Inspection on 12/04/10 for Astley Hall Nursing Home

This inspection was carried out on 12th April 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Astley Hall Nursing Home 17/06/10

Astley Hall Nursing Home 18/11/09

Astley Hall Nursing Home 06/08/09

Astley Hall Nursing Home 05/07/07

Astley Hall Nursing Home 20/07/06

Astley Hall Nursing Home 13/10/05

Astley Hall Nursing Home 28/04/05

Astley Hall Nursing Home 02/03/05

Astley Hall Nursing Home 18/01/05

Astley Hall Nursing Home 19/04/04

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Maple Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Key inspection report Care homes for older people Name: Address: Astley Hall Nursing Home Astley Hall Church Lane Astley Stourport-on-Severn Worcestershire DY13 0RW     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: Sally Seel     Date: 1 3 0 4 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 54 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 54 Information about the care home Name of care home: Address: Astley Hall Nursing Home Astley Hall Church Lane Astley Stourport-on-Severn Worcestershire DY13 0RW 01299827020 F/P01299827020 Carisastley@aol.com None Mrs Kailash Jayantilal Patel,Mr Jayantilal James Bhikhabhai Patel Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 48 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 48. 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 withi the followng categories: Old age not falling within any other category (OP) 48 Physical Disability (PD) Age 50 years and over 48 Dementia (DE) Age 50 year and over 29 Date of last inspection Care Homes for Older People 1 8 1 1 2 0 0 9 29 0 48 Over 65 0 48 0 Page 4 of 54 Brief description of the care home Astley Hall Nursing Home, Church Lane, Astley, is a three storey, Grade II listed building, set in 20 acres of parkland and situated two miles outside Stourport-onSevern. Astley village is a short travelling distance away. Astley Hall is registered to accommodate up to 48 residents who require nursing and/or personal care needs relating to old age and physical disabilities. A maximum of 29 residents of the 48 may have dementia illnesses and 2 people with a physical disability may be between 50 and 65 years of age. Accommodation is provided on all three floors of the home, and access to all floors is gained via stairs or a central passenger lift. Mr and Mrs Patel are the registered providers. The current charges for living at this home can be obtained by interested parties by contactiing the home direct. Information regarding the home was available from the reception area in the Statement of Purpose, the Service Users Guide and the most recent Inspection report. Copies of these documents are given to each new resident or their relatives. Care Homes for Older People Page 5 of 54 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: The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. T his process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. It is recommended that this report is read in conjunction with the previous random inspection report dated the 18th November 2009. The visit to the home was undertaken by one inspector, over a day and a half, which consisted of the 12th and 13th April 2010. We, the commission were assisted throughout the two days by the manager and various staff members. The home did not know that we were visiting over two days, when there were 37 people living there. A pharmacist inspector was present for part of the inspection on the 12th April 2010. The pharmacist inspector checked day the management and control of medicines Care Homes for Older People Page 6 of 54 within the service. This means that they looked at medicine storage, some care records and medicine administration records. An expert by experience was also present for part of this inspection on the 12th April 2010. Mr. Patrick Reddin, an expert by experience is a person who, because of their experience of using services and ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Experts by experience observe what happens in the home and talk to people who live their to get their views of the home. The expert talked with people who live at the home and staff, looked around the home and observed some staff practices. The expert provided a report of their findings, parts of which have been included in this report. It is difficult to get some peoples views about the home due to their differing levels of dementia however we spoke with staff that were on duty at the time and undertook some observations of practices within the home. Two people were case tracked. Case tracking involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Other peoples care records were also looked at briefly. Staff files and health and safety records were also reviewed. Prior to our visit we sent out random surveys to people who live in the home, relatives and staff. Three surveys from people who live in the home, nine relatives and six staff returned the surveys. Comments were positive about the home and also stated where improvements could be considered and are included in this report. We were sent an Annual Quality Assurance Assessment (AQAA) by the former manager. This tells us about what the home think they are doing well and where they need to improve. It also gives us some numerical information about the staff and people who live at the home. Before our visit we reviewed any notifications received about the home, these are reports about things that have happened in the home that they must tell us about. Following our visit we were informed that the manager has now left their employment at this home but will be referred to in the report as, the former manager. We would like this opportunity of thanking people, who live in this home, the former manager and all staff for assisting us with this inspection and making us feel welcome. Care Homes for Older People Page 7 of 54 What the care home does well: What has improved since the last inspection? Care planning is improving but we are concerned that this will not continue due to the former manager having left the home. Risk assessments for bed rails and the use of stair gates are now in place and the former manager was auditing these to make certain they were available for people who required them. There were no concerns confirmed to us about people experiencing any difficulties in getting their clothes returned to them. The introduction of life story books which contain information about peoples lives, their family, interests and hobbies they enjoy is now in place. There are also some care plans which hold information about peoples interests and hobbies which must be used Care Homes for Older People Page 8 of 54 to enhance peoples quality of lives. Complaints are now being logged and a suggestions box has been introduced so that people have the opportunity of placing their complaints, compliments and or any suggestions into this as they choose and can remain anonymous. What they could do better: There is currently management instability at this home following the previous random inspection on the 18th November 2009 and this inspection visit. Management arrangements must provide continuity of good quality care at all times to meet every persons needs. Preadmission assessments and care plans should be in more detail so that staff have all the information they need to meet peoples needs in a way they need, expect and prefer. Care staff should be part of care planning for people so that they are knowledgeable about individuals needs and recognise when changes occur. Some medication practices were potentially unsafe. Storage, administration practices and records must be improved. Staff need more training so that they have all the skills and knowledge they need to be able to meet peoples individual and collective needs in a safe and dignified way. More storage space is needed in the home so that the equipment used to move people does not get in peoples way. The activities available need to be improved so that people can lead interesting and stimulating lifestyles that reflect their gender, personal taste and interest. One persons surveys response told us, More activities. Consideration should be given to finding out about and implementing the research that has been done about colour schemes and signage so that people with confusion, memory loss or dementia can more easily orientate themselves around the home and maintain their independence. The homes environment requires some redecoration work and a review of all the furniture provided this should ensure that people live in a home that is well maintained and pleasant. The quality assurance audits must be more robust and done regularly so that failings can be recognised with actions taken to improve the service in a timely manner. Evidence that all health and safety checks have been conducted in a timely manner, as the five yearly electric and gas inspection reports do not show this as the electric report shown to us was dated in 2004 and the gas certificate could not be found. This is to ensure people can be confident that the home is safe and well maintained. Please see the end of the report where further requirements and good practice recommendations have been made. Care Homes for Older People Page 9 of 54 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 54 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 54 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. People have some information about the home to enable them to make informed decisions about whether it is right for them. The lack of detail in pre admission assessments means there is a risk that people will not have all their needs met consistently upon admission. Evidence: The service users guide and statement of purpose give people some information about the home. They are available as you enter the home, in the reception area. The former manager said in the AQAA that the service