Inspection on 17/06/09 for Avonwood Manor

This inspection was carried out on 17th June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avonwood Manor 08/12/09

Avonwood Manor 12/11/09

Avonwood Manor 20/10/09

Avonwood Manor 21/09/09

Avonwood Manor 13/05/08

Avonwood Manor 25/07/07

Avonwood Manor 25/04/06

Avonwood Manor 28/10/05

Avonwood Manor 25/05/05

Avonwood Manor 27/01/05

Avonwood Manor 16/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for older people Name: Address: Avonwood Manor 31-33 Nelson Road Branksome Poole Dorset BH12 1ES     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sue Burn     Date: 1 8 0 6 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Avonwood Manor 31-33 Nelson Road Branksome Poole Dorset BH12 1ES 01202763183 01202751530 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Avonwood Manor Ltd care home 49 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. Date of last inspection Brief description of the care home Avonwood Manor is registered to provide accommodation and personal care for up to 49 residents who suffer from mental disorders or dementia above the age of 65. Avonwood Manor is still owned by Avonood Manor Ltd, however the home is managed through Affinity Care Homes Ltd. The home is situated in a quiet residential area close to the shops and amenities of Westbourne. The home is made up of two large properties that have been joined by an extension. Each of the properties has three floors and there is a passenger lift at either end of the home. Communal areas are located on the ground floor and there are well maintained and enclosed gardens leading from the back of the home that residents can Care Homes for Older People Page 4 of 38 0 0 Over 65 49 49 Brief description of the care home access. The majority of the bedrooms are for single occupancy with en-suite WC facilities; however there are eight double rooms, in which portable screens are provided. At the front of the home there is parking for staff and visitors. The fees for the home can be obtained from the manager. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality of this service 0*. This means that people experience poor quality outcomes. This unannounced inspection was carried out over one day by 2 inspectors. The second day a visit was carried out by a pharmacist inspector. The term We is used throughout the report to reflect the findings of the Care Quality Commission (CQC). The home had been rated as good at the Key Inspection in June 2008. The inspection was brought forward for several reasons in order to determine compliance with the requirements at the last inspection and evidence whether the home was continuing to provide good outcomes for people at the home. We had received a very high number of notifications from the home, we had received 2 recent anonymous concerns about standards of care at the home, there had been a recent safeguarding investigation. We were notified that the safeguarding investigation was concluded satisfactorily with the local authority. The manager was appointed about a year ago and submitted her application to register in Care Homes for Older People Page 6 of 38 January 2009. The application is progressing. The Annual Quality Assurance Assessment sent to us by the home told us that there was high staff turnover and a significant number of improvements were needed, the AQAA also gave us information about the improvements that had also been made over the past year. We met with the manager, Maggie Riddell and her deputy manager who were very helpful and clear throughout the inspection. Ms Riddell has managed the home for about a year, since just after the last Key Inspection. We gave them feedback of the key issues at the end of the inspection, as did the pharmacist. All staff we spoke to were helpful and courteous. There were 38 people living at the home at the time of the inspection. We gathered information in a variety of ways. We sent out surveys to the home to distribute to people using the service but we did not receive any surveys back. We received 11 surveys from staff. We toured the premises, observed care practices in the home and examined a range of records, including the AQAA and notifications made to CQC by the home and others. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: The manager has been in post almost a year and has identified areas for improvement. Pre-admission assessments need to be completed accurately to ensure that it can be confirmed that the home can meet the needs of the person and develop appropriate care plans. The home must ensure that all needs are fully assessed, consent obtained where required and kept under review. Care plans must reflect current needs, be personcentred and give staff full information to ensure that they can support the person. The manager must ensure that staff are aware of the privacy and dignity needs of people with dementia and the homes practices reflect this. Where peoples rights and freedoms may be affected the manager must ensure that appropriate consent is obtained and the implications of the Mental Capacity Act are considered. A choice of foods must be offered and people assisted appropriately to ensure that all receive a diet suited to their needs and preferences. The home needs to develop a range of activities suited to the varying and specialist needs of people living in the home. The environment should be developed to reflect best practice in dementia care. Infection control practices need to be improved to minimise the risk of cross infection and ensure the home is kept odour free. The manager needs to ensure that supervision for all is suitably robust to address Care Homes for Older People Page 8 of 38 areas of poor practice. Staff training is needed in a range of key areas as identified in the report. Bed rails should be fully risk assessed for individual use and a maintenance check should put in place to ensure they are fit for purpose. Effective methods of audit and Quality Assurance must be put in place to monitor shortfalls and promote improvement. Medication and care plan audits should be a priority. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 38 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 38 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service consults with people before they move into the home and have a clear admission process, but they cannot be assured that their needs will be fully met unless accurate assessments are completed. Evidence: We looked at the pre-admission assessment of one person due to be admitted to the home on the following day. The manager or deputy visit the person prior to moving in to make an assessment of their needs and confirm whether or not the home can meet these needs. The manager told us that a letter confirming this is sent to the person and/or their relatives. The AQAA told us that all people are assessed before admission and reassessed during the first 6 weeks of their stay. The pre-admission assessment document covered all the necessary topics to assess a persons needs. However the assessment we saw contained conflicting information that did not give clear and consistent information that could be used to inform accurate care planning. For Care Homes for Older People Page 11 of 38 Evidence: example there were four different assessments of night time needs. The person was assessed as needing a pressure mat despite conflicting information about their behaviour at night and without a clear rationale for its use. The assessment also stated that the person may pose a risk to self and others, but there was no evidence that this had been considered before offering a place. We discussed this with the manager who confirmed that this assessment had had to be done very quickly but they felt that the home could meet the persons needs. The home offers respite care but not intermediate care Care Homes for Older People Page 12 of 38 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning systems are being improved however people cannot be assured that their health care needs will be met. Medication management needs to be improved to ensure it does not place people at risk of harm. The use of bed rails is not suitably assessed to ensure their safe use. The privacy and dignity of people living in the home is not always upheld. Evidence: The home is in the process of re-writing all the care plans to make the information clearer and more comprehensive. The documentation we saw covered all the necessary topics but would benefit from development to ensure that staff can provide for person-centred care rather than perform tasks for the person. The manager confirmed to us that many care plans were not up to date because the plans are being re-written. The manager confirmed that nutritional screening and moving and handling assessments had been implemented. At the beginning of the inspection we were told that one person was being cared for in bed. We found that 2 people were being cared for in bed. Care Homes for Older People Page 13 of 38 Evidence: We found that the home has sufficient pressure relieving equipment and beds suited to peoples needs. We saw the 2 people cared for in bed several times during the day. There were no plans in place to direct staff as to the type of support these people needed and wanted. We visited their rooms on several occasions throughout the day and the records seen indicated positional changes. The home has notified us of 4 pressure sores since the last inspection, 2 of which were present when people were admitted, and staff have not received any formal training in pressure area prevention. The provider has informed us that informal training was being provided by the deputy manager, this was not evidenced during the inspection or on the training matrix submitted to identify which staff had received instruction. We saw in the care records that the district nurse had advised that one person be cared for in bed due to pressure sores. We did not see a plan in place relating to pressure sores/management. We looked at the care records for 8 people. Some of these were looked at in detail and the people were case tracked to confirm the care provided during the day was reflective of the care plans. Some of the examples where this was not the case were as follows; There was no plan to direct staff in the management of one persons diabetes. Issues around their management have been notified to us and will not be detailed in this report. There was evidence in the daily records that their blood sugar level was being monitored but there was no guidance in a care plan as to what the parameters should be, what staff should look for if the person was becoming unwell or what action to take in an emergency. The district nurse was involved and now administers the insulin. The district nurse has advised the home to get a supply of glucose but this had not been included in a care plan to instruct staff when to give this. The manager told us that some staff have been trained to use the machine that monitors blood sugar levels. There was no evidence available to confirm this and the recording in daily records indicated that following one drug error they could not get the machine working and there was no further recording. This