Inspection on 24/11/08 for Athelstan House

This inspection was carried out on 24th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Athelstan House Priory Way Burton Hill Malmesbury Wiltshire SN16 0EQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Wilcox     Date: 2 5 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 40 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Athelstan House Burton Hill Priory Way Malmesbury Wiltshire SN16 0EQ 01666848000 01666829562 manager.athelstan@osjctwilts.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Charlotte Mary Sievewright Type of registration: Number of places registered: The Orders Of St John Care Trust care home 80 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 80. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) maximum of 10 places Mental Disorder (Code MD) - maximum of 5 places Old age, not falling within any other category (Code OP) - maximum of 80 places Date of last inspection Brief description of the care home Athelstan House is a purpose built eighty bed care home which provides a range of care and nursing services. It is situated in close proximity to the amenities of the local Care Homes for Older People Page 4 of 40 Over 65 0 0 80 10 5 0 Brief description of the care home town, is on a bus route, and is managed by The Orders of St John Care Trust. The home offers six nursing care places for Primary Care Trust referrals, twenty reenablement places for service users requiring help after discharge from hospital, four respite places, and long term nursing and residential care, including care for people with mild to moderate dementia. Accommodation is provided in single rooms with ensuite bathrooms and is situated on two floors. Assisted bathing facilities in communal bathrooms, spacious lounges and dining areas are provided throughout the home. All areas are accessible and a shaft lift is provided. There are large and attractive gardens surrounding the home. Information about the home is available in the Service User Guide which is issued to prospective residents. A copy of this first CSCI report will be made available in the home for anyone to read. The charges for Athelstan House are comprehensive and are based on the type of care and accommodation being provided. The overall fee range is between five hundred pounds and one thousand pounds, with individualised fee information available from the home. Hairdressing, Chiropody, Newspapers and Toiletries are charged at individual extra costs. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This is the first Key Inspection for this home. Two Regulatory Inspectors carried out this inspection on two full days in November 2008. A Pharmacy Inspector also carried out an inspection of the medication management on the first day. Pre-admission arrangements and care records were inspected with the care of two Care Homes for Older People Page 6 of 40 residents from each of the four units being closely looked at in particular. A number of residents and relatives were spoken to directly in order to gauge their views and experiences of the services and care provided at Athelstan House. Some of the staff were interviewed. Survey forms were also issued to a number of residents, staff and visiting health care professionals to complete and return to CSCI if they wished. Some of their comments feature in this report. The quality and choice of meals was inspected and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, provision, training and supervision of staff were inspected as was the overall management of the home. A tour of the premises took place with particular attention to residents accommodation and facilities, health and safety issues and the maintenance and the cleanliness of the premises. We required an Annual Quality Assurance Assessment (AQAA) from the home, which was provided, and the contents of which informed part of this inspection. What the care home does well: What has improved since the last inspection? As this is a new service having its first key inspection there are no areas of Care Homes for Older People Page 8 of 40 improvement to assess. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 40 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Access to information about the home and a comprehensive assessment process prior to admission here gives prospective residents an assurance that their needs can be met. Evidence: The homes Statement of Purpose was inspected earlier this year as part of the CSCI registration process. We saw that a copy of the residents information brochure, the Service User Guide, had been issued to residents, which this being the first inspection for this service, did not contain a CSCI report. The manager told us that a reference would be made within the guide to advise the reader that a full copy of the report would be available in the home for them to read, but would include the report summary in each guide as a minimum. The manager confirmed that guides could be produced in alternative languages, large print or Braille if required. Care Homes for Older People Page 11 of 40 Evidence: A copy of an Accommodation Contract was included in the guide, as was the overarching fee information, detailing what the fees included or did not include. Contracts were not inspected in detail on this occasion, but we were told that individualised fee information and a detailed contract were added on an individual basis. The homes AQAA confirmed that all interested parties were given the chance to view and tour the home to meet other residents and staff, and that residents were able to stay on a trial basis. We inspected a sample of pre-admission assessments for residents admitted to each of the units. There were some variants in the way these had been conducted, but as an overview assessments had been carried out prior to admission being agreed and had been comprehensively and fully recorded on the homes designated tool for the purpose. The assessments took account of prospective residents personal details and their past medical history, their health and care needs, their medications, their ethnicity, socialisation and cultural needs, their understanding and legal status. There was also a manual handling assessment, a pressure sore vulnerability and overall skin assessment, a nutritional and a falls risk assessment. The assessments had been signed and dated with the location