users guide can be made available in large print and picture formats to suit the needs of people who may be considering living at the home. We saw that the service users guide does have some pictures and informs people about some of the facilities, such as, meals and activities for people to refer to as they choose. Further consideration should be given to producing the information guides in audio visual formats so that the information is easier for some people to understand. Care Homes for Older People Page 12 of 54 Evidence: The statement of purpose and service user guide need some work to ensure people have sufficient information to help them to make a decision as whether the home is right for them. For example, we could not find the complaints procedure in the service user guide although the statement of purpose referred to this stating that the contact addresses for the Care Quality Commission (CQC) were in there. Also we could not find the current level of fees that are charged to people if they live in the home. This means that people might not have full information to assist them to make decisions about moving into the home. In the service user guide and the AQAA it encourages people to visit the home, we invite you to come and visit us for the opportunity to view for yourself the added quality of care that we offer at Astley Hall. The six people who live in the home completed our survey forms. All people indicated that they had received enough information to help individuals to decide if this home was the right place for them before they moved in. The certificate of registration and public liability insurance are displayed in the reception so that people can read these if they choose to. The certificate of registration requires to be updated so that the details on this are factually accurate. In the AQAA we are informed that the former manager or nurse and a member of care staff visit people to complete preadmission assessments, to help meet and greet the resident to obtain more information. We looked at the care records of two people who had moved into Astley Hall since our last key inspection. We found that both people had assessments of their needs. This should enable the former manager to make a decision as to whether the home is able to meet each persons needs before they move into the home. Responses in the surveys we received from people who live in the home told us: Provide mother with excellent care with a very cheerful staff to look after all her needs. I like the carers they are very nice and polite. They look after me very well and all staff are pleasant and helpful. Some fine tuning is required when completing preadmission assessments to make Care Homes for Older People Page 13 of 54 Evidence: sure all information about a persons needs are gathered. For example, the persons previous occupation if they worked, preferred language, interests and hobbies and daily routine preferences. By gathering this information staff should be able to meet each persons needs in a way that suits them best. This is particularly reassuring for people who experience dementia as the experiences of a new environment can be particularly unsettling. Due to a number of concerns raised about the quality of care at the home, there is currently an agreed voluntary suspension placed upon the home. This means that Worcestershire County Council will not pay for anyone new to live at the home until they are happy that people are receiving a good standard of care. Care Homes for Older People Page 14 of 54 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. Improvements in the arrangements for meeting peoples personal and healthcare needs must be made so that they receive the right care to stay healthy and safe. Medication is not managed safely, and places people at risk of not receiving their medications which have been prescribed for them. Evidence: We looked indepth at care records for two people who live in the home and some others were reviewed briefly. We saw that assessments had been carried out for all of the activities of daily life, and these had been generally reviewed and updated. For example, to meet peoples short term needs such as, urinary tract infections and chest infections. This means people should receive the care and treatment they require if they become unwell. We saw a variety of care plans to cover peoples needs for, washing, dressing, physical abilities, medication, mental health, colostomy care and sleeping. We were told by the former manager that there are ongoing improvements being made to care plans so that they hold enough information to meet each persons needs. Care Homes for Older People Page 15 of 54 Evidence: We would expect to see care plans to meet the full range of each persons needs. Although we saw some instances where care plans had not been written so that staff have instructions to guide them whilst assisting and supporting people to meet their needs. For example, managing individuals continence needs, falls, expressing sexuality, eating and drinking and taking medications. In a persons daily records we saw that they had developed sore skin and a red mark on their buttocks area. Staff treated these areas with cream and a dressing. It was established after a period of time that the net pants being used with the continence pads were far too small and this had resulted in some of the sore red areas that had developed. However, we could not find a continence management plan. This was discussed with the former manager at the time of our visit who acknowledged that if a care plan had been in place this should have prevented this persons sore skin. This is because a care plan should act as a monitoring and reviewing tool so that it should have helped staff to pick up on the use of too small net pants being used thereby preventing sore skin. This person is now wearing their own pants and the manager understands the importance of having care plans in place. Care plans ensure guidance is given to all staff so that each person should receive the right type of care with the appropriate aids in place to lessen any risk areas. We asked staff in the surveys we sent, Are you given up to date information about the needs of the people you support or care for (for example, in the care plan), two staff said always, four staff commented, usually with four stating, sometimes. We would expect all staff to have sufficient information in each persons care plan. This must be addressed as we are concerned that we could not find some care plans to meet individuals needs. Therefore people cannot be confidence that they are receiving the care and support they require to stay healthy and well. Following the previous inspection there were concerns about people receiving the care they required to meet their personal hygiene needs, such as, assisting individuals to shave and brush their teeth. We are concerned that this continues to be an issue as the Expert reported: Whilst making my visit I inspected the residents dental equipment and found ten toothbrushes out of twelve were completely dry and obviously had not been used that morning, my impression was that some had not been used for some time. I mentioned morning care to the former manager who commented that he had told staff about this previously and would take it up with them again. I saw another resident at 11.30am who had just woken up, staff commented he likes his lie in. I observed three male residents who were unshaven. Care Homes for Older People Page 16 of 54 Evidence: We received six completed surveys from people who live in the home and they told us that they always receive the care and support when they need it. We saw that people were wearing clothes appropriate for their gender and weather conditions which were generally clean. We looked at the individual forms that are kept in peoples bedrooms which staff sign to confirm that each persons personal hygiene tasks have been completed. The forms we saw were generally appropriately completed as tasks having been done. However, due to the Experts observations we are concerned that staff may be completing these forms and some peoples personal care is not being done. We are now making this a requirement for care plans to be in place for each person. These must show how each person chooses their personal care tasks are completed. Staff must record all assistance and support they give to people with their personal care in the daily records. Also the forms in peoples rooms do not seem to be working and these must now be reviewed and correspond with the daily recordings of each person. We noticed that records of some peoples personal care needs, pressure area care, eating and drinking needs and activities were kept separate to care records. Also care staff are not taking part in individuals care planning was brought to our attention. Therefore nursing and care staff must read care plans so that people who live in the home can be reassured that all of their needs will be met appropriately so that peoples health, wellbeing and safety are promoted at all times. The former manager also showed us how they will be developing care records in the future which encompass meeting peoples needs using a person centred approach. In the AQAA it tells us, Staff need to adapt a working practice that is not governed by tasks but more able to perform duties around the individual needs of the resident. The care records looked easier to follow with indexes so that staff are able to retrieve the information they require at a glance. We were told by some staff that the current care record system can be confusing due to information not always being easy to retrieve or follow. The former manager clearly understood the principles of person centred care, and is now trying to incorporate these principles into the care plans. We saw that one persons records contained a very informative section which included information about their likes and dislikes, and