means that staff will not be able to monitor and manage this persons health needs safely. There was no evidence that staff have received training in diabetes. We were told that senior staff have received training from the district nurse in the use of the blood sugar monitoring machine. This person had also raised concerns about their safety with other residents on a number of occasions. The manager told us that this was being monitored by night staff. There was no interim plan in place to address this and no record of how this monitoring was being carried out to protect the person. Another person had care plans that were out of date and had not been reviewed since November 2008. The care plans contained minimal information and would not be sufficient to guide staff to support the resident in a person-centred way. This person had developed a short term health problem since this time but there was no Care Homes for Older People Page 14 of 38 Evidence: assessment or plan in place to inform staff of the care needed. We did not see any detailed social assessments and plans in place as most addressed the physical needs of people. Another record described the person as aggressive. There was no detailed assessment about what this meant for the person or a plan to guide staff in supporting this person and keeping them and other residents safe. We saw the records of another person who was using bed rails. There was no evidence of a bed rail assessment being carried out to ensure that this was the most appropriate way of supporting this person, evidence of informed consent or identifying any potential risks to their safety. We saw that their medication was being given covertly, that is hidden in food, for example, so that they do not know they are taking it. This may be in the best interest of some people with dementia but must be supported with an assessment, plan and the agreement of the GP, pharmacist and representative. This person had a number of bruises recorded in their daily records.There was no evidence that this had been investigated or a plan put in place. We saw evidence that relatives were asked to agree to covert administration of medicines in March 2009. Consent from the persons GP was not sought until June 2009. We saw another care plan that was incomplete. It stated Medication: X takes. There was no further detail on the plan to inform staff. On another record we found that the district nurse had advised that bed rails were not appropriate and a mattress should be placed on the floor should the person fall from bed. This had not been done and a pressure mat put in place instead as it was considered that a mattress may have created a greater risk for this person. This would alert care staff to a fall but might not prevent injury. The daily records indicated that this person was having falls from her bed and chair and on 2 occasions the pressure mat alarm had not gone off. It was not evidenced in the care records how falls were being managed to minimise the risk of injury to this person. The care plan advised that they should be checked at a certain time but there was no detailed plan in place. The manager told us that it was her intention to put pressure mats in place for all people. This is institutional practice and may not be suited to everyones needs and preferences and these mats should only be used following an individual assessment and consent. We also saw on most records reference to resuscitation. Decisions about resuscitation need to be fully discussed with all concerned and ensure that peoples rights and freedoms are not undermined and the Mental Capacity Act 2005 is considered. At the last inspection it was recommended that this training was provided for staff but this has not yet been done. The AQAA tells us that the manager recognises this as an area for improvement. Staff spoken to were not clear about reading care plans although the manager Care Homes for Older People Page 15 of 38 Evidence: confirmed that they were encouraged to read them. We saw that people living at the home have access to health professionals as required and the AQAA told us of all the contacts the home has with statutory agencies. Our pharmacist inspector looked at all the medication arrangements in the home. The medication is stored securely and appropriately except the Controlled Drugs which need to be kept in a cupboard that complies with current legislation. 6 staff have received safe handling in medication training or trained in the system used at the home. the manager confirmed that none have undergone an observational assessment of their competency. Currently no staff who work at night have received training and senior agency carers are used, who are trained in medication administration, whilst this is addressed. A number of the medication errors that have been notified to us have been made by agency staff. Some people in the home receive injections from district nurse. One of these people was previously supported by staff to give her injection but these staff had not been trained to do this. The administration records of these medicines are kept by the district nurse and the homes medication records do not show that these are being used. Some people can only take their tablets when they are crushed and put in food. This is discussed with their family and GP and a record made on admission, however this was not seen consistently recorded in care plans. Reviews of this process were not frequently recorded and a list of medicines, checked as suitable, was not available. Some medicines are prescribed to be given when required. The recording of the use of these