where it was conducted identified. They also identified if the persons family or representative was present. The lead nurse on the nursing unit, Lavender, told us that she conducted assessments for prospective residents requiring nursing care. We spoke to the homes designated assessment coordinator for the re-enablement, respite and personal care placements. We were told that when the hospital referred a person for a re-enablement placement the home went to assess the prospective resident straight away. Residents referred by the Primary Care Trust (PCT) were admitted on the basis of PCT assessment information. Where any concerns or questions had arisen over such an arrangement during the weekly multidisciplinary meeting the home had taken the decision to go and conduct their own assessment to ensure that the home could meet the persons needs. The manager reported a very good working relationship with the PCT for the short stay unit. We saw that a ward discharge summary and a letter had been obtained from the hospital in the case of a person referred by the PCT to a designated placement in Primrose unit. Letters to confirm a placement in the home had not been consistently issued for Care Homes for Older People Page 12 of 40 Evidence: residents and the manager acknowledged that this was an area she had to address. The home has been planned and organised to meet the care needs of a variety of different people, and overall was very suitable in this regard. However, residents admitted for personal care and residents admitted for dementia care all live in close proximity in the Heather and Foxglove units on the first floor, and mix as part of their daily lives together. Some of the residents in these units raised concerns with us about aspects of this type of communal living, saying that certain behaviours of some of the dementia care residents impacted in a negative sense on their lives. Staff had received training in dementia care, but three care staff told us that although it was a good basic introduction they still did not feel knowledgeable enough in this field. The home provided designated facilities for those residents admitted for a short stay re-enablement period, and this included spacious bedrooms and communal areas, and a kitchen for carrying out assessments prior to their return home. We were told that people admitted to this unit had a discharge plan in place, with a view to reenablement within six weeks. A weekly multidisciplinary meeting was held on the unit, involving home staff and management, the PCT, the occupational therapist, the physiotherapist and social workers. We were told that the meeting discusses referrals, establishes assessment plans, and decides and plans discharges. Care Homes for Older People Page 13 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although in many respects people living in this home can expect to have their health and care needs met, the numerous shortfalls within the systems for managing their medications are posing a risk in this area. Evidence: Residents had an individualised plan of care in place that had been drafted on the outcome of a full assessment, and had been done in consultation with them. Residents or their relative had signed their care plan. In the main the plans had been regularly reviewed, although there were isolated gaps in this, where certain aspects had not been reviewed for some time. However, despite this these remained reflective of the persons needs at the time. We chose eight care plans for closer inspection, two from each of the four units. Care plans were very holistic and person centred. They contained a record of the Care Homes for Older People Page 14 of 40 Evidence: persons life history, and were reflective of their wishes, preferences and cultural background. Recorded risk assessments in each case included pressure sore vulnerability, falls, nutrition and moving and handling. Where other risks existed, such as with the use of bed rails for example, these too had been taken fully into account. Pain and wound care assessments were recorded and monitored where applicable, and dependency levels were in all files and were up to date. Daily records showed clear detailed accounts about the residents day. Acute care plans were recorded in the event of illness, with the care and treatments necessary clearly documented. In the main, wound care charts, where applicable, were detailed with evidence of wound mapping, photographs and measurements. We saw clear evidence of General Practitioner (GP) and tissue viability input, with all visits documented, and outcomes and any follow up recorded as required. In one particular case however, where there was a very brief plan of care to address the management of some leg ulcers, direction for staff was minimal with no documentation regarding dressings, the frequency of dressing changes, and the cleansing procedures necessary. In the same case the mobility care plan was also minimal, and was not entirely reflective of the identified risk of falling. When we met this person conversation proved difficult, although the care plan had given no indication that the person had any particular communication needs. Detailed and personalised plans of care were in place to care for those who had dementia, including their preferred approach from staff and their communication needs. Recreational care plans were written so as to be enabling and empowering for the individual. Risk assessments were in place to address the very specific areas of concern that existed in individual cases. A temporary resident admitted for post-operative care through the PCT had care plans in place that promoted her independence, and also addressed the plan for her discharge home, incorporating multi disciplinary involvement. We found that each person had been medically reviewed on a regular basis and saw that a wide and comprehensive range of health care interventions had been provided where necessary and that some very good multidisciplinary approaches had been adopted for the benefit of the residents. Support equipment, such as variable height beds, pressure relieving aids and walking and lifting aids, was in place for those residents for whom it had been assessed as Care Homes for Older People Page 15 of 40 Evidence: needed. Staff were knowledgeable about residents needs and gave good descriptive accounts about individuals. Residents who responded to