the way in which they wished their care to be provided. For example, we saw care plans that gave staff information about peoples choices in relation to the hair, wearing perfume and nail care. Also in one persons care records staff had asked a persons representative to sign the care plans which is Care Homes for Older People Page 17 of 54 Evidence: good practice and means decisions about how care is received is agreed. We recommend that care planning continues to be improved in respect to care plans showing times of when people prefer care and support in their daily living tasks and whether people prefer a female or male member of staff to assist them. If this is not put into practice then it may mean that there is a risk that people do not get the help they need in a way that they prefer. We looked at a persons care plan for meeting their mental health needs. This did not have sufficient information so that staff had strategies to support this person with their behaviours, such as, diversional and or known triggers. This means the care and support provided to this person will not always be consistent. This is concerning as there had been a safeguarding incident where this persons behaviour would require some support to safeguard themselves and other people who live at this home. The former manager acknowledged this. The incident has been referred through to the local authoritys safeguarding team. We shall be reviewing care plans for people who have mental health needs when we next complete an inspection at the home. We saw from the care records that the family of one person had expressed concern that the person was losing weight. We saw that a persons weight had been recorded in January 2010 and then in April 2010. The manager acknowledged that peoples weights have not been done regularly. Making certain people are weighed regularly ensures that any losses and gains are detected at an early stage which may indicate an underlying health condition. Therefore it is required that each person is weighed on a regular basis and that eating and drinking care plans are in place for each person. We do acknowledge that work is currently being done in relation to each person having an eating and drinking care plan. This is particularly important as some people who live at this home experience varying levels of dementia and would find it difficult to express all of their feelings. We saw in care records that people are seen by the GP, social worker, chiropodist, optician, tissue viability nurse and dentist. We received six completed surveys from people who use the service and they all said that they always receive medical support when they need it. At the previous inspection concerns were raised about staff knowledge around the care and treatment of people who had sore skin areas. The former manager told us that audits had been undertaken to ensure that each person with sore skin had been identified with care plans in place so that staff had the guidance required. We looked at two peoples pressure ulcer risk assessment and prevention audits. These measures Care Homes for Older People Page 18 of 54 Evidence: should make sure identification, treatment, equipment and prevention methods are in place to meet each persons pressure area needs. We are also aware that a tissue viability nurse has visited the home to review the care that is provided to people who have identified pressure sores and to give some practice guidance to staff. This means that each person who has sore skin should now be receiving the care and assistance they require not only to heal any sores but measures for prevention are in place. We will be reviewing peoples pressure sore care again when we next undertake an inspection at the home. We looked at a persons care plan which shows staff how to assist the person correctly in relation to all physical movements. The care records showed that this person had a moving and handling assessment that indicated they needed considerable assistance with all moves. We saw guidance about how these moves should be carried out within the care plan so that the persons safety is promoted throughout all of their physical movements. There is some further room for improvement to make certain that these care plans have the type of hoist to be used, size of sling and which loop colours correspond to the part of a persons body. This should ensure staff have all information they need to help keep people safe. Throughout our observations we saw that people were helped to move by staff in a safe way. We shall be reviewing care plans to meet peoples physical needs to make sure that they continue to give staff sufficient information. Concerns were raised with us about some people who live in home appearing to be sedated. The Expert completed some observations and commented, four others (people who live in the home) who appeared to be sedated. However, this was discussed with the former manager who conducted a review of all individuals who were prescribed sedative type medications which involved looking through the Medication Administration Records (MAR) of each person. The former manager shared the outcome of their review and this showed that each person who is prescribed medications receive these as directed by their clinicians. Although it was acknowledged that clinicians should be more precise in relation to their prescribing instructions as some medications directions said give one or two tablets. Staff must use a clear and consistent rationale when giving medications. We will be reviewing this area of medications when we next undertake an inspection at the home. The pharmacist inspector visited the home on 12th April 2010 to check the management and control of medicines within the service. In summary, the medicines management systems within the home were poor. As a result of our findings we issued immediate requirements to the former manager. These are requirements that must be made to the management of medicines so that people who live in the home Care Homes for Older People Page 19 of 54 Evidence: are fully protected from risks to their health and wellbeing. We looked at medication storage, some care records and medication administration records. We spoke to staff and the manager. We saw that the available storage for medication was safe and secure including locked cupboards, medicine trollies and a locked refrigerator. This means that there was adequate provision of suitable safe and secure medication storage for the number of people living in the home. We found a lack of stock control and rotation of medication. For example, we saw that there were seven boxes of the same medication for an identified person stored in a cupboard. We saw that the boxes dated back to 15th December 2009. The records did not record the amount of medicine stored in the home. This means that it was not possible to accurately check the amount of medication that had been given to the person and there was an increased risk of a medication error. Medication that was no longer required was not always removed for destruction. For example, we found a box of tablets for a named person inside the medicine trolley, dated 3rd May 2009. The tablets were not recorded on the persons current Medication Administration Record (MAR) chart. We spoke to a nurse who was not able to tell us any more information about the tablets and did not know why they were inside the medicine trolley. We found an entry dated 28th May 2009 in the persons care plan, which recorded the start of the medicine but we were not able to find any further information about the medicine. We were informed by the nurse that it would be returned. This means that medication, which was no longer required, was still available and therefore increases the potential for the risk of harm to people living in the service. Controlled drug medication, which requires special storage, was stored according to legal requirements. However we also saw that money and peoples valuables were stored in this cupboard. This means that there is an increased risk of unnecessary access to the controlled drugs and also that peoples money and valuables were not stored correctly. The storage temperatures of medicines were not being monitored each day and it was not possible to ensure that medicines were being stored at the correct temperature. For example, medication should be stored at 25 degrees C and below, however there were no temperature records available for the room where medication was stored. We saw a thermometer inside the room, which was reading 20 degrees C, which is within the recommended safe storage temperature. A nurse informed us that they were not aware that this should be recorded daily but it would be done. We looked at the temperature records available for the refrigerator. Medication requiring refrigeration Care Homes for Older People Page 20 of 54 Evidence: should be stored between two to eight degrees C. We saw recorded temperatures between four to five degrees C, which was within safe storage recommendations for refrigerated medicines. We found medicines were not always labelled and therefore could not be identified. For example, we found a medicine bottle in the stock cupboard with no label attached, which means we could not identify what the tablets were or who they were prescribed for. We also found a medicine tot inside the medicine trolley, which contained four white tablets. We were not able to identify the four tablets. This means that there was a risk of a medication error and an increased risk of harm to people living in the service. Medicines were not always given to people following good practice guidelines. For example, we saw a nurse place three peoples medicine into three medicine tots, which were placed onto a tray. The tray was then carried by the nurse to give the medicine to the three people. The nurse returned and signed the three MAR charts for the three people at the same time. This practice