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Inspection on 08/05/09 for Astley House Care Centre

Also see our care home review for Astley House Care Centre for more information

This inspection was carried out on 8th May 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Medicines are stored safely. The activities person organises group social events during the week which are clearly enjoyed and well attended. People`s dietary needs and preferences are being well catered for. The home looks attractive and clean and provides comfortable and spacious living that suits all needs.

What has improved since the last inspection?

Staff who administer medication have received training and Blanchworth managers have assessed their competence for this task. Regular audits of medication are in place. Care plans contain more information to guide staff about the use of medicines prescribed to use `when required`. The one full pre admission assessment we looked at showed that this had been done in far more detail than those of the past. Individuals` pressure area care is now being correctly assessed and addressed, as is wound care. There have been improvements in how people are moved and transferred resulting in the manoeuvres we observed being done safely. Care generally is being delivered according to the agreed written care plan and these are being amended as needed. The content of the care plans seen shows that these are being used by staff that are competent to do so. People are receiving ample support to eat and drink, particularly those who are at nutritional risk. Qualified nurses are more aware of people`s individual health needs and were observed to be being proactive in addressing these. Care staff were observed carrying out their work in a more knowledgeable way and with more awareness of their practices. The general improvements in the home`s organisation and routines means that people`s choices and preferences are being listened to and met where possible. Some new arrangements means that any concerns or irritations expressed by people either in the home or when visiting can be dealt with quickly and effectively. Staff are all receiving or due to receive, a broader understanding of adult protection issues. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 The environment looks well maintained and clean. Changes to the layout and use of some communal rooms have provided people with a better choice. Staff morale has improved and people living in the home are benefiting from a more relaxed and less stressed workforce. Consistent communication within the staff team means that people are aware of what they need to be doing and what is expected of them. Additional support and staff supervision means that staff are being effectively monitored, resulting in a higher standard of care being given to people. There is ongoing company support for the acting manager, which is including regular monitoring, which is helping shortfalls to be identified and addressed.

What the care home could do better:

Some records about medication need improvement so that there are always consistent and accurate records kept and medicines are administered in accordance with the doctors` directions. Prompt action must always be taken to make sure prescribed medicines are always available in the home to use. Actions taken in response to shortfalls in medication audits need to be demonstrated. The competence of some staff with regard to the recording and administration of medicines needs reviewing. Locate suitable training in the management of challenging behaviour. Ensure there are designated hours to support people`s social needs at all times of the year. Avoid increasing the likelihood that people may have to wait for attention or help from staff, this is with reference to the drop in night staff. Ensure that the recruitment documentation can clearly demonstrate that robust practices are in place.

Key inspection report CARE HOMES FOR OLDER PEOPLE Astley House Care Centre 1 Lypiatt Road Cheltenham Glos GL50 2SY Lead Inspector Mrs Janice Patrick Key Unannounced Inspection 8th May 2009 09:45 DS0000016373.V375409.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astley House Care Centre Address 1 Lypiatt Road Cheltenham Glos GL50 2SY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 08453 455742 01242 255971 helen.haughton@blanchworth.co.uk Mrs Sally Anne Manby Roberts Mr Jeremy Walsh, Mr Roy Harris Manager post vacant Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (27) of places Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 7th proposed Dementia Care bed, currently occupied by one named service user without a diagnosis of Dementia, will become a 7th Dementia Care bed when that specified service user no longer requires the bed on their discharge or death. 27th October 2008 Date of last inspection Brief Description of the Service: This care home is situated in a residential area very near to Cheltenham Town centre and is in close proximity to local shops, amenities and bus services. It provides nursing and personal care, predominantly to the older person. There are six beds designated to the care of those with dementia. These are not separate but integrated within the home. All bedrooms have en suite facilities; there are ample communal rooms and additional bathrooms and toilets. There is a passenger lift large enough to accommodate a wheelchair dependant person and one escort. Behind the home is a sizeable paved garden area, which provides safe outdoor space, accessible by wheelchair. Off road parking is provided at the front of the building for a number of cars. There are steps to the front entrance but wheelchair access can be gained through a side gate which leads to the paved area and its entrance. The fees depend on the type of care being provided and the room occupied. Fees at the time of this inspection range from £485.00 to £685.00. The home’s terms and conditions outline any additional charges. Information about the home can be found in the reception area. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Information given to us by the service itself within the Annual Quality Assurance Assessment was also considered. As part of this key inspection one of our (Care Quality Commission) pharmacist inspectors reviewed some of the arrangements for the handling of medicines. This was specifically to check what action had been taken to meet requirements made in relation to medication at the last key inspection in October 2008. We looked at some stocks and storage arrangements for medicines and various records about medication. We saw how staff administered some medicines to people living in the home. We visited different areas of the home and spoke to two people living in the home. We spoke to the registered nurse on duty and to the manager designate. We also spoke with two staff from Blanchworth head office who were based in the home at the moment. We gave full feedback after the inspection to the manager designate and the operations manager about the medication issues we found. The medication inspection took place over seven hours on a Friday. As well as the pharmacist inspector a second inspector reviewed compliance against many other areas of the Care Home Regulations 2001. This included revisiting repeated requirements made in previous inspection reports. We can confirm that all outstanding requirements have been met or are well on the way to being met. Further requirements were made however in relation to the safe administration of medicines. This means that where there were previously serious concerns about this homes ability to care for people appropriately, improvements and new arrangements mean that this was no longer the case at the time of this inspection. However, this was not the case in respect of the safe administration of medicines which has been addressed in this report by the Pharmacist Inspector. We can also confirm that the home was running smoothly and the routine of the day was benefiting those that lived there. We have expressed concerns regarding this at night, which is discussed in the Staffing outcome of this report. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 6 It is now imperative that these new arrangements and improvements remain in place and are sustained so that the home can continue to provide appropriate and safe care to those that live there. This part of the inspection took between 9.45am and 7.25pm on the first day and between 9.45am and 3.10pm on the second day (fifteen hours, five minutes). What the service does well: Medicines are stored safely. The activities person organises group social events during the week which are clearly enjoyed and well attended. People’s dietary needs and preferences are being well catered for. The home looks attractive and clean and provides comfortable and spacious living that suits all needs. What has improved since the last inspection? Staff who administer medication have received training and Blanchworth managers have assessed their competence for this task. Regular audits of medication are in place. Care plans contain more information to guide staff about the use of medicines prescribed to use ‘when required’. The one full pre admission assessment we looked at showed that this had been done in far more detail than those of the past. Individuals’ pressure area care is now being correctly assessed and addressed, as is wound care. There have been improvements in how people are moved and transferred resulting in the manoeuvres we observed being done safely. Care generally is being delivered according to the agreed written care plan and these are being amended as needed. The content of the care plans seen shows that these are being used by staff that are competent to do so. People are receiving ample support to eat and drink, particularly those who are at nutritional risk. Qualified nurses are more aware of people’s individual health needs and were observed to be being proactive in addressing these. Care staff were observed carrying out their work in a more knowledgeable way and with more awareness of their practices. The general improvements in the home’s organisation and routines means that people’s choices and preferences are being listened to and met where possible. Some new arrangements means that any concerns or irritations expressed by people either in the home or when visiting can be dealt with quickly and effectively. Staff are all receiving or due to receive, a broader understanding of adult protection issues. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 7 The environment looks well maintained and clean. Changes to the layout and use of some communal rooms have provided people with a better choice. Staff morale has improved and people living in the home are benefiting from a more relaxed and less stressed workforce. Consistent communication within the staff team means that people are aware of what they need to be doing and what is expected of them. Additional support and staff supervision means that staff are being effectively monitored, resulting in a higher standard of care being given to people. There is ongoing company support for the acting manager, which is including regular monitoring, which is helping shortfalls to be identified and addressed. What they could do better: 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. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People and their representatives have access to the information they require to make an informed decision about the service. They also benefit from their needs identified and appropriate arrangements made to ensure these are met once they have been admitted. EVIDENCE: On arrival to the home, information can be found in the entrance area. The company who own the home have also confirmed in their Annual Quality Assurance Assessment, that all prospective service users are furnished with adequate information to help them make a decision about their future care at the care centre. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 10 People have told us that even if funding is required towards their care, they or their representative have had the opportunity to visit the home before making a decision to stay there. These arrangements may be different in the case of an emergency admission where there may not be time to do this. We saw some people’s admission agreements/contracts these gave details of how much needed to be paid and details of what that includes. As we viewed electronic versions of these the copies we saw were not signed. People receive an agreement/contract with the home whether they pay their own fees or receive a degree of funding towards their care. Those that receive a contribution towards their nursing care are informed what this amount is. In our previous inspection in October 2008 we assessed the home as not providing the care and services that were stipulated within their Statement of Purpose. We made a requirement for this to be complied with and this report will evidence that this has been achieved. As a result of concerns expressed by multi agencies the County Council and Health Authority decided to suspend placements at the home. This has meant that there was limited evidence available during this inspection to show that the home makes an assessment of a people’s needs before they move into the home. However, three days prior to this inspection one person had been discharged from a local hospital to the home. This admission took place because the individual was paying for their own care. The records showed that the acting manager went to visit this person four days prior to their admission to see what their needs were and to be satisfied that the home could meet these. The assessment we read showed that all the relevant areas of this person’s physical care and psychological care were noted and considered. In this case the pre admission assessment was very important as it identified particular problems that the home would need to be aware of in relation to infection control arrangements. It was a situation that the home has managed before, but needed to be prepared for. The assessment also showed that the acting manager had made a specific assessment of the person’s skin, recording its general condition but also making particular note of the areas susceptible to deterioration through pressure (their pressure areas). This information meant that the staff in the home were fully aware of this person’s needs and arrangements could be made to ensure these were met prior to the person’s admission. We were also made aware of another person being admitted during this inspection. Again, they were funding their own care and due to stay for a short period only (respite care). The home had been aware of this person’s needs prior to their admission. Just prior to this inspection we spoke to a person who was arranging care for their relative. They had gathered some information about the home and had been to visit it. They had read our last inspection report on the former Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 11 Commission’s website and contacted us to discuss some of its content. In this situation we were only able to discuss the factual content of the report. The assessment of peoples’ needs prior to their admission is good practice and complies with the Care Home Regulations 2001. This service does not provide designated intermediate care. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are now benefiting from having their healthcare needs adequately met, but shortfalls in the safe administration of medicines must now be addressed in order to protect people fully from potential mistakes. EVIDENCE: The overall judgement of this outcome has taken in to consideration all the evidence gathered and, although there are shortfalls in the handling and recording of medicines that must now be addressed, there are overall improvements in how people’s needs are met. Many of the requirements made in the previous inspection report were in relation to ongoing serious shortfalls in meeting some people’s health and personal care needs. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 13 We therefore inspected in detail, the care being delivered to six people to see if this had improved. This included looking at their care plans and additional assessments and then observing some of the care being delivered. We also spoke to other people to seek their views on specific areas of their care and observed interactions between the staff and those they care for throughout the inspection. One of the previous shortfalls was the care given to prevent pressure sores and the recording of wound care. We looked at four people’s needs in respect of pressure area care and saw that all were now receiving the care that was written in their care plans. We saw people sitting on designated pressure relief cushions, lying on specialised mattresses or being cared for in bed during a period of increased redness to the skin, in order to relieve the pressure in a certain area of the body. This practice helps to reduce the risk of a pressure sore developing. The records showed us that some have been or are still being monitored by specialist external healthcare professionals in respect of their pressure care. One visitor who spends a lot of time with their relative was able to describe staff coming in and regularly changing their relative’s position in the bed. This person appeared well informed and was able to tell us why this was being done. We inspected the records of one person who has a wound, which originated from a pressure sore. The past wound care records did not explain the lead up to what was assessed eventually as being a highly graded pressure sore. This had developed after our last inspection, so we have asked the Registered Provider to carry out an investigation in to what care was originally given to this person, how the sore developed, what was done about it and the reasons for the lack of documentation. We have asked for a copy of their findings to be forwarded to us with details of any action they may feel is required following this. We