our survey forms and those who we spoke to in person felt that they received the care and attention they required, indicating that they were well looked after in the home. Residents confirmed that staff were caring and kind to them, and were polite and helpful. There was just one exception we found, with the resident saying that some staff were better at giving care and support than others. Some of the residents in the short stay unit also said that the home had good nursing staff. They spoke very highly about their surroundings, and told us that they were encouraged to be as independent as possible but that they should not be frightened to ask for help if they wanted it. We saw that residents looked well cared for, and were clean, warm, and appropriately attired. We saw staff interacting with residents in a polite and respectful manner, and we witnessed their gentle and sensitive approach with them. Staff knocked on residents doors before entering their rooms. We were shown evidence of the planned implementation of an End of Life Wishes and Resuscitation policy for the home, with care plans regarding individuals choices and wishes for their end of life being drawn up. The home provided accommodation for family members that might want to remain with their relative at the end of their life. One of the eight residents had some documentation about their end of life wishes and not wanting any active treatment. This had been discussed in a meeting with the resident, their next of kin and GP. All paperwork had been signed by those present to agree that no active treatment would be received or delivered in the event of illness. Most of the inspection of medication was limited to a detailed review of the arrangements on Foxglove and Heather units. The pharmacist visited the other two units briefly. Staff who had undertaken specific training about the safe handling of medicines were responsible for the management and administration of medicines for people living in this home. These staff also completed practical assessments of their competency as part of the training programme. Where nurses were responsible for the medicines on certain units we were told that the Quality Assurance manager for the company is conducting clinical supervision and competence assessments for these staff. Care Homes for Older People Page 16 of 40 Evidence: A number of errors involving medication have been reported to us since August 2008. We discussed with the locality manager how these were managed and changes put in place to reduce the risks of errors happening again. During our inspection we saw one of the nurses on Primrose carrying out a weekly audit of medication. Staff also told us that there should be monthly audits of medication on the units on the first floor but this was not always possible. We saw a part completed audit form dated 9.10.08. Effective audit systems are important to try and identify and reduce the risk of errors with medication particularly in a home where there have been so many incidents. Some of the issues identified at this inspection could have already been picked up if effective audit systems were in place. We were very concerned that some of the next periods supply of medicines had not been delivered for six people, so up to two doses of various medicines had still been missed at 6pm on the day of the inspection whilst we were still in the home. Some of the records about the medicines ordered for the current period were missing so it was not possible to see what had been ordered. We were told the missing medication was partly because of shortcomings of the supplying pharmacy but staff in the home should have followed this up more vigorously. We left an Immediate Requirement for this to be corrected and saw that staff were taking action to deal with this. The Lead Inspector found the following day that the Immediate Requirement had been complied with and suitable action taken to protect the health and wellbeing of these people. We have since had a more detailed written response telling us about the actions being taken to prevent this again. At the same time we found a medicine change for one person was not well managed as one product was printed on the new medicine chart to be administered but a different (but similar) product had been supplied. Staff took immediate action to clarify this. Some people living in the home were able to look after and administer their medicines if they wished and when a risk assessment showed this was safe for everyone in the home. There was one person where there was no risk assessment in place. Locked storage space was provided and recording systems were in place to monitor this. We saw a member of staff administer some medicines to people living in the home at lunchtime. They were mainly at this time in the dining room. The member of staff asked people about their need for medicines such as painkillers. These people were often at various stages of eating their meal. We discussed with the locality manager about finding out about each persons choice about where they wanted their medicines and if it respected their dignity and privacy for certain medicines to be administered in public in the dining room at a mealtime. We saw eye drops being instilled for two people who were still sitting at the table for their lunch. We pointed out that the Care Homes for Older People Page 17 of 40 Evidence: specific directions for one medicine were for administration half to one hour before food yet this person was already eating their lunch. This can be more critical for some medicines such as antibiotics. Staff said they would adhere to these directions for antibiotics. During this time the pharmacist spoke to two people living in the home who said they were happy with their care and that staff give them their medicines. There were arrangements for recording medication received, administered and leaving the home or disposed of (as no longer needed) for each person in the home. Complete and accurate records about medication are important so that there is a full account of the medicines the home is responsible for on behalf of the people living here and so that people are not at risk from mistakes, such as receiving their medicines incorrectly. Most of the samples of medicine records we looked at were in order so that there were clear records about the medicines people living in the home had taken. Exceptions to