is not safe and there is an increased risk of a medicine error. We looked at the MAR charts, which were printed by the pharmacy and overall found that they were documented with a signature for administration or a reason was recorded if medication was not given. This ensured that staff knew when to give medicines. However not all of the MAR charts were clearly documented with a signature. We found that prescribed medicines for external use such as a cream or ointment were not accurately documented with a staff signature. For example, one person was prescribed an ointment to be applied to the scalp once or twice a day, however a tick was documented onto the MAR chart to show it had been applied. This means it was not possible to know who had applied the ointment. Medicines were not always given to people as prescribed. For example, one person was prescribed a short course of antibiotics to treat an infection. We checked the MAR chart and saw that 28 capsules had been received, however the MAR chart records showed that 24 capsules had been given and we also saw that there were four gaps in the records with no indication if the antibiotic had been given. We counted a total of nine capsules remaining in the box for the person. We spoke to two nurses who could not give an explanation why there was extra capsules remaining. This means that the check showed that the antibiotic had not been given according to the directions of the GP and placed the person at an increased risk of harm. Medicines prescribed to be given as a variable dose, such as one or two tablets, were Care Homes for Older People Page 21 of 54 Evidence: recorded onto the MAR charts so that it was clear how many had been given. However, there was no information available in order for staff to determine exactly how many tablets should be given to the person. It was not clear how staff decided whether one tablet should be given or two. For example, one person was prescribed a tablet to be taken at night to help with sleeping. The tablet was prescribed as one or two tablets to be taken at night. We looked at the MAR chart and saw that staff had recorded one or two tablets next to their signature. There was no information available to explain why one tablet was given on one night and two tablets were given on another night. This means that due to a lack of clear information it was not possible to determine how many tablets to give the person. We found that the medicine records were not always documented with the balances of medicines available, which made it difficult to check if medicines had been given to people as prescribed. This was particularly seen for medicines available in a box or a bottle. For example, we looked at one person who was prescribed eight different medicines. We checked the amount of tablets or capsules available in the home and checked the amount of medicines given according to the MAR chart. Five of the medicine checks were correct. Three medicines could not be checked because the date of opening of the box was not recorded, the total balance of tablets available in the home was not recorded and the amount of tablets removed did not match the MAR chart records. This means that the medicine records were not accurate and therefore we were unable to check that medicines had been given to people as prescribed. Personal care plans were not kept up to date with information relating to peoples medication. For example, we looked at one persons care plan with regard to a prescribed medicine which required careful monitoring. There was no information documented to inform staff what to do if a dose was missed and what side effects to expect. There was no information about the need for regular blood tests and the importance of informing a GP if the person was ill. We were informed by the Manager that this would be written into the persons care plan immediately. This means that the care plans were not kept up to date with regard to peoples medication which increases the risk to their health and welfare. We will be undertaking a further inspection visit to the home to audit and review the management of medicines. We looked at how staff practices showed that peoples dignity, respect and privacy is maintained. The Expert reported: The staff interaction with residents seemed quite good. On two occasions I was talking to residents with their room door closed when staff knocked on the door, entered, used their Christian names and asked if they would like anything down the Care Homes for Older People Page 22 of 54 Evidence: shop. Care Homes for Older People Page 23 of 54 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities may not meet all the needs of the people living at the home so that they experience a meaningful lifestyle. Some improvements should be made so that all people are consistently offered, with aids used, choices of meals to meet individuals dietary, cultural needs or preferences. Evidence: In the residents handbook it is stated, our activity organiser undertakes a number of social activities for residents to encourage community contact. These include shopping trips, games, hairdressing, manicures, arts and crafts, music, dance and access to various religious services to ensure a diverse range of needs are met. However, we were told by the former manager that following the resignation of the dedicated activity coordinator there had been some difficulties in recruiting a new one. Therefore three members of staff are now arranging activities for people to enjoy as well as completing their normal caring duties. However, this arrangement must not mean that these staff members other caring duties are not compromised. We saw the weekly activities planner which noted hairdresser, exercise with mobility plus, trips out, in the garden and summer house, entertainer, arts and crafts etc. It was unclear as to how peoples religious needs are met, such as, church visits and Care Homes for Older People Page 24 of 54 Evidence: or religious services in the home so that people are supported to follow their religious beliefs. This will be reviewed when we next visit the home. One member of staff who is arranging activities seemed enthusiastic about ensuring people have the opportunities to lead stimulating lives. Staff told us that activities planned were, bingo, drafts, chess, musical instruments, gardening, exercise, jigsaws and visiting local safari park. Staff are also trying to raise some funds to adapt the dining room on the first floor into a bistro but this is very much dependent upon an injection of cash. At the previous inspection a recommendation was made to make sure information about peoples interests are noted in their care plans. We saw in the care plans we looked at that interests and activities noted were, listening to local radio station, pictures of family, joining others, newspapers, reminiscence, loves dogs, horses and to knit, enjoys classical music and adventure films. This practice must continue so that staff have the information they need to provide stimulating activities that meet peoples individual needs. Also My Life books are being developed with each person and their representatives. These detail peoples family, working life, interests and hobbies. We were told that these books are in peoples own rooms and if this is not appropriate in the nurses station for staff to refer to. In response to whether activities are arranged in the home for people to take part in, two peoples surveys said, always, three said usually and one confirmed, sometimes. On the day of the inspection, we saw that one person lays the dining tables in readiness for meals, some people were having a sing a long and others were reading. There was quite a lot of staff activity happening on the first floor of the home with people who experience dementia. We also saw a rummage box with items in for people to pick up and use as they choose. Rummage boxes and objects for people to use had been introduced by staff who work for the local authority. They are working with staff to improve practices for people particularly for those who experience dementia. The former manager also told us they had brought in some soft toys for people to use. It was of some concern that some people were in their rooms for a large part of the inspection but we did not see any purposeful activities and or interaction by staff for good periods of time with people in their rooms. The AQAA told us, A more Care Homes for Older People Page 25 of 54 Evidence: collaborative working where the staff will feel confident that management will not discipline staff for interacting with residents is being used to some success but staff still concern themselves with tasks. Staff we spoke with said that the opportunities for activities had improved and was continuing to do so. In the staff surveys we received comments ranged from: Organising activities (could do more). More outings for residents. More entertainment (singers etc.). Improve activities. The Expert reported: By coincidence, an activity lady was scheduled for the afternoon and stayed for one and a half hours. She comes every two weeks, it was mentioned that someone else comes the other weeks. Two other staff, one of whom is part time are designated to look after activities. There was lots of music and singing with fourteen residents taking some part where possible. Five staff also joined in as well. During the activities a carer came in asking who was supposed to be looking after a certain resident as she was walking up and down the corridor without supervision. Group activity is confined in part with dementia residents. I did not see any other activity between staff and people in residents rooms. It is clear that activity opportunities are beginning to improve for some people who live in the home. There is still work to be done which was acknowledged by the former manager and staff. This means more social stimulation and activities to make sure people