when new staff start. She had no evidence of what had been covered during the induction. A worker with previous experience said in their survey that they were not provided with an induction. Mrs Wenlock had a detailed induction pack that had been purchased from the training organisation she uses. This would comply with the nationally recognised Common Induction Standards, but none of the current staff have completed this. Mrs Wenlock said that staff often come with previous experience so she has not felt it necessary for them to complete a detailed induction. In these circumstances she should show how she has checked their knowledge level and what in house induction had been provided. Training modules are used through an external company who assess the completed module and issue certificates. The modules include infection control, fire awareness and moving and handling. Mrs Wenlock said she gives a demonstration of the hoist as the course does not involve practical teaching. A record of this should be kept to show that staff were assessed as competent. Mrs Wenlock said she has not always photocopied the certificates to prove the course was completed. Some external courses are also arranged. For example some staff have attended training recently on Deprivation Of Liberty Safeguards, Sensory Deprivation and Falls Prevention. A training Matrix is in place but this only covers the modules. Other training information Care Homes for Older People Page 26 of 36 Evidence: was difficult to assess as it relied on the certificates being located in the filing system. It did appear that most staff have attended Dementia Awareness. The information found indicated that some staff need to attend refresher courses. One seniors last first aid training was in 2002. Fire drills have not been carried out regularly to remind staff about the procedure. No one has had Diabetes training even through there is a person with this condition in the home, however this is planned for July 09. It is positive that currently seven of the fourteen care staff who have a National Vocational Qualification at level three are working towards level 3. Mrs Wenlock needs to ensure that her policies are followed or training can be undermined. For example seniors have attended accredited medication training but all staff, including Mrs Wenlock have been carrying out unsafe daily administration practices. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people in the home are pleased with the service they receive. Their best interests are not always being protected by the way the home is managed. Evidence: Mrs Wenlock has owned and managed the service for several years and she is appropriately qualified. The outcomes for residents are generally positive and they and their visitors like the service and feel it is personal and homely. Mrs Wenlock is supported by a longstanding deputy who is part time. The deputy does not have any designated office hours. There is no record of the hours Mrs Wenlock spends in the home apart from her usual shift working with the residents on a Monday. Mrs Wenlock reported that she carries out assessments, does the weekly shop, financial tasks such as banking and wages but that staff may not be aware of how she is spending her time. Some staff feedback indicated that other than working Mondays and doing the shopping Mrs Wenlock only popped in an out of the home. Mrs Wenlock Care Homes for Older People Page 28 of 36 Evidence: agreed to keep a record of her management time in the home. The AQAA was quite brief and there were gaps in the information required, such as, dates the hoists were serviced. In some cases the information provided was not accurate, for example Mrs Wenlock reported that recruitment procedures have been improved in the last year and meet with the regulations. This was not the case. Some of the areas for planned development were the same as those reported at the inspection two years ago, such as, the introduction of staff supervision. This indicates that developments are slow to be implemented fully. The AQAA showed that some essential policies and procedures were not in place, such as Safeguarding Adult from Abuse, Sexuality and Relationships, Smoking, the use of Alcohol, and Emergencies and Crises. This shortfall was noted in the previous inspection. Mrs Wenlock said these have now been completed. However, when she was asked to show us the Emergency and Crisis policy she said she had never considered what to do if the home had to be evacuated and the residents temporarily accommodated elsewhere. As mentioned policies and procedures are not always being followed such as how medication should be administered. By deviating from the homes guidance in her own practice Mrs Wenlock has set a poor example to staff and compromised her ability to carry out any disciplinary action if staff fail to follow procedures and cause negative outcomes for residents. There is no formal probationary period and an appraisal system. Mrs Wenlock said she has an informal agreement with them that the first month is a trial. Supervisions have recently been introduced but only two staff have had a session so far. Mrs Wenlock said in the AQAA that the senior team is competent and meetings are held regularly. Staff told us that the last seniors meeting was approximately six months ago. Mrs Wenlock said staff meetings were held three monthly but often staff would not attend so one has not been held since October 08. Several staff reported in their surveys that they could be better supported. Regular supervision, annual appraisal and more frequent meetings could help achieve this. Mrs Wenlock seems to have taken appropriate action when significant events have occurred in the home in the last two years. However, she has not reported these events, such as deaths in the home, falls that have resulted in injuries and an intruder, to us in line with the requirements of Regulation 37. Mrs Wenlock told us at the last inspection that she was setting up a Quality Assurance system. She said that she did send out satisfaction surveys in January 2008 but has not sent them out January 09. She reported in the AQAA that as a result of listening to peoples views she has increased consultation about the menus and to improve Care Homes for Older People Page 29 of 36 Evidence: equality arrangements ministers from different faiths have been approached to visit the home. She has recently acquired a Suggestion Box for the entrance to encourage feedback. Staff told us there had not been a residents meeting in the last year. There are no routine audits, such