this were on one chart with some unexplained gaps in the records; the tablets were missing from the blister packs so had they been taken or the dose refused? There was another record where an error was marked but without further explanation. We had received a notification about one medicine error for this person but what we found recorded did not correspond with this. The directions for some medicines such as eye drops or creams were not always specific. Examples were as to which eye the treatment was for or where or how often a cream or ointment was to be applied. Some of the records about creams and ointments staff had applied were kept inconsistently so that we could not always tell if and how the prescribed treatments were used. We discussed consideration of alternative ways for recording these treatments so that there is a clear and consistent system that provides complete and accurate records for this. A number of medicines were prescribed to use as required. We found there were entries in various care plans where there was information to provide further guidance to the staff responsible for administering medication. This should help make sure these people receive their medicines in a consistent way and to meet identified needs. We pointed out some examples that needed updating or where more information was needed to give clearer guidance to staff. For one person prescribed two medicines to administer when required there was no care plan for these. The manager from a sister home began dealing with these during the inspection. There were suitable arrangements to store medicines safely. Containers of creams or ointments that were opened for use were often kept in bedrooms. This arrangement must be checked as being safe for everyone in the home as the bedrooms were left open when not occupied and there is a risk that some people may try to use these inappropriately. We pointed out some vials of a sterile irrigation solution that had an expiry date of March 2008 and a tube of cream that must be stored in the fridge. The Care Homes for Older People Page 18 of 40 Evidence: date of first opening medicine containers to use was sometimes but not always written on the labels. This is particularly important for some medicines such as eye drops and certain liquid medicines because of risks from microbial contamination or stability of the medicine. It is best if this is standard practice for all medicines as it also provides a system for audit checks that correct amounts of medicines remain in stock. Since the inspection we have spoken to the manager to clarify the arrangements that must be in place for the disposal of any medicines in the home that are no longer needed, particularly controlled medicines. Further guidance is also published on our website www.csci. org.uk. There was a medication policy and procedures available so that all staff should be aware of how the company expected medication to be handled in a safe way. Conclusion of Pharmacists Report: There are some safe arrangements in place for the management of medicines but the inspection highlighted particular weaknesses where improvements in these arrangements are needed so as to always protect people living in the home from unnecessary risks with medication. Care Homes for Older People Page 19 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home have the opportunity to remain socially active and, although they are largely able to exercise choice and have a nutritious diet that offers them variety, there are some inconsistencies in these areas which have an adverse impact for a few. Evidence: The home had a designated social activities manager and an activities coordinator, with a varied social activities programme in place to suit differing tastes and abilities. We were unable to speak to either of these people, as they were not on duty during this visit. There were well maintained and up to date notice boards in each part of the home, on which forthcoming social events and competitions were advertised. The activities programme showed that there was an organised group activity twice each day, although there was nothing happening on the first day of this inspection due to staff absence as previously reported. There was a calendar of important dates, celebrations and events displayed, and there Care Homes for Older People Page 20 of 40 Evidence: was a Christmas bazaar planned. Residents were supported to pursue their personal interests and hobbies, and there were arrangements for visiting entertainers. There were weekly dates for in-house religious services, plus other dates for visiting ministers from different denominations. The home had produced a monthly newsletter, and there appeared to be an ethos of forging links within the local community, and of promoting a sense of community with other homes in the care group. The home provided two computers with internet access for residents, but none of those we spoke to had used it as yet. Some residents had their own television in their room, and their own telephone. Some had also brought in musical stereos, radios and DVD players for their own personal use. Two residents who were staying in the home for respite care said that they were enjoying their stay and that it was like living in a hotel. Residents confirmed there were regular activities for them, with some confirming that they enjoyed participating in them, whilst others said that they chose not to join in, preferring their own company. We saw a number of visitors coming into the home to spend time with their relative, and we spoke directly to four of them. Each was complimentary about the home and said that they felt welcome here. They reported that they had experienced staff being kind and respectful towards them and the residents. The home provided smaller and more intimate lounges where residents could receive their visitors in privacy if they wished, in addition to the main communal rooms. The AQAA stated that the home encouraged residents to maintain their social networks, and that their relatives could stay for a meal with them. Most residents were evidently moving around the home and spending time according to their wishes, although there were a number who were clearly more reliant on the staff to support them with this, either being poorly, chair or bed bound. Some of the staff on Heather and Foxglove told us that the current staff deployment on their