who stay in their rooms and people on the ground floor also have sufficient staff interaction. We shall review how all people are encouraged to make their choices known in relation to activities when we next inspect the home. We saw some eating and drinking plans which identified what help people required when eating and drinking together with how individuals needs are monitored. However, we saw very limited information about individuals likes and dislikes in relation to their meals and drinks. We examined whether menus are planned around peoples choices and nutrition requirements for older people. There was only one Care Homes for Older People Page 26 of 54 Evidence: choice stated for the main meal of the day, which is served at lunchtime, apart from on a Monday when we saw two choices. Although we were told that people could choose an alternative. Menus should be produced in differing formats, such as, using pictures of meals as the menus we saw had pictures of flowers on them which do not help peoples understanding of the meals on offer. Also these should be prominently displayed (we saw them on the reception desk) so that people are able to easily view these. As at the previous inspection the nutritional value of the meals offered to people who live in this home continues to be a worry. We spoke with the former manager who acknowledged that meals need to be further improved particularly to make sure they are appealing and nutritious in content for older people. We were told that a new cook has been recruited who is specifically trained in nutrition and we were told that this should make a big difference to meals offered. We discussed the value of finger food snacks and fruit being available throughout the day, on tables in peoples view, so that people to choose to eat as they want. It was acknowledged that some people would require staff to support and encourage with snacks. In our surveys, everyone told us that they enjoy the food provided by the home. The Expert reported: I requested that the manager put me in the dining room with the most people having lunch. There were eight people eating with four staff that were both preparing the food and serving it. There was a choice of two meals, beef burgers or fishcakes with either chips, mash, beans or vegetables. It seemed very bland but was freshly cooked. There was no menu available, staff asked each person what they would like to eat. There was a good staff interaction, most were able to eat without help. Comments from people told us: I ask the cook whats for dinner, if I dont like it, they cook me something else, and nothing is too much trouble. Staff very helpful, food is fine, get what is given, I eat in my room, I cannot walk. Later I spoke to the manager about the food asking if it was mostly frozen, he agreed that it was, they purchase from Batleys. During our meeting with him, I mentioned Care Homes for Older People Page 27 of 54 Evidence: that there were no menus available. He then showed me some and admitted that these were to show visitors. A large number of residents choose to eat in their rooms. Environmental health officer visited the home in February 2010 and awarded good in relation to the kitchens cleanliness and hygiene practices. The evidence of compliance for these standards was mixed and the organisation must develop strategies to ensure that people experience consistently good quality standards in the outcome areas in this section. Care Homes for Older People Page 28 of 54 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. Improvements are being made to ensure people can always be confident that their views are listened to and acted upon. Lack of staff training does not ensure that people are fully safeguarded from harm. Evidence: The homes complaints procedure is documented in the statement of purpose but there are no contact addresses so that if people are not happy about how their complaints have been managed they can let us know. We saw that the complaints procedure is not provided in the service users guide that was supplied to us. This needs to be rectified so that the complaints procedure is readily available. People who responded to the surveys said that they did know how to make a complaint. The former manager also told us that there is a suggestions box now in place for people and visitors to place any complaints and or compliments in. We looked at the homes records of complaints and saw that there had been two complaints received within the last year and we were told that these have now been resolved. This information is also documented in the AQAA. We looked at how the former manager was managing safeguarding training for staff. We could not find satisfactory evidence that all staff had received safeguarding training. The training matrix indicated that fourteen staff have received this training which is only half of the staff working at the home . We spoke with some staff, who Care Homes for Older People Page 29 of 54 Evidence: showed knowledge of how to report suspicions of abuse together with the signs of abuse. However, this does not appear to be consistently put into practice as it was a concern to us that the unexplained bruising of one person who lives in the home was not reported immediately to the local authoritys safeguarding team. Also CQC did not receive a Regulation 37 Notification about this incident. This demonstrates that people cannot always be confident that they will be protected by staffs reporting procedures of incidents that require to be investigated so that people living in this home are safeguarded from harm. There have been a number safeguarding referrals made to the local authoritys safeguarding team and some investigations are currently ongoing. The other areas of training which we would expect to see the majority of staff receiving training in is dementia care, Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS). This is because the home provides specialist care to people who experience dementia. Only six staff were identified to us as receiving dementia training with five staff having DOLS training. This examines how risk assessments and decisions to restrict someones liberty such as movement, leaving the home or making decisions for themselves should be done to ensure that their liberty is not denied. This training is important as a significant number of people living in the home have some form of cognitive impairment. Checks are carried out, including a Criminal Records Bureau (CRB) check, before new staff start work. This ensures only suitable staff are employed and helps protect people who are living at the home. Care Homes for Older People Page 30 of 54 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are needed in the home so that it is provides a pleasant place for people to live, meets their needs and it is a safe environment. Evidence: Astley Hall is a large detached building standing in its own extensive grounds and views of the countryside can be seen out of many of the windows in peoples rooms. An adequate number of bathrooms and toilets are available on each floor. There is a passenger lift available so that people can access all parts of the home. There are thirty two single rooms and eight shared rooms. Screening is provided in the shared rooms so peoples privacy can be maintained. Each room has a wash hand basin. Peoples bedrooms contained personal items and photographs so that they were more homely and reflected peoples tastes and interests. Rooms are situated over three floors of the home with the main reception area on the ground floor and there is seating in this area so that people can choose to sit here if they wish to watch the world go by. The ground and first floor have lounge areas and dining rooms. We looked at the room that had dining tables and some easy furniture in it, on the first floor. This room was not a pleasant place for people to sit and enjoy their meals. The tables were bare, there was a piece of green carpet to the far end of the room and some red lino type flooring by the dining tables. We confirmed with staff that it was upsetting to think of Care Homes for Older People Page 31 of 54 Evidence: people having their lunch in this room. When we looked in this room later we found that flowers had been placed on the dining tables and the floor had been cleaned. We noticed that a piece of stair carpet had become loose on the stairs that lead from the reception area to the other floors. We told the maintenance person about this and later when we looked this had been fixed so that it was no longer a potential tripping hazard. The Expert reported: My first impressions were of a home with extensive grounds and nice views of the countryside. I felt that the inside the home was shabby and in need of investment for decoration and furniture. During the tour some poor bedding was observed, corridors blocked with large boxes of incontinence pads and wheelchairs. The boxes were hastily cleared away following inspectors comments. Strong urine smells were apparent near the toilets on the second floor. We have also been made aware from one comment in the surveys we have received from people who live in the home that the toilet on the second floor is not up to standard. This needs to be addressed in the planned redecoration programme. As the Expert has reported on the second floor we saw large cardboard boxes filled with incontinence pads along the corridor area next to a store cupboard and fire door. We discussed this with the former manager and some staff as it was a potential tripping and or falling over hazard to people who live on this floor together with a fire hazard. We were told that they had been in the corridor following a delivery on the previous Friday. The fire door was also left unlocked all day which means people could have opened this. We also saw a metal cabinet on this floor where one of its doors was propped open with an empty cardboard box and the other