as monthly health and safety checks or medication reconciliations. As reported some record keeping has improved, such as care planning, but other areas like recruitment and training need to be improved and effective audits would have helped identify the shortfalls. Mrs Wenlock is not appointee for any of the residents. Relatives provide funds for personal items such as toiletries, chiropody and hairdressing. A log is kept for each person to show how this is spent. A sample seen showed the money was being spent appropriately. Staff told us that sometimes people do not have the personal items they need. Mrs Wenlock said that some relatives are reluctant to provide the funds even though it is from the residents pension. This has led to her having to buy communal toiletries and giving people second hand slippers, when their own need replacing, for their own safety. The arrangements for billing families for items such as this are not included in the contract. It may be in peoples best interests if this were the case and costs for agreed areas are then included in the bill for the fees. Routine checking systems are in place such as fridge temperatures. Accident reporting forms are in place for staff. Mrs Wenlock said for residents a record is just made in their daily notes. She said the fire risk assessment was reviewed in 2008 and she is clear how a staged evacuation should be carried out. As mentioned, fire drills have not been held regularly to ensure staff are also clear about this. The last was in April 08 but the record did not include the names of the three staff present. One senior had not been involved in one for two years. An effective health and safety audit would have shown up these shortfalls. An urgent action letter was sent to Mrs Wenlock following the inspection about the risk to people from a lack of fire drills and unsafe medication practice. Care Homes for Older People Page 30 of 36 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 31 of 36 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 9 13 Staff must be trained to 17/07/2009 follow safe practice procedures for giving medication by consulting each persons administration chart before giving any dose and signing the chart immediately afterwards. This is essential to ensure that people are given the correct medication. The timeframe for action was given as June 15th 2009. 2 33 37 The registered person must report events and incidents in the home to us in line with Regulation 37. This is to help protect residents. 31/07/2009 3 38 23 The registered person must 17/07/2009 make arrangements for all care staff to take part in a fire drill and ensure they are competent in carrying out the fire evacuation procedure. Page 32 of 36 Care Homes for Older People This is to help ensure the safety of people living in the home should a fire occur. The time frame given for this was June 30th 2009. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 Develop a Service Users Guide that is in an accessible format for potential residents and contains the current range of fees. Develop care planning further to better demonstrate that the complex needs of people with dementia are being met. Ensure current care plan information is clear for staff and that all high risk areas are assessed, planned for and monitored. Review plans every month. 2 7 3 8 The owner should always request a reassessment in a timely manner when peoples needs change, so they do not miss out on continuing health care funding and support. Arrange with the pharmacy for allergies to be entered onto the medication charts. Obtain and use a bound Controlled Drug Register. Restart offering people the opportunities to go into town. Ensure staffing arrangements allow a presence in communal areas to support those with dementia and help others make decisions during the day. If softened meals are needed the meal should not be liquidised all together. The owner needs to be informed about the role of the Independent Safeguarding Authority and her changing responsibilities. The owner should arrange for staff to attend a refresher course on safeguarding vulnerable adults and ensure they are all familiar with the homes policy that she has just developed. Keep all three bathrooms clear and ready for use so residents can be offered a genuine choice about which Page 33 of 36 4 9 5 6 12 14 7 8 15 18 9 18 10 21 Care Homes for Older People facility to use when bathing. 11 24 Fit an effective door alarm to the fire escape so the alarm can be in permanent use and reduce any risk of someone confused leaving the building without staff being aware. Provide a privacy screen in shared rooms and ensure staff use this to ensure peoples dignity. Keep evidence of how building maintenance tasks are reported and responded to. Fit an effective door alarm to the fire escape so the alarm can be in permanent use and reduce any risk of someone confused leaving the building without staff being aware. 13 26 Provide red bags for staff to use when moving soiled laundry around the house. Provide a washing machine with a sluice cycle so the poor practice of hand sluicing can stop. 14 26 Ensure infection control systems, such as good hand washing regimes, are consistently implemented. Provide suitable storage for domestic and clinical waste so it is not seen or smelt by the residents. 15 16 32 33 The owner should keep a record of her time in the home carrying out management duties. The owner should re-implement the quality assurance surveys and residents meetings so people using the service can give feedback and ideas for improvements. Quality audits should be carried out to help ensure good outcomes for people using the service by monitoring areas against the National Minimum Standards. 17 35 Review how personal shopping and services such as hairdressing are paid for to ensure people can access these when needed. Manage and support staff through annual appraisals, bi monthly supervision sessions and more frequent staff and senior meetings. Develop policies for all areas of the running of the service including an Emergency and Crisis Plan and ensure all staff are aware of these and implement them. Separately accident reports should be completed when residents have accidents so the owner can demonstrate that she has seen these and investigated the circumstances 12 24 18 36 19 37 20 38 Care Homes for Older People Page 34 of 36 appropriately. An accident audit system should be developed so any trends can be identified and addressed as part of the quality assurance system. 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