unit meant that residents requiring support to rise in the morning often had no choice other than to be left until late or nearly lunchtime before they could get up. One resident commented I particularly like the home because there are no rules. We go to bed when we like, watch television when we want and have our meals where we wish. Care Homes for Older People Page 21 of 40 Evidence: There was a variety of information available for people should they have wanted or needed it, regarding support, advice and advocacy services. Residents were able to choose what they had in their own rooms, with some having a more personalised and individual appearance as a consequence. The AQAA stated that the home embraces individual preferences. Residents were offered choice with their meals, and we observed the service of a breakfast and a lunchtime meal. Meals were served from a hot trolley in the servery adjoining the dining room on each unit. The meals looked very wholesome and appetising, and were plentiful. There were at least two choices available, with residents being offered a choice at the time rather than in advance, as staff said this met needs better due to some residents forgetting if they ordered in advance. The chef, catering assistant and manager all confirmed that alternative meals would be provided if a resident did not want anything that was on the menu. Special diets were catered for. The dining room tables were attractively laid, with drinks, condiments, napkins and flowers. Staff were present and were assisting residents where necessary, and adapted crockery and cutlery was provided where required. Some of the residents had their meals served on a tray in their room. A number of the residents said that there was plenty of food and variety for them, and three said they enjoyed the social advantages of dining together. A small number of the residents on the first floor said that there were a few residents who could be disruptive at mealtimes, which spoiled their dining experience. However, the surveys that were returned to us highlighted a number of concerns regarding food, with some residents clearly not satisfied with the quality of a lot of it. One person wrote that meals were not always ready when they were supposed to be, they were not very hot and were not well flavoured. This person went on to write that it was the food that let the home down. Another person wrote that food was sometimes badly cooked, and that stale cake had made more than one appearance. The AQAA had acknowledged that this was an area that required improvement in the home. We discussed these concerns with the chef and the home manager, and could see that meal surveys had been carried out with residents, and that meetings had been held with them to address their dissatisfaction with the food, with a further one planned for later in the same week. Also, as part of the effort to address the food concerns a catering assistant had been designated to serve and rotate around the units at mealtimes to maintain close links with the residents. The chef had also been tasked with overseeing the strategy to address these issues. Care Homes for Older People Page 22 of 40 Evidence: We visited the kitchen at lunchtime, and saw that it was immaculately clean and well kept. Appropriate catering records were maintained. We discussed the chefs knowledge of diabetic diets, and he had received recent training in this area. Extra support was being given to two particular residents who had expressed concern over their diabetic diet. Care Homes for Older People Page 23 of 40 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home generally feel reassured by the homes procedures to address their concerns and to prevent and protect them against abuse. Evidence: The home had a clearly written procedure for dealing with complaints and concerns. A copy of this was issued to residents within their service user guide, and was also displayed in the reception. The AQAA stated that the written procedure could be provided in alternative formats for easier access if required. A register of complaints was maintained and this contained records associated with the four complaints that were reported in the homes AQAA. We saw recorded evidence of outcomes, correspondence and audits associated with each circumstance. The manager demonstrated an open and honest approach towards concerns received, and told us that she viewed them as an opportunity to drive improvements in the service. Other staff also displayed this attitude. Residents who responded to us on our survey forms confirmed that they knew how to raise concerns if they had any and that generally staff were helpful in this regard. One person said that some staff were excellent and reliable at dealing with issues, whilst others were not. There were policies and procedures in place for addressing the safeguarding of Care Homes for Older People Page 24 of 40 Evidence: vulnerable residents, which had been drafted in accordance with the Department of Health (DoH) No Secrets guidance, and we saw that all staff had been provided with an easy read summary of this. Training records showed that training in the recognition and prevention of abuse had been delivered as part of new workers induction, with an ongoing training programme in place. The home had additional DVD learning materials from the DoH to provide training in the Mental Capacity Act 2005 (MCA), with an electronic learning module being phased in. Some staff had received MCA training, and the manager told us that a further session was planned for the following month. We saw evidence that a mental capacity assessment had been completed in one particular case, and that visits from the social worker and the doctor were recorded along with any outcomes and follow up from the home that may be required. The staff handbook contained guidance on the homes policy for dealing with gifts and gratuities from residents, and residents wills. The case tracking exercise showed appropriate risk assessments and care planning were in place to address any safeguarding issues that had arisen in the home, with staff having made the appropriate and required referrals to the Safeguarding team within the local authority, and to CSCI. The staff disciplinary procedures had been implemented where concerns around staff practice had been identified. Care Homes for Older People Page 25 of 40 