medicines was not clear as no times were noted and in one case the record looked as if it was being offered regularly and refused. The senior staff stated that this was not the case, but there were not always clear guidelines available to support staff in their use. The provider has told us since the inspection that a policy was being put in place. One medicine had been out of stock previously, but this was found to be due to the pharmacy being unable to supply. Another medicine was out of stock at the time of the inspection and had been reordered after 6 days. The records for this person showed that they had suffered no ill effects, but the system for monitoring stocks of medicines has not worked. The medication administration records were signed when medicines were given and we saw staff give medicines safely. Anti-coagulant therapy was carried out in accordance with recent safety guidelines. Changes to the medication records were not always clear, for example one entry had been crossed through when the dose had changed in such a way as to obscure the previous dose. The manager told us that there is not a regular audit in place for medication. This would help to identify any shortfalls and put in plans to rectify them. The provider has told us that medication audits have been carried out by the deputy manager and the regional manager for the management company. These audits have not been formally recorded. We saw a number of examples where institutional practices compromised the privacy Care Homes for Older People Page 16 of 38 Evidence: and dignity of people. One person was seen by the GP but another resident and 2 care staff were present and the discussions with the GP about the persons health took place in the corridor. Staff were seen walking up to people with a continence pad and asking them if they needed the toilet. We saw 2 staff discussing peoples personal care in detail in the corridor. In 2 shared rooms the screens were not being used in a way that would ensure privacy. One was wedged in by furniture and another was stored in an en-suite with things stored on top. We saw one person being assisted to change with the bedroom door open and a number of people had food-stained clothing and were not helped to change after lunch. Some staff knocked on doors before entering, but not all. Care Homes for Older People Page 17 of 38 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst some people benefit from the activities provided for many the opportunities are limited to engage in recreational and social activities specifically tailored for people with dementia. Visitors can be assured that they are welcome at any time. Meals provided are adequately nutritious but no choice is offered and not all people can be assured that they will have a full meal. Evidence: The home employs 2 part time activities organisers. We saw that there is a programme of activities displayed, although we did not see the activities on the programme offered during our visit. We saw the activities organiser engage a small group of people in table top activities for a period during the morning and afternoon. These people looked engaged and to be enjoying the activity. Recreational opportunities for others was variable and limited. Some people were seen to enjoy going into the garden whilst a significant number of people were seen asleep for long periods with no interaction other than to receive personal care or meals. The 2 people in bed had no stimulation in their rooms and staff only attended to them for personal care and meals, although the interaction we saw was kindly and friendly. We saw the Care Homes for Older People Page 18 of 38 Evidence: daily records for one of these people which recorded that they received personal care but no plan or record of how they could have their social needs met. We saw one carer inappropriately try to involve 2 people in an activity with a ball. There was no introduction or warning of the activity and the people were seen surprised and bewildered. This activity then stopped as suddenly as it started. We saw another person who sat in the same dining chair throughout our visit. She displayed behaviour that indicated boredom by picking her nails throughout the day. When we approached her she enjoyed conversation. The home did not have any rummage areas, sensory equipment or reminiscence areas which would be expected in a dementia care home that would enable people to independently occupy themselves and assist carers to engage with people in what they are interested in. All daily records seen concentrated on the provision of physical care and there was little evidence of how social needs were being met. The AQAA told us that the home has begun to purchase new activity equipment, including TVs and CDs and increased the hours for activities organisers. The staff surveys told us that more activities and more choices were needed for people and also identified that improvements are being made to the surroundings. The AQAA tells us that this has been identified as an area for improvement for the home with the intention to improve the activity programme, purchase more activity resources and book more entertainment. We spoke with a visitor who told us they were happy with the home and were made welcome at any time. The manager told us that the home does not manage the financial affairs for anyone living in the home. We saw lunch being served and spoke to staff and the cook about meals. The home has 2 pleasant dining rooms that overlook the garden. Some people sat at dining tables and others remained in their armchair. The home has a menu that offers