can confirm that the care records show that this person subsequently received specialist wound care and that current wound care records report regular reviews taking place. The records also tell us that the written care plan for this wound is being followed and that it is showing signs of healing. Previous shortfalls were also identified in staffs’ moving and handling techniques i.e. people were not being moved safely and according to their needs or moving and handling assessments. Reasons for this, apart from a need to review staffs’ competency, was that staff were in a rush. There were not enough of them to care for all the people properly. This was also the view of visiting healthcare professionals at the time. During this inspection, we observed people being moved from wheelchair to armchair and vice versa either by means of a stand aid hoist, full hoist or just two staff and no hoist. We did not observe any poor practice and the manoeuvres were carried out in an unrushed way. Training records have always demonstrated that all staff receive update training but this was not being reflected in their practice. The training records Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 14 are again up to date, but staff have also received extra training and support from one of the company’s senior managers who is also a moving and handling trainer. Staff are also now being supervised in their practice. Another previous area of concern was the times people were receiving their food, their access to drinks and how those that were at nutritional risk were being monitored. During this inspection we read people’s care plans and additional assessments in respect of this. We then observed the support they were receiving, their access to drinks during the day and the times meals were being served. When we first arrived some people were eating breakfast and several were able to confirm they had already had this. There were staff present in the dinning room and the atmosphere was relaxed. One person confirmed that they had chosen to get up later and was now enjoying their cooked breakfast. Through the day we saw that people had access to drinks that were handed out, such as the coffee/tea rounds in the morning and afternoon but, also in between. We saw a jug of squash beside someone who was in bed and alongside someone who stays predominantly in their bedroom. A visitor confirmed that this was always in her relative’s room when she visits. We saw bowls of sweet and savoury snacks in both lounges, including fresh fruit. At lunchtime we observed several people being fed with soft or pureed food. We were already aware of one person’s specific needs and cross referenced what we observed with their care plan, which had been written following advice from the Speech and Language Therapist (SALT). We observed this person being fed from a teaspoon; there were clear instructions in the care plan regarding this. The carer supporting this person also confirmed that all staff had received training in how to feed this person and what to do if the person choked. One other person, who was not showing any interest in eating during our last inspection, was now doing very well. We sat by her while she fed herself and finished the whole meal of flaked fish, mashed potato, mushy peas and parsley sauce. Staff explained that she is doing much better, now they have managed to encourage her to come out of her bedroom and sit with other people. We noted as we held this person’s plate that a non slip mat would help, so we let staff know about this. Another person, totally dependant on staff for any food and drinks, was being fed at lunchtime in a caring and unrushed manner. Everything that was written in her care plan was being followed by the staff. She was sitting in a chair that could recline but, which was in an upright position for feeding. Records showed that their weight was being monitored and that she was nutritionally at risk. We noted that this person had gained nearly three kilograms since February. One other person was asleep for most of the day. The nurse was able to explain to us why this was so and that it was being addressed by the doctor and visiting Community Psychiatric Nurse. We asked a carer if this person had eaten and drunk anything. The carer confirmed that they were aware of her present condition and that they were waking her up at intervals to have a drink Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 15 and at mealtimes to eat. We observed her being offered a drink at one point during the day. On the first inspection day we spoke to the cook on duty. This person is new to the home since our last inspection but, has worked with the current acting manager before (see Staffing outcome). She was fully aware of who was at nutritional risk. She showed us her copy of the nutritional scores which cooks have always been supplied with. This cook’s knowledge of the peoples’ dietary requirements was very good. At 2pm she had prepared a jug of milkshake, which had been made with full cream milk and a calorie loaded product especially designed for drinks. The cook was able to name the people that this would probably be offered to by the care staff. She had also prepared pureed fruit for those who cannot eat whole pieces of fruit. On the second day of our inspection we spoke to the other cook who has worked in the home for longer. We asked her if she was aware of one particular person’s specific diet and how she meets this need in her cooking. Initially she explained that this person had eaten the same as everyone else but then confirmed that the whole dish had been made with a low fat product and therefore could be tolerated by this particular person. The dietician has given the home advice on what this person can tolerate and this was noted in her care file. The manager confirmed that the cook is able to order products such as low fat yogurts if she needs to. We also spoke to the relative of this person who had been clearly upset by her relative’s recent admission to hospital. She explained that her relative had been in a lot of pain and that she had not always been confident in the past, of the home adhering to the dietician’s instructions. We were able to give some reassurances that the cook was aware of her relative’s needs. We also explained that there will probably be better continuity in the kitchen as the home has now employed a second permanent cook, thus getting rid of the reliance on agency cooks. There have been previous shortfalls in the content of care plans, where the written plan has just not been relevant to the needs of the person, or what we were observing bore no resemblance to the care plan. This problem was beginning to be addressed at our last inspection but during this inspection it was noticeable that the care plans we read were being used as ‘working documents’ meaning; dated amendments or additions were being recorded as people’s care needs altered or when new information had been received. We were also pleased to see, that what we were reading was being delivered despite two members of the care team admitting they do not read people’s care plans. One of the current acting manager’s main aims has been to improve staff supervision and general communication within the team; so although care plans are not being read by the care staff there are other arrangements in place to ensure people are getting the right care. The wipe board in the office also provides information for care staff that can be read quickly. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 16 One shortfall however, related to someone’s oral hygiene. We specifically highlighted this during this inspection because the lack of oral hygiene has been a problem in the past. In this case, this person was an ideal candidate to speak to about their care and their care plans because they are still able to be very involved, as are their family, in deciding how the care is delivered. The personal hygiene care plan clearly stated that oral hygiene should be given following an inhaler and on a daily basis as a minimum. This person said they have never been offered oral hygiene after the use of an inhaler and in the morning, it is dependant on who helps with their wash as to whether their teeth are cleaned. This person has never complained about this but does not like it when their teeth and mouth are not fresh. This is a very simple care task but one that is important in maintaining good oral hygiene and one that will become more relevant for this person in the future because of their growing dependency on staff. It is also about how it leaves the individual feeling if they have not had their mouth and teeth cleaned and is a simple shortfall in maintaining someone’s dignity. We therefore asked the acting manager to look into this particular person’s care and to ensure basic support in this area was being afforded to everyone. This particular person has very specific care needs for a condition that will get worse. It is therefore vital, that staff are able to identify changing needs and adapt their