was wide open. Inside the cabinet were a mixture of continence pads, towels, socks, tights, aerosols, toiletries including shampoo, and a bottle containing a fortified drink. This means that people could potentially be placed at risk due to the hazards caused by having access to the various substances within this cabinet. We were told by staff that these cabinets should be locked. Staff did close the doors after we expressed our concerns but they were not locked as this was checked by the former manager towards the end of the day. Expert reported: I also observed a number of poor quality wardrobes in bedrooms which were tipping forward at an angle. These could quite easily tip over if a resident lost their balance and pulled the door towards them. Care Homes for Older People Page 32 of 54 Evidence: Rooms as a whole were clean, some were personalized but others had very few personal items on display. Two rooms were without carpets. The manager spoke about a number of refurbishment plans that he had for the home, when I asked if he had an agreed budget from the owners, he said this had not been agreed. Staff member, She also commented the place was shabby with broken furniture but there were plans to rectify this. Since our last inspection we were told that no further redecoration work has been completed. This was also confirmed in the AQAA as the section that should have been completed with any improvements in the last twelve months was left blank. Astley Hall is an old house and although some redecoration work has been done over the years, most of the home now requires further redecoration work as the decor is looking tired and shabby. The former manager has acknowledged this within their AQAA, The home needs updating with its decor. The home has become in a state of poor visual repair. We saw that there had been a leak from the roof area which had affected the state of decoration, such as, wallpaper was pealing, cupboards and doors were not closing effectively. This must be reviewed and remedial action taken. There is one full time maintenance person and another who works part time but due to the size of the home it would take some considerable time for the work to be completed by the maintenance people employed by the home. However, the AQAA confirms, A rolling programme of redecorating has been implemented and this has included asking residents their choice of colour scheme. We shall be reviewing the homes environment when we next undertake an inspection visit as it must be decorated to an acceptable standard with all furniture in good order. This will make certain that people live in pleasant surroundings that are well maintained with safety promoted. In one survey received from a person who lives in the home it responded to what could do the home do better by confirming, Redecorate. Staff surveys told us in responses to, what could the do better: Decor. Outside of the building, it could do with a good clean, toilets and bathroom. Care Homes for Older People Page 33 of 54 Evidence: ...decor. Maintenance (beds, chairs etc). Better facilities (like bathroom, decorating home). Maintenance, decor very tired and scruffy. Housekeeping e.g. linens and curtains need updating. We saw that some improvements have been made to the first floor decoration to help people with dementia and memory loss easily find their way around themselves. Improvements noted were some people had name plaques on their doors and pictures of flowers or other pictures of interests that hold meaning to people. We also saw that some areas of the corridor are going to be themed, such as, a trip down memory lane with pictures on display that people living in the home would be able to relate to. Improvements must continue to signage and using colour schemes so that people are able to orientate themselves easily and be more independent in the home. In some of the rooms we looked at with the former manager we saw examples of poor care and attention made to make sure rooms and items in them were well maintained. For example, in one room a persons wall clock was left lying on the side and the former manager said it looked as though batteries were needed. Another persons quilt was fraying at the edges with some of the filling falling out. The top of one persons taps on their wash hand basin had been removed. The former manager said this was because this person leaves them running. However, it is suggested that spring loaded taps would resolve this difficulty but enable this person to maintain some of their independence and show them some respect. The home has a range of equipment available to assist people to keep safe and maintain their independence including hoists, raised toilet seats, wheelchairs, pressure reducing mattresses, bed rails and bumpers. We saw some equipment is stored in communal areas of the home and may get in peoples way. There is an attractive garden area with seating facilities for people and a summer house. As was reported at the previous key inspection people who experience dementia live on the first floor of the home and they do need to have readily available access to the garden area at all times as people choose. In the surveys received from people living in the home satisfaction was expressed with the cleanliness within the home. Care Homes for Older People Page 34 of 54 Evidence: At communal wash basins, there was liquid soap and paper towels to help prevent spread of infection. We saw staff using personal protective equipment appropriately. Care Homes for Older People Page 35 of 54 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment procedure does ensure that people are safeguarded from harm. Staff training is required to ensure that staff have the knowledge and skills to meet peoples needs effectively. Evidence: We were told by the former manager that there are some staff vacancies, one for a trained nurse and five for care staff. On the day we inspected the home we were told that there were two trained nurses and six care staff on duty. In addition to the nursing and care staff, there is also a receptionist/administrator, domestic, cook, kitchen assistants and maintenance staff to meet all the needs of the people who live in the home. We were shown the staffing rota for four weeks and this reflected what we were told about staffing arrangements in the home but we did notice that sometimes there are five and or four care staff on duty. If staffing levels do drop below what we were told then people cannot be confident that their individual and collective needs will be met. Therefore we would expect whoever is managing staff to employ agency staff to fill any gaps whilst recruitment is ongoing. Also we shall be reviewing the system that is used to ensure that the dependency levels of people who live in the home are assessed with appropriate number of staff on duty to meet each persons needs in a safe way. Staff that we spoke with seemed to feel that there was normally enough staff on duty Care Homes for Older People Page 36 of 54 Evidence: to meet individuals needs. The staff responses to the surveys question, Are there enough staff to meet individuals needs of all the people who use the service? Four staff said, usually, with four stating sometimes and two staff said, never. It is suggested that the proprietor may want to address this as the home only has thirty seven people living there on the day we visited and the home is registered for forty eight people. Therefore staffing levels will require to be reviewed as more people come to live at Astley Hall so that we can be assured that there is sufficient staff to meet the individual and collective needs of people living there. We will be reviewing staffing levels when we next inspect the home. The Expert reported: I also spoke to two visitors, one said staff are amazing, seem understaffed and stretched at times, food is good, extra choice would be nice. The other visitor who comes in every day praised staff and care very highly. He commented that during the snow, he could not get to the home the manager came out in his car to get me. We were told that fourteen staff have a National Vocational Qualification (NVQ) level 2. In the AQAA it confirms that twenty seven staff are employed to work at the home. This means that the recommendation of at least 50 per cent of staff have this qualification is met so that a knowledgeable and skilled workforce can meet peoples needs individually and collectively. We spoke with the receptionist/administrator who showed us how they are updating staff files. Indexes are now in place so that it is easier to notice at a glance what information has been received and when. We looked at four staff files. We saw that the files contained references which make certain that people are safeguarded from harm. The former manager also supplied us with the records that told us that all nurses registration PIN numbers had been checked and had not expired, including the former managers. Also in the files we looked at were Protection of Vulnerable Adults first (POVA1st) checks as well as Criminal Records Bureau checks (CRB), which deemed them safe to work with vulnerable people. A copy of the training matrix was provided, however this showed that there were some gaps in the training. In the AQAA we were told, Staff training needs to be updated as evidence shows little training in the last eighteen months. We certainly found this to be the case as the training matrix shows that the majority of staff had received training in first aid. Some staff had received training in fire drills, fire awareness, food hygiene, depression in later life, end of life care, loss and bereavement, activities for people with dementia, food nutrition. However, the Care Homes for Older People Page 37 of 54 Evidence: majority of these training courses were attended by only the minority of staff. It was of a concern that we could not find any information to confirm that people have received up