a choice of interesting meals. The AQAA told us that a choice of meal is offered and menus are being reviewed. Wes saw that everyone was only offered one main course and one pudding. One person told staff she did not like the pudding and then staff mimicked her expression in the dining room. The pudding was removed and she had only eaten part of her main meal. No choice was offered and a carer went and got a supplement drink, which was refused. There was no attempt made to find out what she might like or showing her alternatives. A number of people were seen struggling without plate guards and adapted cutlery that would have helped them eat independently. They did not eat a full meal and some had a cold meal. Staff were putting out the hot pudding beside people before they were finished. This was confusing for some and others had a cold pudding. Some staff were attentive Care Homes for Older People Page 19 of 38 Evidence: and sat beside people to assist them, offered extra drinks etc. But lunch time was very busy and some staff moved from different people feeding them and we saw staff standing over people feeding them and another feeding someone without any prompts or conversation. We spoke to the cook who was experienced and knew of the specialist diets in the home. He told us that he did not have any information about individual likes or dislikes and said he judged this by what was returned to the kitchen. He did not have any information about increasing the calorie content of meals, which is often needed for people with dementia who are higher risk of weight loss. Care Homes for Older People Page 20 of 38 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that complaints will be addressed. Policies and procedures are in place to protect people but the home needs to ensure that all staff are trained and informed about complaints and protection. This will ensure that policies are be put into practice. Evidence: The home has a complaints policy and we saw a copy of this displayed in the hallway. We saw that complaints are being recorded and action taken. We saw the Safeguarding Policy and Whistle blowing Policy both of which have recently been updated. The staff surveys told us that most know who to raise concerns with but 2 staff told us they did not know. The manager needs to address this. The homes training matrix shows that most staff have completed safeguarding training, including the manager. There are still 11 staff who require this training to ensure that they know how to protect people from abuse. There has been a recent adult protection investigation by the local authority which has now been concluded and appropriate action taken. We found that one person had complained on a number of occasions that she was being hurt. The manager told us that this was being monitored but there was no recorded evidence of this and no interim plan put in place to protect the person. Care Homes for Older People Page 21 of 38 Evidence: The manager confirmed that staff had attended a 1 day dementia awareness course. Staff have not received training in challenging behaviour. This training is listed as required on the homes training matrix. Staff have not received Mental Capacity Act training as recommended at the last inspection. Care Homes for Older People Page 22 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is safe and secure but people will benefit from the continued refurbishment and an environment that is better adapted to suit the specialist needs of the service. Infection control practices place people at risk from cross infection. Evidence: The manager told us that a refurbishment programme was underway and improvements being made to the fabric of the building. We saw that some new furniture had been purchased and bedrooms and other areas decorated. The lounges were large and spacious and people had space to move around the home. The manager was aware that some rooms were sparse and told us that staff were being encouraged to work with residents to personalise their rooms. After the inspection we spoke to the Responsible Individual who confirmed that there had been considerable investment in the home. The AQAA told us that the environmental improvements include redecoration of some areas, refurbishment of a number of bedrooms and the lobby, new wet rooms have been created and new furniture purchased. We toured the building and grounds and found that it was generally safe for people but needs considerable development to be suited to people with cognitive impairment. There is a selection of communal rooms and people can access all areas of the home Care Homes for Older People Page 23 of 38 Evidence: and garden if they are able. The home has long corridors and dead ends and lacks cues, signage and colour that would help to guide and orientate people. This would create a more enabling and less confusing environment consistent with best practice in dementia care and ensure that monies spent on improving the home reflected the needs of the residents. We saw that the home has sufficient bathrooms and showers and some rooms have en-suite showers. Not all the communal bathrooms are usable. One had items stored in the shower and another had the shower disconnected. Staff told us that they usually use just 2 bathrooms, one on either side of the house. We saw a number of examples of poor infection control practice that must be addressed to prevent cross infection. Continence products are stored in communal toilets and are not protected by packaging. One member of staff was seen taking a resident back to the dining room after assisting them with personal care. The