care accordingly. Since our last inspection staff have received further training and support in respect of this condition from an external healthcare specialist. The person receiving the care is fully aware of their condition and was able to tell us that it was getting worse, but that their confidence in the staff to look after them was growing. This was also a sentiment expressed by a member of the family. On speaking to one other person they explained how ‘low’ they felt. We spoke to one of the qualified nurses about this. This nurse was able to explain to us that the person had been prescribed an antidepressant and in her view, this now needed a review and possible increase. She had already arranged a visit by the doctor for this very reason but, also to review other areas of this person’s health that could be affecting their overall mood. In summary, with regard to the care plans and additional assessments we read, we are able to confirm that the recording of care, its planning and the monitoring of care needs appears more relevant, consistent and competent. With regard to what we observed, the delivery of people’s care needs and the general routine of the home, it appears more organised with obvious monitoring and supervision taking place. The staff team are more aware of their care practices and morale has improved. Qualified nurses and the acting manager were aware of people’s healthcare needs and were addressing these. All of this enables adequate standards of care to be delivered as is required by the Minimum Care Standards and Care Home Regulations 2001. There were however, areas of practice relating to the safe handling and administration of medicines that were of concern. Some of these have been Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 17 discussed and reported on at various inspections during the previous twelve months. These have been addressed in the pharmacist inspector’s report below. Pharmacist’s Report. Although some issues about medication identified at the previous key inspection have been attended to some ongoing weaknesses in the arrangements for handling and managing medicines continue to be a risk to people living in the home. At the time of this inspection no people living in this home were assessed as able to self medicate and look after their medicines. We were told that this would be possible if a risk assessment showed that it would be safe. People living in the home were therefore totally dependent on the staff for this part of their care. Registered nurses were responsible for administering medication, except for some prescribed creams and ointments that carers applied. Training for the safe handling of medicines has been provided by the Pharmacy that supplies this home. Blanchworth managers have put in place competence assessments for the nurses and they have found them competent with medication. Some of our findings do still sometimes demonstrate some lack of competence that needs addressing. We saw that some staff have undertaken training in the use of syringe drivers for administering medicines and that two more staff were booked for this in June 2009. This was an outstanding requirement at the last inspection. We saw that during the time we were in the home medicines were administered promptly in line with the times included on the medicine records and that there were suitable intervals allowed between doses. Some clarification of dose times for the lunch period was needed as we saw that the medicine records showed a number of different times but staff appeared to administer the medicines at one time regardless of the various times printed. Discussion with the pharmacy should allow the home to choose the times that the pharmacy prints on the records to reflect the actual practice in the home. We spoke to one person who told us that (s)he is able to tell staff when (s)he needs medication and staff then administer this. All medicines needed appeared as in stock on day of inspection except records indicated that a particular barrier cream had been out of stock for one person since 8pm on the day before the inspection. Before this the chart was signed as administered twice daily and this was confirmed in the care plan as being applied after cleaning and drying and pad changing. The registered nurse confirmed that there was no stock in the home and straight away contacted the surgery and pharmacy to obtain a new supply as soon as possible. This Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 18 person was at risk as the barrier cream had not been applied since 8am on 7th May 2009. There were arrangements for keeping records about medication received, administered and leaving the home or disposed of (as no longer needed) for each person in the home. A sample of medicine records we looked at appeared to be generally in order (with some exceptions as noted below) so that there were clear records about the medicines people living in the home need and had taken. We were concerned however that on the medicine charts we looked at starting from 27 April 2009 there were gaps in the administration records for five different people for 19 individual doses of eight different medicines that were prescribed for regular administration on eight different days of the twelve days of records we looked at. For some people we saw that the tablets were missing from the blister packs for those days and times but this does not necessarily mean that people had received these doses as they may have refused the prepared doses. Other medicines were in liquid form or in one case was a particular cream so we could not check if the dose may have been given. Although this may represent a small percentage of the total number of doses that were administered during this period and where the records appeared to be correctly completed these examples could still place these particular people at risk from mistakes with their medicines. We were particularly concerned for one person living in the home where the records indicated a once daily dose of one medicine due each evening had been missed recently. (We were told an agency nurse was on duty). This person experienced a health problem ten hours later that could have been as a result of this missed medication as it was to prevent the person experiencing this type of problem. It seems that in each of these examples the home staff who administered subsequent doses of medicines ignored the gaps on the medicine record charts rather than following up these in a structured way in the interests of each person. For one person prescribed a variable dose of one or two tablets of a painkiller ‘as required’ on the three occasions signed as given this period, the actual dose noted was not written on the medicine chart. Some other records we looked at did indicate the dose given where variable doses were prescribed. We found inconsistent practice in the records made for prescribed skin treatments staff had applied to people living in the home. This has been raised at previous inspections where we also found lack of consistent recording or evidence that people were receiving these types of treatment correctly. Although some changes have taken place we still conclude that the arrangements for keeping records for the application of prescribed skin treatments were not sufficient to make sure there were accurate, clear and Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 19 complete records about what, when and where the treatments the staff had applied. This has been an ongoing issue so the provider needs to consider the reason for this and why these current recording arrangements do not always meet the Care Homes Regulations. The home policy needs reviewing to make sure that it is practical to implement and it is quite clear to staff about how these records are supposed to be kept to help make sure that people living in the home receive these treatments correctly and with minimum risk of mistakes. The manager designate showed us an example of a new record for topical treatments that the Pharmacy has provided and it may be that this could be considered to help with the recording issues we keep identifying. We also could not establish the frequency for application of an antibiotic ointment for one person recently admitted. The pack supplied by the hospital on discharge did not have a label with dose instructions for this person. We were concerned that this person may be under-treated leading to possible development of resistant bacteria. The staff told us the doctor was due that day and would clarify the dose then. As the people in this home were totally dependent on the staff to administer their medicines, accurate, clear and complete medicines records are very important. All the people in the home were prescribed a large number of medicines and over any one week period there would be different staff involved in administering the medicines. In order to protect the health and well being of people living in the home it is really important that people receive their medication in accordance with the doctors’ directions and