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home are provided with accommodation to a high standard, which is very suitable and safe to meet their needs. Evidence: Athelstan House is a newly constructed and purpose built care home, and provides an immaculate, safe, clean and spacious environment for the people living there. All areas were easily accessible throughout. The home was warm and comfortable, and provided good quality furnishings, fabrics and decoration. A maintenance person was employed, who was professional and helpful when we spoke to him, and kept good clear records for cyclical maintenance in the home. There were numerous large and small communal rooms, and in addition to these each of the four units had its own lounge and dining room. We were told that that induction loops were installed into the lounges and dining areas to assist those residents with hearing and communication needs. Residents had their own private bedroom with ensuite bathroom, incorporating a walk in shower. There were also a number of communal bathrooms that offered assisted bathing facilities. Care Homes for Older People Page 26 of 40 Evidence: There were good storage facilities provided for the residents use and for equipment in the home. The surrounding gardens were well planned, were accessible, attractive and well kept. The laundry room was large and well equipped, containing washing machines with sluicing and disinfection cycles to deal with foul or infected linen. All laundry was segregated and colour coded as part of the homes infection control procedures. We spoke to the two laundry assistants on duty, and each was fully conversant in laundry procedures, and was helpful and cooperative with us. There was a ready supply of gloves, aprons, liquid soaps, paper towels and sanitising hand gels for staff in all areas, and the home had specific arrangements in place to manage all grades of clinical waste safely. Sluice rooms were clean and tidy and were secure. All areas of home were very clean and odour free. Residents who responded to our survey acknowledged that the home was kept very clean, although one person wrote that they had noticed unpleasant odours on occasions, and that armchairs were sometimes left dirty. Care Homes for Older People Page 27 of 40 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home receive care from a competent work force which undergoes full pre-employment checks and which is supported to train and develop professionally. Evidence: We looked at the staff rotas for each of the homes four units, and discussed them with the manager and staff. Rotas showed the staffing structures were as agreed with CSCI at the point of registration. There was one registered nurse in the short stay Primrose unit and one in the long stay Lavender nursing unit. There was one care leader and six carers on the early and late shift on these units, but the manager confirmed that this would rise to the required seven as the beds became fully occupied. In addition to these numbers there were also two care support workers during the day time hours. The personal and dementia care units, Heather and Foxglove were working as one combined unit, with one care leader and four carers on the early and late shift. There were also two care support workers in addition to these numbers during day time hours. Staffing overnight comprised of two nurses and seven carers for the home as a whole. Care Homes for Older People Page 28 of 40 Evidence: Staff we spoke to on Heather and Foxglove unit told us that residents dependency levels on these units were high, with those requiring personal and dementia care needing a lot of support. Staff felt that there were inadequate numbers of staff on these two units to meet the needs of the residents accommodated there. They said that care was compromised as a consequence, and that they rarely had time to sit down and talk to the residents. Staff also said that there were occasions when staff from Heather and Foxglove were called upon to work in Primrose unit, and that this had a further impact on their ability to address the work load on their unit by depleting their numbers. Staff said that they had spoken with the manager and the locality manager to explain the situation but nothing had been resolved yet. Staff in Primrose and Lavender units were happy and enjoying working in the new premises. They explained that the settling in period had gone well and that they felt supported by the management. The atmosphere was calm and peaceful, but there were only seven residents in Lavender at the time of this inspection. The homes AQAA demonstrated that a lot of agency staff had been used in the home, but the manager told us that four more nurses had just been recruited, including a Head Nurse to work in a totally supernumerary capacity. Another experienced registered nurse just recruited was also going to have at least one supernumerary shift each week. We were told that these two senior nurses would be having significant input into the Heather and Foxglove units in terms of guidance, leadership and management. The manager confirmed that supernumerary shifts were also given to the assessment coordinator for the short stay and personal care residents and to the unit leaders on Foxglove and Heather units for medication management and care planning duties. The training coordinator also had supernumerary time to address her additional responsibilities. In addition to the care and nursing team there was a full ancillary team of catering, cleaning, laundry, maintenance and administrative staff. Residents who responded to our survey forms or who we spoke to directly generally spoke well of the staff, saying that they were readily available to them, although this could be reliant upon how busy they were. One said The staff are wonderful, whilst another said they were excellent. Two residents felt that there was sometimes a lack of staff. A visiting GP told us that although some aspects of communication among the staff could be improved, they were always helpful and did their best. Another GP expressed Care Homes for Older People Page 29 of 40 Evidence: some concern about the amount of agency staff the home had been using. We saw the computerised records of National Vocational Qualified (NVQ) care staff, and these showed that thirty seven out of sixty two permanent carers were qualified to at least level 2. There were additional care staff