staff member still had on an apron and gloves, which whilst protecting her would have contaminated everything she had touched. There are no hand wash facilities in bedrooms although everyone living at the home needs assistance with personal care. Staff use anti-bacterial hand rub and/or wash their hands in a downstairs kitchen, both practices pose a risk of cross infection. Most of the communal toilets and bathrooms had bins that were unsuitable and were either broken or flip-top that would involve touching the lid when disposing of items. We saw that the cleaner prepared the tea trolley in the kitchen. She wore her uniform without any additional protection. We saw toiletries in shared en-suites and communal bathrooms that could not be identified as belonging to residents. These toiletries may be shared presenting a risk of cross infection. The AQAA identified that the home has had 2 infectious outbreaks and 4 wounds that have become infected since the last inspection and staff have not received training in infection control. We discussed this with the manager and advised that she seek advice from the PCT Infection Control Nurse and get a copy of Essential Steps guidance which will help audit and inform practice at the home. This can be obtained from www.dh.gov.uk We saw that the laundry was clean and well ordered. However we saw it is left open and at times unstaffed, and accessible to people living at the home which may place them at risk of harm as they have ready access to the garden. We toured the kitchen and found this to be suitably clean. The home was malodorous on the first day of inspection. On the second day the carpets were being cleaned and this had rectified the unpleasant smells. We saw that radiators had been guarded in bedrooms but not communal bathrooms. These could pose a risk of scalding of they are not covered before the heating is turned back on. Care Homes for Older People Page 24 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home can be assured that they are protected by a robust recruitment process The level of staffing and expertise in dementia care restricts the delivery of person centred care. Peoples physical needs are mostly being met. Staff have received basic training but more needs to be done to develop and train staff to carry out their roles. The home has a plan for training which when completed will benefit staff and people living at the home. Evidence: The AQAA shows high levels of agency use, which were confirmed by the manager at inspection. The manager also told us there has been a high staff turnover, but this has been due to unsuitable staff leaving. There is also a shortage of carers to recruit. We saw the staff rotas which showed regular use of agency staff - 84-96 hours at night and 12-20 hours day. The provider has told us that they have engaged agency staff to ensure that adequate numbers of staff are on duty whilst a recruitment drive is completed. The rota showed that there are usually 7-10 care staff on duty 7am-7pm but only 4 staff from 7pm-7am when people need assistance to go to bed. This may Care Homes for Older People Page 25 of 38 Evidence: impact on the time people go to bed and the quality and amount of assistance they receive. The home is also supported with cleaning, catering and administrative staff. The manager and deputy are in addition to the care staff Monday to Friday. Whilst there appears to be sufficient numbers of care staff on duty we saw that they are very busy and care is task not person centred. The staff surveys all identified that they felt that more staff are needed, particularly at peak times during the day. they also told us that they felt that they work well as a team and work hard. The staff surveys confirmed that all have received induction training, although some felt it only partly met their training needs. 2 staff felt that the training was good in the home. The other 9 felt that more training was needed. We saw the training matrix during the inspection and the provider has also submitted a training matrix and training needs analysis completed in January 2009. Staff have had training in food hygiene, moving and handling and fire safety. Medication training is needed for night staff and competency assessments should be implemented given the number of drug errors. The home have 3 staff trained in First Aid, none of these staff work on night duty and not every shift is covered with a First Aider. Unless the service has a risk assessment to determine the first aid needs more need to be trained given the high risks of people living at the home. 15 staff have received infection control training and 21 people are yet to be trained. The matrix submitted shows that the deputy is a nurse on the NMC register and eight of the care staff has NVQ level 2 or 3 and another level 4. This is 40 of the care staff. The AQAA tells us that staff are supported to complete NVQ training. Staff have received a dementia awareness training day and would benefit from further training to support person centred care for people with dementia. One of the staff surveys identified that staff needed more training in dementia care. 3 staff have received training in continence management.We could not evidence that there is a staff training and development programme which would enable training needs to be identified and prioritised. The provider has confirmed since the inspection visit that further staff training is planned and that there is training needs analysis in place. We looked at the recruitment files of 5 staff and found that all recruitment checks had been made before staff started work. The files