the agreed plans of care. Accurate recording is needed in order not put people at risk of mistakes with their medicines and so that there is a full account of the medicines the home is responsible for on behalf of the people living here. We were concerned to find these issues as similar issues have been identified and reported on at previous inspections. Also the nurses were signing daily medication handover forms to confirm that the medicine administration records were checked and signed and that stocks of medication were not running low. These findings demonstrate some lack of competence of the staff to keep accurate medication records. Regular management audits were in place that were identifying similar issues. In some, but not all cases, follow up action to the findings of the audits were noted. There is no value in carrying out audits unless there is definitive action to address any shortfalls found and so reduce the risk for people living in the home. On 15 May 2009 we sent a letter for urgent action to the registered provider detailing these particular issues and asking for a response by 22 May 2009. On 19 May we received an acknowledgement of this letter from the registered provider promising that a response would follow, which we subsequently have Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 20 received. We will carry out a random inspection to make sure that the registered provider has taken suitable action to address these issues. We looked in various care plans and saw these contained more detailed information to guide staff for the use of medicines that were only prescribed to use ‘when required’. We also saw that this topic was part of the regular management audits. Dose changes for an oral anticoagulant were now confirmed in writing from the surgery. This is in line with a national directive so as to reduce the risk of giving the wrong dose to any person in the home who takes this type of treatment when there are regular dose changes. There were arrangements in place to keep all medicines securely. Checks of controlled medicines we made agreed with the recorded stock and we saw that the manager designate made regular recorded checks of these medicines. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 21 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New arrangements mean that people’s daily preferences and choices are being accommodated, by staff who are now able to do this, although the company managers need to be aware that by not replacing key hours, such as the activity coordinator’s annual leave, will still mean that there is a potential for social preferences not to be met. EVIDENCE: During our last inspection and for sometime before that the home has not been run in a manner that best suited the needs, choices and preferences of the people living there. However during this inspection this was not the case. In this outcome we are able to give examples of preferences being met and the general aim of the service being, to improve the quality of people’s lives. One of the previous problems raised by visitors was that there was nowhere quiet or private to visit their relative. Since our last inspection the redecoration of the conservatory has been completed and it has been made more Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 22 comfortable for general use. The acting manager said it can be used for visitors who want more privacy and when it is vacant can be used for other things. During our visit we saw a prospective new member of staff interviewed in there and we were also invited to give our feedback in there. It would therefore be important, for this to be successful as far as visitors are concerned that it is available when they want to use it without them feeling they need to ask. The main use of one of the lounges on the ground floor has been altered. Before, both lounges offered the same thing; both had televisions and music centres that were usually on. One lounge is now for quiet use and the snoozelum machine (a device, when switched on helps provide visual stimulation for people who have lost or are unable to respond to usual daily stimuli) stands in the corner. Quiet music can be played at someone’s request and there are books to read. The armchairs have been arranged to either look out of the windows or in small groups. One person enjoying the view from the window, said she hates crowds and quite liked watching ‘life go by’ outside. Her companion in the room explained she had been asked to come upstairs while her bedroom carpet was being cleaned. She told us that she did not like sitting in front of other people because some of the symptoms of her condition now embarrassed her. She said she would previously have not agreed to come upstairs but, now felt the room was quiet enough to be in for a short period of time. During a tour of the home we saw the main meal of the day displayed on a blackboard in the dinning room, with alternatives. On the first day, at lunchtime, five people chose the alternative. At breakfast time we saw people eating a variety of food including cooked food. One particular person was enjoying a personal preference, black pudding. We were particularly pleased to see staff in the dining room area at breakfast time available to deal with requests, socialise and help those that needed help to choose what they wanted to eat. At lunchtime we observed one person enjoying a glass of sherry, which the home said it provides and one person having a glass of wine which is supplied by her family and labelled for her use only. When the activities coordinator is absent from the home such as on annual leave, these hours have not been replaced. In previous inspections we have been informed that it has been down to the care staff to provide activities when they are able to do so. This has often been difficult to achieve as people’s care needs have needed to take precedence. During the first day of this inspection the activities coordinator was on holiday but, we witnessed one carer organise a well attended quiz. Care staff commented that they have been able to provide activities during the activity coordinator’s absence because the home has had less people living there. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 23 Another carer said it has been nice to be able to spend this time and not feel stressed in doing so. The Registered Provider has subsequently informed us that they view the provision of activities as being as important as meeting people’s physical needs. We have been informed that care staff were able to provide these activities because there had been an alteration in the daily routines, not because there were less people requiring attention. The Registered Provider has told us that a carer had been specifically allocated to provide these activities, leaving the remaining care staff free to attend to other aspects of peoples’ care. We will continue to monitor this as the home increases its numbers of admissions and subsequent care demands increase. On the second day, the activities coordinator was back and ready to start activities of their choice at 10am. It had been decided to play a game of armchair netball, which one person said they really enjoyed, followed by a quiz. It was also one person’s birthday so the activities coordinator was going to see if there was anything particular this person wanted to do. The birthday celebrations were shared by all which included opening cards, a cake supplied by the family, visits from relatives and singing Happy Birthday. We are also aware that the activities coordinator also visits and spends time with people who stay in their own bedrooms. Throughout this inspection we saw visitors arriving and leaving as they wished. We also saw two people who specifically visit in order to provide shared prayer time for one of the people who live in the home. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 24 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Following a change of management and several senior staff, plus the new arrangements for ensuring people have a point of initial contact within the home and the improved standards all round; people should feel reassured that there are now systems in place to address small concerns quickly and fully address any complaints. EVIDENCE: The current acting manager told us she adopts an open door policy. She is keen for communication between those that live in the home, their representatives and staff to be open and constructive. We were told that the home had not received any complaints since our last inspection in October 2008. A summary of the complaints procedure is on the wall in the entrance area and is contained in the literature that people receive when they first move in to the home. Prior to this inspection we had received information about a person in the home who had suffered some kind of event that resulted in a change to their condition. This information told us that the family were first made aware of this following a review by an out of county authority responsible for funding this person’s care. The relatives were surprised and upset to hear this, because Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 25 they visit the home regularly and nothing had been said, although they had made some observations of their own at the time. We were able to speak to this family during this inspection and they explained that this had left them feeling they needed to visit more frequently to ‘watch over’ their relative. They were able to say that they had been happy with the care, but also felt some things had definitely improved lately. We agreed that although it would appear that this event happened before the new manager was in post, it was really important for her to be aware of their current anxieties. The acting manager was able to listen to these during this inspection and confirmed that she would always ensure that any changes in their relative’s health would be immediately communicated to the next of kin. On inspecting this person’s care file there was no significant entry that related to what may have occurred. We have therefore requested that the Registered Provider investigate the events of late 2008, including any medical reviews that may have taken place and confirm what took place to the family and us. One very valuable change since our last inspection is the presence of a person in the office from Monday to Friday who can answer the phone, answer the front door and generally greet people as they arrive. This person is in fact the company’s training coordinator who was relocated to the home from the company’s head office to help the acting manager in organising staff training and with general administration tasks. We observed this person being very effective in making people feel welcomed. People were offered tea on arrival, simple questions could be answered without the person having to find a member of staff and if they wished to pass a message on or talk to the nurse, this could be arranged. We also noted that he provided a link for staff that sometimes needed simple clarification or confirmation on something as they passed the office door. This role was clearly providing a first point of contact for people and not only allowed the acting manager or nurse to be able to manage the home and direct care but provided an opportunity for concerns or irritations to be listened to and dealt with immediately. We witnessed an example of this when a visitor who was concerned about the lack of heating in her relative’s bedroom (see Environment outcome for further detail) came to the office door. We observed her concerns being acknowledged immediately by this person. This is an improvement on comments we have received in the past or situations we have witnessed before where visitors have been unable to locate a member of staff to help them. This person told us that on the occasions he is not in the office the telephone is put on to answer machine but also explained that these calls are acknowledged as soon as he returns. For sometime now the home has been assessed by us as providing poor outcomes for those living in it (see Management and Administration outcome). There have also been serious concerns relating to people’s safety. The local County Council, under its Safeguarding Adults protocols, have therefore been Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 26 responsible for reviewing and monitoring people’s care and the practices in the home. It was due to these concerns that a decision was made by the Community Adult Care Directorate (CACD formally Social Services) not to admit anyone to the home until practices had improved. At the same time as this inspection the local funding authority were carrying out reviews on the people they were helping to fund. The reviewing officer was able to tell us that, where people were able to express a view on the home and their care, they were generally happy. She had been given some feedback from people about what would improve their individual quality of life and she was going to feed this back to the acting manager to address. One example being a person enjoyed doing large jigsaw puzzles and they wanted to be able to keep this out somewhere and return to it when they wished. This inspection has identified improvements in the care and organisation of the service, which will be fedback to the professionals that attend the Safeguarding Adults Strategy Group. Some of the arrangements that we would expect to see in place within the home to help protect people against abuse and harm would include, relevant training on abuse issues with robust policies and procedures in place to help guide staff. Company policies and procedures are in place and include a Whistle Blowing Policy for staff to use if they have concerns about other staff members’ practices or actions. The new acting manager has attended the Enhanced Safeguarding training, provided by the local County Council and is also due to attend the ‘alerters’ training in July. She is attending the ‘alerters’ training because it is aimed at care staff and she wanted to be aware of what her staff are being told and it also consolidates some of the information she received on the enhanced course. We were told that five further members of staff are booked on the ‘alerters’ training. These staff last attended training on the Protection of Vulnerable Adults (POVA) in 2007, given by the company itself. Other staff that received training on abuse in February 2009 also attended the ‘alerters’ training which, we were informed is now the chosen training for all home staff. The training coordinator explained that awareness in how to manage Challenging Behaviour used to be given internally with the POVA training and the company still needs to source this training externally in order to update staff. It is important that they do this as they also have designated beds in this home for the care of those with dementia. The company are aware of the criteria that needs to be considered under the Mental Health Act 2005, which now includes the more recent guidance from the Department of Health on the Deprivation of Liberty Safeguards (DOLS). Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 27 The company’s care documentation was altered in 2008 to accommodate some of this. We were informed during this inspection that the acting manager was due to attend a days training on DOLS and its implementation, later in May and that six staff have already completed a half day training. This training is also being provided by the local County Council. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 28 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 25 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home now offers people a clean and comfortable environment that caters for all needs and preferences. EVIDENCE: In our last inspection report we acknowledged improvements being made to the environment. These included some redecoration, replacement of carpets and soft furnishings. We also acknowledged that the home was looking cleaner. During this inspection some of the redecoration was now complete and again the general environment looked cleaner. We fed this back to one of the long standing cleaners. This person confirmed that there had been a period of time when the home had several cleaners, Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 29 working together, to improve the standard of cleanliness. This person informed us that they work weekday mornings until 2pm and that they clean each floor with the help of another cleaner. The Registered Provider has subsequently confirmed that there are three cleaners working six hours each, Monday to Thursday and on Friday’s there are two cleaners. On Saturday and Sunday there are two cleaners working ten hours between them. There is a laundry assistant each day. We acknowledged the new carpets during the last inspection saying how much cleaner and respectable the home looked. We said the same this time but asked the cleaner if there would be time to shampoo (spring clean) communal carpets so that they remained this way. The cleaner explained that they would not have time to shampoo the main communal carpets but they are able to attend to areas of spillage, usually in bedrooms that result from continence accidents. We asked the acting manager to discuss with senior managers’ arrangements that included the shampooing of all communal carpets so that they can be kept looking fresh and thus avoid a return to the badly stained carpets seen in 2008. We have been subsequently informed by the Registered Provider that the home does have a schedule for spring cleaning which includes the shampooing of communal carpets and bedroom carpets. We have also been informed that at the time of this inspection only 20 bedrooms, three communal lounges and the dining room were in use and it would be the expectation of the Registered Provider that spring cleaning would be achieved. We observed plenty of new cleaning products being put away during this inspection and noted that there were paper towels and liquid soap in areas where staff would