currently on a training programme as well. We inspected four staff files of recently recruited staff. In each instance, the prospective employee had completed an application form providing details of their employment history. Interview notes confirmed that any gaps in the employment history had been explored and discussed, although in one case the interview notes were missing from the file to confirm this absolutely, but the manager confirmed to us that this had been done in this case. Two written references had been provided in each case, with at least one of these having been obtained from the previous employer. Proof of identity and medical statements had been obtained. Correct POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed for each person ahead of their commencement of employment. We saw evidence that employment contracts, job descriptions and the General Social Care Council Code of Conduct for care workers had been issued, and that equal opportunities and sickness was monitored. A staff handbook had also been issued to each worker, which included useful information in relation to the homes policies and procedures, health and safety matters, organisational rules and expectations and training and development. The home had its own designated training coordinator, as well as support from the organisations training and development manager. We inspected samples of the computerised and paper records that were maintained in relation to the staff training and development programme. There were records for training at induction, manual handling, food hygiene, medications, fire safety, managing challenging behaviour, first aid, infection control and recognition and prevention of abuse. Three staff had enrolled on a dementia care mapping course, and staff had received training in dementia care through a specific Alzheimers Society training programme. The manager also told us that a Challenging Behaviour training course had been developed, and was to be delivered to all staff. The home also had some additional DVD learning materials for development in infection control, health and safety and nutrition, with the MCA also being phased in. We were told that the clinical training courses targeted for the nurses included Care Homes for Older People Page 30 of 40 Evidence: venepuncture, care of syringe drivers and delivery of medication by this means, care and delivery of gastrostomy feeding and wound management. Training in conditions such as multiple sclerosis, Parkinsons disease and caring for people who have had a stroke was also being looked at. The local hospice trainers were looking at providing courses to the home in palliative care, symptom control, communication and dealing with emotional pain. We saw samples of induction training undertaken for new workers, and this had been delivered in line with the Common Induction Standards for Care Workers as part of an electronic learning package. We were told that all existing staff were encouraged to do this course as a refresher as well. Records also showed that other topics covered at induction included equality and diversity, customer care, food safety, medications, fire safety and manual handling. New workers were put with an experienced worker for mentoring during their induction to the home, and the coordinator told us that this tended to be a care leader. Staff we spoke to said that their induction had been thorough. Care Homes for Older People Page 31 of 40 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems in place here ensure that the interests, and health and safety of the residents living in the home are safeguarded. Evidence: The manager of Athelstan House is a registered nurse, and has been registered with CSCI for her position. She is currently undergoing a Registered Manager Award, and was part of the way through the course. The manager demonstrated a very open and professional approach during the inspection, and was helpful and cooperative throughout with the whole process. Some of the residents said that the home was very well run and that the manager was pleasant and always listened. A GP who responded to our survey told us that the home had experienced some teething problems as a new home. Care Homes for Older People Page 32 of 40 Evidence: A management structure to increase stability and consistency was being developed within the home, which incorporated lead personnel for each unit, with supernumerary additions to assist with the management and supervision of the care in the home on all units. A Manager Report Form was in use during each shift so that the manager could remain sufficiently informed about any issues on each unit on an ongoing basis. The manager demonstrated a very clear commitment towards monitoring and improving standards in the home in all areas, and had been carrying out a range of internal quality audits as part of this. The homes AQAA had been thoroughly completed to a high standard. The organisations quality assurance manager had carried out an audit of standards in the home, and external assessors had also successfully assessed standards at the home for the ISO quality award. An annual survey had recently been issued to residents and their representatives in order to gain their views and experiences of the home as part of a quality monitoring approach, and the manager had devised a written action plan on the basis of any issues raised, although a copy of this was not seen directly. We also saw samples of End of Stay quality surveys for those residents who had stayed in the short stay Primrose unit. We saw records of regular resident meetings, to which their relatives had also been invited, and it was clear that residents ideas and views were discussed, and that they could have a say in how their home was run. A number of residents had chosen to place personal money with the home for safekeeping, and each unit had its own safe storage arrangements for this. The systems for managing and safeguarding these arrangements were satisfactory, with records totally transparent. We carried out a random check on arrangments made for three particular residents, and these were completely in order. A staff supervision programme was in progress, and some examples of associated records were seen and discussed with the manager. The manager told us that supervision was given frequently in group sessions and at handover periods between shifts, and