were organised and contained all the required information. Care Homes for Older People Page 26 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents personal finances are managed appropriately. Day to day leadership of the staff team could be improved to address institutional practices. Chemicals are not always stored securely to minimise the risk of harm and comply with legislation. Formal supervision has been put in place for all care staff and records maintained. The manager has identified weaknesses and areas for improvement but this needs to be supported by a clear timed action plan. Evidence: Maggie Riddell is the manager and was appointed about 1 year ago, following the last inspection. She has submitted an application to us in January 2009 to register as manager as required. This application is progressing. As Ms Riddell is not registered standards 31 and 32 have not been fully assessed. During her employment at the home she has identified a number of improvements that have to be made, but has yet to fully implement systems that will identify all the shortfalls found at this inspection. Regulation 26 visits are carried out by the homes Care Homes for Older People Page 27 of 38 Evidence: external management company. Staff surveys expressed a range of views about the management of the home. It is not appropriate to detail these views in this report, however some staff felt well supported whilst others did not not. The home does not have a range of audits and quality assurance systems in place and these would enable a systematic review of the provision. This has been identified in the AQAA as an area for improvement. We saw that accidents and incidents are recorded and the manager advised us that she has recently started to analyse these on a monthly basis. The manager confirmed that there was no regular check of bed rails to ensure that they remain safe to use. We saw widespread use of pressure mats in bedrooms. The home had covered these with a rug to make them look more homely. However all the rugs we saw were presenting a trip hazard and needed attention. We saw a number of areas where chemicals were not stored securely and could pose a risk to people living at the home. The manager is prompt in telling us of incidents in the home as required but given the high incidence of reports and drug errors we cannot be confident that effective action is being taken to reduce the risk of these happening again. We saw evidence that staff meetings and staff supervision meetings for senior staff have been implemented. Formal supervision has also been introduced for all care staff to support the delivery of care and address poor practice, however this may need to be more robust given the observations made during this inspection. Whilst training has been provide in some areas this is inconsistent. We saw that staff were very busy but this was task orientated and institutional and not actively led during the day to provide a person-centred service responsive to peoples needs. There are not enough trained first aiders to cover every shift. Staff have received training in fire safety but there have not been any fire drills since 2006. There were no records of recent fire drills in the fire records or training matrix. Staff have received training in moving and handling and the deputy manager is a trainer. We saw a range of maintenance records that were well ordered and showed that equipment was being serviced as required. As detailed earlier in the report records relating to care/medication were not all up to date and accurate. Care Homes for Older People Page 28 of 38 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 29 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 18 13 v v 17/08/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The registered person must ensure that the needs of people are fully assessed and kept under review To ensure that the home is able to provide the nursing care that each person needs 18/08/2009 2 7 12 The registered person must ensure that people living at the home have an up to date plan of care that is sufficiently detailed to meet their health and welfare needs. To ensure that staff have accurate and detailed information to meet each persons needs 16/09/2009 3 8 12 The registered person must ensure that there is proper provision for the health and welfare of service users. Where bed rails are used an 31/07/2009 Care Homes for Older People Page 30 of 38 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 individual risk assessment and relevant consent must be put in place. This ensures the health and welfare of people living at the home. 4 8 12 The registered person must make proper provision for the care and supervision of people in the home To ensure that the use of pressure mats does not limit any persons rights and freedoms 5 9 18 All staff who administer medication must have suitable training to undertake tasks required of them. This will ensure that people are protected from harm by having trained staff to handle their medication. 6 9 17 The homes must keep a record of all medicines kept in the home and when they are administered to people. This will ensure that people are protected by having complete records of their treatment. 7 9 13 The administration of medication which has been 24/07/2009 24/07/2009 31/08/2009 16/08/2009 Care Homes for Older People Page 31 of 38 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 presribed as required must be clearly recorded including the time and dose given, and supported by suitable guidelines. This will ensure that people are given their medication safely. 