need to clean their hands. There were also specialised products for cleaning hands where these were required, including colour coded bags for the segregation of laundry. In toilets and some bedrooms there were plastic gloves and aprons for staff to use to prevent cross infection. With this in mind, we noted that a different coloured plastic apron was used when serving food. On the first day of this inspection we found one person in their bedroom saying they were cold. They were cold to the touch and they had taken themselves to bed to warm up. The bedroom has a connected lounge area for that person’s use, which has a lot of glass (like a conservatory) and the wind was quite strong and chilly on that day. We felt the radiators in this room at 3pm and they were barely warm. We reported this to the senior staff and after a brief discussion on the temperature reading of the room, which we were informed by the senior company manager as being 23 Celsius our point of this being irrelevant if the person in the room was actually cold, was acknowledged and a visit by one of the maintenance team took place straight away. At the same time a visitor reported that their relative’s room was also cold (similar design of lounge area). The result being that the timer on the boilers was increased and the temperature of the boiler turned up. We asked for the first person’s Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 30 temperature to be taken in case their core temperature had dropped but this was a healthy reading. We saw one hoist used for transferring those that cannot stand, marked as ‘not in service’ but it was confirmed that the home has three full hoists and two stand aids which are currently required by eight people. The home has additional adaptations to help people bath safely. People in wheelchairs have access to the paved garden area at the back, but they would require the assistance of someone to get through external doors. The paved garden area is also the main entrance for someone in a wheelchair as there are steps up to the front door. Specific and specialist equipment and furniture is supplied to the home by the health authority following an assessment process. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 31 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The increased investment in staff training and support has benefited those in the home by improving the standard of care provided; however, this could be compromised at night due to a recent reduction of care staff. EVIDENCE: During this inspection there were twenty people in the home requiring care and one person due to be admitted. We have received copies of the weekly duty rosters, as requested, since the last inspection. These currently show us that there is always a qualified nurse on duty twenty four hours of the day. In the mornings there is usually five staff altogether; one nurse with four carers or two nurses with three carers. In the afternoon (from 2pm until 7pm) the aim is five staff again; four or three care staff depending on how many nurses are on duty (usually one). There have been days when these numbers have been different such as Tuesday 14th and Sunday 19th April 2009 when between 2pm and 4pm there Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 32 were three care staff and one nurse and on Friday 17th April when there were two nurses and four care staff in the morning. The general numbers for staff on duty have dropped since February’s rosters by one member of staff per shift. We presume this was in response to the number of people in the home, dropping from twenty- three in February of this year to the current number of twenty. The duty rosters also tell us that from Monday to Friday, between 10am and 4pm the activities coordinator is on duty, taking the lead with social activities. This person only concentrates on people’s social needs and is in addition to the numbers of staff spoken of above. We know that at the discretion of the Registered Provider these staffing numbers can alter as seen since February for day staff and below with night staff. The number of night staff on duty on any given night has been reduced from three to two between the hours of 10pm and 6am, again we presume, in response to numbers of people in the home dropping. An adjustment to the hours that day staff work has also taken place to help meet people’s needs between 6am and 7am and 7pm and 10pm. One afternoon carer now remains on duty until 10pm and one morning carer comes on duty at 6am instead of 7am. We were obviously keen to seek confirmation from the acting manager that two night staff between 10pm and 6am could adequately meet the needs of the people in the home. The acting manager said she had witnessed the shift working until 10.30pm and confirmed that the fourth floor (top floor) was still closed, meaning staff are only working across three floors instead of four. She therefore was of the opinion that there were ample staff on duty. We acknowledged the extension of the day shifts and were aware that the top floor was not currently in use, but we remain of the opinion that the reduction in staff numbers does not offer any benefit to those living in the home. Instead it has increased the chances of someone not receiving help as and when they require it. At worst people will not wait for help that they would have otherwise received and attempt to do something on their own; such as transfer from one place to another and possibly fall. In forming our opinion we were aware that the top floor was not currently in use and we took into consideration what the Annual Quality Assurance Assessment (AQAA) told us about what care people require at night. This told us that no one required the help of two staff at night; it also told us that only one person required help or support at meals times. We know the latter to be incorrect as we observed several people needing to be fed by staff. We also know, by reading various care plans, that there are people in this home that require help at night with their continence needs and those that require to be manoeuvred. If these needs are to be met safely, in some cases, this would definitely require two staff. As the information supplied by the AQAA conflicts with the known care needs of the people in the home, we have made a recommendation that the staffing levels at night be reconsidered for the general benefit of those in the home. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 33 We remained concerned about fire safety across four floors and the possible need for staff to evacuate people at night. We have made a requirement that a copy of the home’s Fire Safety Risk Assessment be forwarded to the Commission, in order for us to see if consideration was given to this (in the absence of a ‘stay put’ policy) when the decision was taken to drop the numbers of night staff. We were informed at the time of this inspection that all staff are up to date in fire safety training except for one, who requires an update. We asked the Fire Safety Officer to review the company’s arrangements which has subsequently been done and the Fire Services have confirmed that they are satisfied with the current arrangements. The rosters also provide information about the hours that the current acting manager is working in the home. We have been told that these hours are in addition to any of the above. This manager appears to work varying hours per week and the shifts pattern alters. The shifts can vary from 7am until 1pm, 1pm until 7pm, 7am until 2pm, 7am until 5/5.30pm or 7am until 6pm and are worked predominantly Monday to Friday. There are seven staff who hold the National Vocational Qualification (NVQ) in care either at Level 2 or 3; two further staff members were qualified nurses in their own countries and are viewed by the company as being equivalent to NVQ level 3. These numbers are above the national minimum standard required. Two more members of staff wish to do NVQ level 2, one a carer who already started the award a while ago and for various reasons was unable to complete and a cleaner. Another overseas nurse wishes to be considered for NVQ level 3. The Annual Quality Assurance Assessment information tells us that staff participate in a 12 week induction programme at the beginning of their employment. We are aware of staff having certificates to demonstrate they attended two days of initial training right at the beginning of their employment, but during this inspection we were unable to fully inspect this standard and verify a 12 week induction programme. We inspected four recruitment files. Three of the new staff to Astley Care Centre worked until recently, in a care home that used to be managed by the same umbrella company as Astley Care Centre (Blanchworth), until they sold this earlier in 2008. So all of these staff are known to the Registered Provider. All required new clearance by the Criminal Records Bureau (CRB); records tell us that two started after receipt of a CRB and one started just before. The one that started just before had been cleared against the Protection of Vulnerable Adults (POVA) list before working in the home. All had various references. The fourth person was also known to the home from a care agency. Records show that this person was employed after receipt of the CRB, but the dates on Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 34 the references imply that only one reference was received before the person commenced employment. The Registered Provider has subsequently informed us that one of the original references was destroyed so the company asked for this to refaxinated. Despite this having been refaxinated the date on the reference is still after the date of the person’s employment. The Registered Provider has subsequently referred us to additional notes that imply the second reference was received prior to employment. Due to the actual date on the reference, it is difficult for us to establish whether this was actually received after or before commencement of employment. Therefore we have strongly recommended that in future all documentation such as references must be able to demonstrate that robust recruitment practices are being adhered to i.e. that the reference was provided and obtained prior to employment. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 35 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are benefiting from the home being managed in a consistent manner and from staff being adequately supervised. These arrangements however need to be sustained to offer consistent safety and protection to those living in the home. EVIDENCE: Since late 2007 and across a period of three Key Inspections we have evidenced inconsistent management for various reasons. This resulted in a lack of leadership and supervision for the staff, which then led to a drop in the Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 36 standard of care being delivered and ultimately resulted in unsafe practice. The process of trying to address this with the Registered Provider and seek compliance with the National Minimum Standards and the Care Home Regulations has also caused unrest for relatives and families. The Commission has received correspondence from concerned relatives, in support of the staff, but it is the duty of the Commission, through its enforcement pathways, to protect the welfare of those within the home. Since our last inspection in October 2008 the then manager designate has left and on the 12th February this year we received notification that the present acting manager had begun. This person is a Registered Nurse and has been a Registered Manager for another of the company’s care homes since 2001. At the time of this inspection the acting manager had been in post three months. We had also received an application from this person to be the future Registered Manager of Astley House. Registration is subject to a successful ‘fit person’ interview which will take place on receipt of a Criminal Records Bureau (CRB) clearance, medical clearance and references. The current acting manager demonstrated knowledge of people’s needs and was clearly able to explain what actions had already been taken in relation to the outstanding healthcare related requirements and what her involvement had been in this. We observed her working ‘out on the floor’ and being available as opposed to staying in the office. We were informed of several other things that had taken place and which were continuing such as adequate staff supervision and monitoring of care practices. Both senior staff and care staff indicated that morale had generally improved and the care staff told us that they felt valued. We could see that changes had been made to the allocation of work and from what we were observing during this inspection, this had resulted in the home being run to suit the needs of those living there. We were told by care staff that communication had improved and that the current acting manager was approachable and supportive. We could see that people living in the home were being cared for in an unrushed way and that staff were working as a team. The acting manager confirmed that she was also getting plenty of support from the company to ensure she was able to achieve her goals. One of the company’s senior managers, responsible for providing this support, was present in the home and presented us with information that demonstrated his involvement in relation to staff supervision and training. Qualified nurse competency assessments had also been carried out. We could see that there had been a change in some of the qualified nurses working in the home. We discussed some of the reasons for this and some of the appropriate action currently being taken by senior managers in relation to this. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 37 Monitoring and auditing of the new arrangements and systems is clearly taking place to ensure their effectiveness, but comments made by the Pharmacist in the Health and Personal Care outcome of this report, need to be acted upon. We have continued to receive reports from the service that comply with Regulation 26. These follow a monthly unannounced visit to the home by the company’s own senior managers who report on the wellbeing of the people in the home, the general management, care plans, any concerns or complaints, maintenance issues, staff supervision and training. The content and the systems for ensuring that what has been identified during these visits and how and when issues are being addressed did improve in 2008. This is a positive step forward as one of the company’s previous shortfalls has been having a system in place that ensured shortfalls were addressed and not repeated. We can confirm that all outstanding requirements have been met or are well on the way to being met, such as care planning. There were however shortfalls in respect of the safe administration of medicines which have been addressed in this report by the Pharmacist Inspector. We have inspected documents relating to health and safety which demonstrate that all the main utilities and equipment is serviced and checked by external contractors on a regular basis. We were informed that the usual safety checks on hot water, radiators and window restrictors were still carried out, although we did not specifically inspect records pertaining to this during this inspection. Since the last inspection there has been a review of the use of bedrails and all staff using these during care delivery have completed an ‘on line’ awareness course in the safe use of bedrails. The Annual Quality Assurance Assessment tells us that all policies relevant to people’s safety have been updated in the last year, others in 2007. This document was very informative telling us how improvements have already been made and tells us of future improvements which, were taken into consideration during this inspection and will be looked for in the future inspections. Information within section 8 of the Dataset however was incorrect. Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 38 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 3 X 3 Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 39 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Review and put in place robust arrangements that make certain that people living in this home always receive their prescribed medicines in accordance with the directions of their doctor and that this is supported by accurate, clear and complete medication administration records for all prescribed medicines including those products applied topically to the skin. This will help to make sure people receive the correct levels of medication and are not put at unnecessary risk of medication mistakes. This was included in a letter for urgent action sent to the Registered Provider on 15 May 2009. Timescale for action 22/05/09 2 OP38 13(2)(c) The Registered Person must 26/06/09 forward a copy of the homes Fire Risk Assessment to the Commission, demonstrating that robust fire safety precautions and the ability to evacuate people if needed can be achieved with two night staff. DS0000016373.V375409.R01.S.doc Version 5.2 Page 40 Astley House Care Centre RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The Registered Person should reconsider having more than just two staff on duty between the hours of 10pm and 6am for safety reasons and to ensure people can receive help when they need it. We strongly recommend that staff are not employed prior to receipt of a satisfactory Criminal Record Bureau (CRB) clearance unless particular risk can be demonstrated in not employing someone, such as extreme shortage of staff where all other avenues have been explored or tried out. We strongly recommend that any references obtained in respect of a person the home wishes to employ are fully able to demonstrate that they were obtained prior to the person’s commencement in post. 2 OP29 3 OP29 Astley House Care Centre DS0000016373.V375409.R01.S.doc Version 5.2 Page 41 Care Quality Commission South West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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