we saw records for some of these. Annual appraisals featured as part of this programme, although records of these were not inspected. It was the aim of the home to provide at least three individual sessions per year, in addition to group sessions and the appraisal. The manager also confirmed that every individual had received a full supervision prior to the move into the new build, and we saw samples of records to confirm this. Care Homes for Older People Page 33 of 40 Evidence: Care Leaders said they were trained to help deliver the carer supervision programme but that they had not been able to deliver many sessions on an individual basis. They felt that this was partly due to the busy six months of settling in to the new home. Some of the carers we spoke to on Heather and Foxglove units indicated that they felt unsupported. When we mentioned this to the manager she acknowledged that this might be the case, but that the introduction of the new Head Nurse would go some way to rectify this. Clinical supervision groups had been provided for the nurses, and had been delivered by the trusts Development Nurse. We were told that these sessions were to be delivered in future by the quality assurance Nurse Manager for the trust. The manager confirmed that this would also include clinical supervision for the new Head Nurse. Records for three of these meetings showed that nurses training and development needs were considered. The lead nurse on Lavender unit said that she had regular contact with the manager and had regular supervision, and had done a clinical skills analysis in order to identify her professional development needs. The assessment coordinator on Primrose unit also said that she had regular contact and supervision from the manager. The home had written policies and procedures in relation to the promotion of the health and safety of the residents, visitors and staff, and associated training was provided for staff in all health and safety matters, including fire safety. Records showed us that regular checks had been carried out on the fire safety systems, and there was a fully documented and up to date fire safety risk assessment, with a fire safety risk assessment in each residents care plan. Records confirmed that hot water temperatures were regularly checked for safe levels, and regular Legionella checks on the water supply had also been carried out. There were appropriate control measures in place, including for the cold water storage. The necessary safety checks and maintenance of utilities and equipment had been undertaken, and the associated records were kept in these areas. First aid facilities were widely available, with staff trained to varying degrees to deliver first aid. Accident records were checked and were regularly audited by the manager. The home was secure, with coded door entries in appropriate places and chemicals safely stored. Care Homes for Older People Page 34 of 40 Care Homes for Older People Page 35 of 40 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 36 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The registered manager 31/01/2009 must ensure that all aspects of residents care plans are written in full on the basis of all of their needs. This is to show in detail how the residents needs are to be met in relation to the management of wound dressings and any communication needs, in order that there is clear direction for staff when delivering care. 2 9 13 When any medication is administered to people who live in the home it must always be clearly and accurately recorded. (This particularly relates to records for prescribed treatments applied to the skin). This is to help to make sure people receive their prescribed medication 31/12/2008 Care Homes for Older People Page 37 of 40 correctly and to help reduce risks of mistakes. 3 9 13 Take action to make sure 31/12/2008 that there are effective arrangements in place to monitor stock levels and to reorder medication and prescribed items in sufficient time. This is to protect people from risks of not having their prescribed treatments available when needed. 4 14 12 The registered manager 31/01/2009 must review the working arrangements on Heather and Foxglove units to ensure that there are sufficient resources to help residents rise in the mornings at a time that is acceptable to them. This is so that residents can exercise choice in all aspects of their daily lives, including when they can get up in the mornings, rather than when the work dictates they can. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 4 The registered manager should review and monitor the living arrangements within Heather and Foxglove units to ensure there is the capacity to meet the assessed needs, including specialist needs, of those accommodated there. The registered manager should review staff skills and levels of confidence on Heather and Foxglove units regarding dementia care and take appropriate action where necessary. Page 38 of 40 2 4 Care Homes for Older People 3 4 7 9 Staff should review all aspects of care plans on at least a monthly basis. Care plans to reflect what choices people who live in the home were given and have made about how their medicines are administered and their consent to the way in which staff administer their medicines. (This particularly relates to the administration of some medicines during meals times and in a public area.) Review and update the individual care plans written for medication prescribed for use when required so that there is always clear written direction to staff on how to make decisions about administration for each person and medicine. This will help to make sure there is some consistency for people to receive the correct levels of medication in accordance with their needs and planned actions. Where creams and ointments are stored in bedrooms carry out risk assessments to make sure the arrangements are safe for everyone in the home. The home should review the lunchtime arrangements in the Heather and Foxglove unit dining rooms to ensure that all residents, regardless of their individual ability and need, can enjoy the dining experience. The registered manager should keep the staffing provision on Heather and Foxglove units under review to ensure that it can meet the needs of the residents. 5 9 6 9 7 15 8 27 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. 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