8 9 13 Peoples medication must be 24/07/2009 in stock and available for use at all times. This will ensure that people receive the treatment that has been presribed for them. 9 9 13 A controlled drug cupboard must be purchased and installed that meets the current storage regulations (The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 must be purchased and installed. This will ensure that all controlled drugs are stored securely. Arrangements must be put in place to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. 18/09/2009 10 10 12 24/07/2009 Care Homes for Older People Page 32 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure that people receive their health and personal care discreetly. 11 12 16 Arrangements must be 17/10/2009 made to consult service users about a programme of activities and provide facilities for recreation having regard to the needs of the people living in the home. This will ensure that all people will have the opportunity to engage in a recreational and stimulating activities. 12 15 16 Arrangements must be 31/07/2009 made to ensure that all people living in the home have adequate quantities of food suitable for their needs. This will ensure that people have an enjoyable meal time experience and have a full meal that they enjoy. 13 18 13 Arrangements must be made , by training staff and other measures, to protect people from risk of harm or abuse. This will ensure the safety and well-being of all people living at them home. 21/08/2009 Care Homes for Older People Page 33 of 38 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 14 19 13 The registered person must ensure that all parts of the home to which service user have access to are so far as is reasonably practicable free from hazards to their safety. This will ensure that radiators are guarded and people are protected from the risk of scalding and entering the laundry. 04/10/2009 15 26 13 The registered person shall 14/08/2009 make suitable arrangements to prevent infection, toxic conditions and the spread of infection. This will ensure that all people living and and working at the home are protected from harm. 16 29 18 The registered person must ensure that staff receive training appropriate to the work they are to perform. This would include person centred dementia care, challenging behaviour, infection control and pressure area care. To ensure that the needs of people living at the home have their needs met. 17/12/2009 Care Homes for Older People Page 34 of 38 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 17 33 24 The registered person shall 17/12/2009 establish and maintain a system for reviewing and improving the quality of care provided at the home. This will ensure that all areas of the home are monitored in a systematic way. 18 38 13 The registered person shall 31/07/2009 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The rugs covering pressure mats must be removed or replaced. This will ensure the safety of people living at the home. 19 38 13 The registered person shall 17/12/2009 make suitable arrangements for the training of staff in first aid. This will ensure that all shifts are covered by a first aider and protect people living at the home. 20 38 13 The registered person shall 24/07/2009 ensure that all parts of the home to which service users have access to are so far as reasonably practicable free from hazards to their safety. Care Homes for Older People Page 35 of 38 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 Chemicals must be stored securely. This will ensure the safety of people living at the home. 21 38 23 The registered person must ensure, by means of fire drills and other practices, that persons working at the home are are aware of the procedures to follow in the event of a fire. This will ensure the safety of all who live and work at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 17/10/2009 1 2 8 8 People living at the home or their representatives should be consulted about their plan of care The policy of decisions about resuscitation should be reviewed to ensure that this complies with the Mental Capacity Act 2005 Any medication that is to be crushed or mixed with food should be checked by a pharmacist for suitability and the use of these methods regularly reviewed. A monthly medication audit should be put in place. Written alterations and additions to the medication administration record should be clear Best practice guidance should be sought to develop activities suited to people with a range of dementia care needs. 3 9 4 5 6 9 9 12 Care Homes for Older People Page 36 of 38 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 7 8 9 15 18 23 The menu displayed should be followed and choices made available to people in a way that they can understand. All staff should receive Mental Capacity Act and Deprivation of Liberties Training. Refurbishment work should take account of the specialist needs of people living at the home and current best practice guidance regarding enabling environment for people with dementia. The manager should review the deployment and skill mix of staff, particularly at peak times. On going support should continue be offered to enable more staff to achieve an NVQ qualification. Staff competency in medication administration and carrying out blood sugar tests should be arried out and regularly reviewed by the appropriate person. A record of this should be kept. A system should be established for the regular checking of bed rails to ensure they remain fit for purpose. 10 11 12 27 28 28 13 38 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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