to date training in infection control and there is no indication of numbers on the AQAA, it was left blank. Only six staff had received moving and handling training. When we spoke to some staff they were identifying that they do need up to date training in infection control and manual handling. The former manager acknowledged that this was the case. The training matrix also highlighted that six staff have received training in pressure area care and one member of staff has received wound care and dressing. People not receiving good pressure care management was of a concern which was referred to the local authoritys safeguarding team for investigation purposes. It became unclear as to whether any care staff have received any training in these specific areas of care and therefore it is recommended so that staff have knowledge and skills to meet peoples needs. Care Homes for Older People Page 38 of 54 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. People do not benefit from living in a home that is well run with their best interests at heart. Evidence: At the random inspection of the home on the 18th November 2009 the registered manager left the home whilst the new manager was completing their induction to the home. The new manager did take part in this key inspection but following this we were advised that they had also left the home. We have spoken with the proprietor about the management arrangements for the home. We were told that a manager from one of the providers other homes would be overseeing management responsibilities in the afternoons. However, it has come to our attention that this is not the case and we are therefore going to formally write to the proprietor to request information about the management arrangements for Astley Hall. The Expert reported: Conversation held with a staff member who commented they had lost four good staff since Christmas to other care homes due to low pay. I Care Homes for Older People Page 39 of 54 Evidence: mentioned this to the manager who denied the number stated and came up with reasons why staff had left. She also said that the owner had agreed to look at pay once they had a full complement of staff. She also commented the place was shabby with broken furniture but there were plans to rectify this. The Annual Quality Assurance Assessment (AQAA) returned to us by the former manager was brief but showed some insight and recognition into what they need to do to improved the service provided. Some of the data information supplied in relation to staffing numbers did not always correspond. There were some examples of how the former manager planned to achieve the improvements. However, we are now concerned that the former manager has now left the home and this may result in the ongoing improvements not being put into action to ensure the health and safety of people who live at Astley Hall. We asked to see minutes from staff and residents meetings but these could not be located and no dates could be produced for when these meetings might have taken place. These meetings are important so that people have the opportunity to raise concerns or ideas about the home and how it can be improved and have some input into decisions about home. We could not find any examples of satisfaction questionnaires being given to people who live in the home, their relatives and other stakeholders. These enable people to have their say and ensure improvements are driven by the influence of people who use this service. This was also the case at the last key inspection on the 10th August 2009 where it was reported that, The home has a quality assurance system but the manager told us that she has not surveyed residents or interested others for over two years. The provider and or their representative should complete Regulation 26 visits once a month to monitor the quality of service being provided, however the last reports found was dated January ad February 2010. This was discussed with the former manager and the providers representative who undertakes these who acknowledged this. It is important that these visits are completed as they are required by law and we have found aspects of this service that should have been identified and work undertaken to address shortfalls in service. As stated earlier in this report the staff do not have all the training they need to meet peoples needs. Also we were told that formal staff meetings are not being held so that staff are given the opportunity of sharing information and making suggestions for improvements to the service people receive at this home. Care Homes for Older People Page 40 of 54 Evidence: The AQAA confirms, Staff supervision also lacking which is showing shortfalls in skills. However, some staff that we spoke with told us they had now received supervision but this must be continued and sustained. As discussed earlier in this report staff responses told us that staff feel that they are not always given up to date information they need to meet peoples needs and staff training is lacking. Personal monies are held for peoples safekeeping and we examined some of these records with the administrator. This money was stored securely and accurate records kept of the balance of money held and expenditure, with receipts available to verify expenditure. The AQAA indicated that policies and procedures were last reviewed in April 2008. Documents we looked at had not been reviewed since. We expect policies and procedures to be reviewed on an annual basis. Equipment in the home is regularly serviced and we examined the records that told us this. The maintenance person who carries out minor repairs, decorating and gardening tasks with the help from a part time maintenance person has already mentioned earlier in this report. Fire safety systems were well maintained and monitored and staff had received in house training and taken part in a fire drill. We could not find the certificate of electrical worthiness which is normally issued every five years. However, a copy of the last inspection was faxed over to the home on the day we were inspecting and this was dated the 13th May 2004. This meant that this was the last time the electrics were fully inspected so we cannot be certain that the electrics are well maintained and safe to use. We spoke with the engineer by telephone and it would appear that the certificate has now lapsed but arrangements were now in place for the engineer to undertake an electrical inspection. The last gas certificate for the home also could not be shown to us and therefore we cannot be certain that this certificate has also not lapsed. This is concerning as it does not protect the health and safety of people who live at Astley Hall. The former manager and the proprietor are fully aware of our concerns and they must supply a copy of these certificates to CQC as soon as the inspections have taken place. Care Homes for Older People Page 41 of 54 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 42 of 54 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 To make arrangements to 23/04/2010 ensure that care plans include detailed information and instructions for staff in respect of administration and management of medicines, including the reasons to give medicines when required and what constitutes needed for the named person. This is to ensure that there are clear directions for care staff to give medicines prescribed when required. 2 9 13 To make arrangements to 23/04/2010 ensure that medication administration records are accurately maintained. The reasons for nonadministration of medication are recorded by the timely entry of an appropriate code or entry on the medication administration record, that the meaning of any such codes are clearly explained on each record; and that the person administering the medication completes the medication administration record in respect of each individual person at the time of administration. This is to ensure that the care service maintains accurate records of medicines administered to people including reasons for Care Homes for Older People Page 43 of 54 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 non administration of prescribed medicines. 3 9 13 To make arrangements to 23/04/2010 ensure that records are kept of all medicines received, administered and leaving the home or disposed of. This is to ensure that the care service maintains accurate records of medicines received and disposed of. 4 9 13 To make arrangements to ensure that only controlled drugs are stored inside the Controlled Drug cabinet in accordance with the requirements of the Misuse of drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973 and in accordance with the guidelines from the Royal Pharmaceutical Society of Great Britain. This is in order to ensure that controlled drugs are stored safely to prevent misuse. 5 9 13 To make arrangements to ensure that all medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. This is to ensure that people get their medicines correctly and that procedures for medicine administration are Care Homes for Older People Page 44 of 54 23/04/2010 23/04/2010 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 safe. 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 7 13 Risk assessments must be in 18/06/2010 place for all identified areas of risks to a persons health and wellbeing which must inform staff practices. This will help to maintain peoples safety at all times. 2 7 12 You must make sure that people living in the home receive appropriate levels of personal care and that this is recorded. This will ensure that their personal hygiene and dignity is promoted. 18/06/2010 3 7 12 All care plans must be 18/06/2010 accessible to staff delivering the care and be a reflection of the care given and be reviewed and amended at the point where a persons needs change or routinely all staff must be aware of these changes. This will enable all staff to meet individuals needs at Care Homes for Older People Page 45 of 54 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 all times to make sure peoples health and safety is fully promoted and met at all times. 4 7 12 Care plans must be in sufficient detail so that staff have the instructions and guidance to meet each persons needs. This will ensure to ensure risks to individuals health and wellbeing is minimised. 5 8 12 All staff that provide care to 18/06/2010 people who live at the home must have the knowledge, skills and competency required to meet individuals needs together with their planned care. This will make certain that individuals health and welfare is not placed at risk by staff practices. 6 8 12 To ensure that people with 18/06/2010 poor nutritional intake and or weight loss are monitored using a recognised screening tool as frequently as required by their risk assessment and care plan. This will ensure that staff takes required actions to promote peoples health and 18/06/2010 Care Homes for Older People Page 46 of 54 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 well being. 7 15 13 Arrangements must be 18/06/2010 consistently in place so that the quantity of food eaten by people who use the home is being assessed, monitored and reviewed. This should ensure that staff take appropriate action if people are not eating enough to maintain their health and well being. 8 18 12 Training must be provided for all staff that work with people who have dementia some of whom may be assessed as having difficult to manage behaviour. This will make sure that individuals needs are met in a safe way that respects their dignity. 9 18 13 All staff must receive appropriate safeguarding training and the homes procedures to protect vulnerable people must be implemented and followed diligently at all times. This is to safeguard all persons living at the home from risks of harm. 18/06/2010 18/06/2010 Care Homes for Older People Page 47 of 54 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 10 20 13 The registered persons are 18/06/2010 required to undertake a documented health and safety audit of the premises, from which written risk assessments must be implemented, reviewed and action taken to safeguard all people from risks of harm within identified timescales. To include the following: (1) Substances left in the metal cabinets in communal areas should be locked away. (2) Cardboard boxes must not be piled up in the communal corridor areas of the home. This is to ensure the health and safety of all people who live in the home. 11 24 13 The registered persons are 18/06/2010 required to undertake a documented health and safety audit of the premises, from which written risk assessments must be implemented, reviewed and action taken to safeguard all people from risks of harm within identified timescales. To include the following: Care Homes for Older People Page 48 of 54 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) The wardrobes must be secured in all bedrooms. This is to ensure the health and safety of all people who live in the home. 12 28 12 The homes staffing levels 18/06/2010 must be reviewed. This must be in line with individuals dependency levels and available for inspection. This will ensure that people living in the home receive care in an appropriate and timely manner that meets their needs. 13 32 17 Suitable arrangements must be in place for the management of the home in the absence of a manager. This is to ensure that people can be assured that improvements to this home are made to promote the health and safety of people living at Astley Hall. 14 33 26 The registered persons or a person who they instruct on their behalf must undertake monthly visits to the home as part of their quality assurance process. These 18/06/2010 18/06/2010 Care Homes for Older People Page 49 of 54 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 reports need to available at times of inspection. This is to make certain that it is run in the best interests of the people living there. 15 33 37 Notifications to the Commission must be made in accordance with current guidance. This is to comply with the law so that health, safety and welfare are protected. 16 33 24 To ensure quality monitoring 18/06/2010 systems are effective and demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. This is to safeguard the health, well being and safety of people living at the home. 17 38 13 Staff must receive training in infection control. This is to make sure the safety and wellbeing of individuals is promoted and protected at all time. 18 38 13 Staff must receive training in manual handling. 18/06/2010 18/06/2010 18/06/2010 Care Homes for Older People Page 50 of 54 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to make sure the safety and wellbeing of individuals is promoted and protected at all time. 19 38 12 Evidence of the worthiness of the gas must be available in the home. So that people can be confident that they live in a safe well maintained environment. 20 38 13 Evidence of the worthiness of the five yearly electrical hard wiring report must be available in the home. So that people can be confident that they live in a safe well maintained home Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 18/06/2010 18/06/2010 1 1 It is recommended that all information required by the Care Homes Regulations 2001 be provided in the Statement of Purpose and Service User Guide, specific to this home; and this should contain information about fees be easy to read and understand for people needing to use the service. All management and staff who are responsible for pre admission assessments should ensure that they collect information in a comprehensive and individualised manner so that it provides a person centred approach to meeting Page 51 of 54 2 3 Care Homes for Older People 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 that persons needs once living in the home. 3 7 Care plans should provide details about personal preferences so that people receive care in a way that they prefer. Care plans for meeting peoples mental health needs should be comprehensive in detailing information about what strategies staff should use to support people with their behaviour together with known triggers so that these can be minimised. This should ensure that people receive the care and support they require to meet their needs to keep them safe. To ensure records are available to ensure that medication is stored at the correct temperature recommended by the manufacturer. This is to ensure that medication does not deteriorate which can make the medication ineffective and possible harmful to people living in the home. Activities must be reviewed and based on individuals needs. Following this review an action plan should be drawn up and findings implemented so that each person has an activity planner that meets their specific needs in a meaningful way. Utilising peoples social histories would assist with this task. People should have opportunities to access the local community with staff on a regular basis so that they are supported to lead interesting and meaningful lives. It is recommended that the management team obtains a copy of the Department of Health guidance Mental Capacity Act 2005 core training set and staff are provided with training, so that staff are aware of their responsibility and peoples choices and rights are protected. People should be offered a choice of meals daily and if individuals are unable to participate in this process their relatives and representatives should be involved. This will ensure peoples personal and dietary preferences are met. A pictorial menu may assist as an aid to this task. An audit of all complaints should take place periodically so that any trends can be picked up to ensure people are able to influence practices within the home and to note future plans for areas in need of improvement. 4 8 5 9 6 12 7 13 8 14 9 15 10 16 Care Homes for Older People Page 52 of 54 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 11 16 Complaints information should be made readily available in the information guides about the home along with contact details of CQC so that people can choose who they refer their complaints to. It is recommended that all staff receive training in DOLS to ensure that staff have the understanding and skills to be able to support people keeping their best interests at the heart of any processes where peoples liberties may be restricted. Continued improvements must be continued to meet the specific needs of individuals who experience dementia so that peoples privacy, dignity, rights, choices and independence is fully promoted. This will make sure that the environment not only meets individuals specific needs but is in line with homes are for living in. The planned programme of redecoration must continue so that people live in a pleasant environment. Consideration should be given to providing alternative and adequate storage space for equipment in the home so that it does not get in peoples way. The management team must continue to review and audit the suitability of the premises against recognised national guidance such as Alzheimers 50 Point Action Plan and the needs of current people who live in the home. It is recommended that all care staff training receive training in pressure and wound dressing care so that people receive the required care to meet their needs in this specific area so that peoples health and safety is promoted at all times by all staff. Staff should be clear on their roles, be supervised at least six times a year, and have meaningful regular appraisals of their knowledge, performance, and development needs. We recommend audits of safe working practices and quality of care as well as observed practice is used to confirm competences. 12 18 13 19 14 15 19 20 16 22 17 30 18 36 Care Homes for Older People Page 53 of 54 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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