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Inspection on 30/09/09 for Brunswick House Nursing and Residential Home

Also see our care home review for Brunswick House Nursing and Residential Home for more information

This inspection was carried out on 30th September 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What the care home does well

The Home has been well managed on a day to day basis by the previous Manager. Staff said that they felt well supported by the previous Manager. The Manager notified the Commission appropriately of issues as required to do by regulation. The staff are keen to provide good care and have been upset by their lack of ability to do so. Appropriate recruitment procedures are followed, ensuring that checks are carried out on staff prior to them starting work. The new Manager has already identified areas in which urgent improvements are needed. She has started talking to staff and residents about these.

What has improved since the last inspection?

It is difficult to see what has improved since the last Inspection.

What the care home could do better:

The residents personal and health care needs are not being met. Residents are not able to have a bath on a regular basis and are waiting for a long time to be assisted with personal care. Some residents are left sitting in wheelchairs as there are not enough staff to assist them to use the hoist to transfer to armchairs. One of the comments made in the residents surveys was that "sometimes I cant find anyone to help me". Residents told us that they try to help each other as they cant find staff to help them. At the time of the Random Inspection residents were not being offered hot drinks mid morning and were only able to have sandwiches for tea seven days a week. At the time of this most recent visit the residents were offered a hot choice at tea time that had been cooked at lunchtime and been left in the hot trolley until teatime. There are areas of the Home that are not clean and the domestic staff do not have time to carry out the necessary tasks. There is an unpleasant smell in some areas of the Home. At the time of the last Key Inspection it was noted that the Home would benefit from having a deputy manager. The Operations Manager said that they are currently recruiting for this position but that there are no plans for this role to be supernumerary. One of the reductions in staffing has been the loss of a qualified nurse on each shift during the day which means that the senior care staff now take on more responsibilities. There is a need for more training for all levels of staff to ensure that they all receive training appropriate to enable them to carry out their roles. There are health and safety issues that need addressing. There are outstanding requirements from the latest Environmental Health Officers visit, the main lift in the Home has not worked for several weeks. The company who provides pressure relieving equipment refused to provide equipment due to unpaid invoices and the company who service the hoists initially refused to do so until outstanding invoices were paid. These situations were addressed during our visit.

Key inspection report Care homes for older people Name: Address: Brunswick House Nursing and Residential Home 81 Bacton Road North Walsham Norfolk NR28 0DN     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: Lella Hudson     Date: 3 0 0 9 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 36 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 36 Information about the care home Name of care home: Address: Brunswick House Nursing and Residential Home 81 Bacton Road North Walsham Norfolk NR28 0DN 01692405818 01692404423 brunswick_house@hotmail.com www.brunswick-house.co.uk Brunswick House Care Home Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 75 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Brunswick House is a care home providing personal care and nursing care for up to seventy-five people. Brunswick House Care Home Ltd is the registered provider. The services offered within the home are described in the Statement of Purpose and Service User Guide. The Home was built in the 1980s and is located in the town of North Walsham and is close to all local amenities. Brunswick House is a large detached property on two levels and stands in its own grounds with an extensive parking area. It is divided into three units: Grant Hadley, the first floor of Brunswick and the ground floor of Brunswick. Each unit provides nursing and residential care. The home also has a day centre in the Care Homes for Older People Page 4 of 36 Over 65 0 75 10 0 1 1 0 2 2 0 0 9 Brief description of the care home grounds and some people living at the home attend the centre. The owners have changed the use of some rooms and they intend to accommodate only 70 people and use 6 double rooms and 63 single rooms, most of which have some en suite arrangements but not all have full en-suite toilets and showers or baths. There are three lifts within the home. The weekly fees are currently between £555 to £730 and are agreed dependent on individual residents needs. Please contact the Manager for up to date information about fees. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 Home was last inspected in February 2009 and at that time it was considered to be providing good quality outcomes for the residents who live there. In May 2009 we were told that the proprietors had plans to reduce the staffing but this was denied by the proprietors at that time. However, in August 2009 we were told that the staffing levels had been reduced with immediate effect. During August and September 2009 the Commission received several complaints relating to the lack of cleanliness in the Home, poor care being provided to residents and to the reduction in quality and choice of meals provided. In September 2009 a Safeguarding referral was made with regard to a resident who was not provided with suitable pressure relieving equipment. We carried out a Random Inspection to the Home on the 18th September 2009. At that time we found that the staffing levels had been reduced across all areas of staffing Care Homes for Older People Page 6 of 36 nursing, care, domestic and catering. We found many examples of residents needs not being met, we saw that the Home was not being kept clean and that the quality and choice of meals had reduced. At that time we issued an Immediate Requirement for the staffing levels to be increased to ensure that the residents needs could be met. We found that this had not been met when we carried out our visit on the 30th September 2009. Two Inspectors carried out an unannounced visit to the Home on the 30th September 2009 to carry out a Key Inspection. During our visit to the Home we spoke to the new Manager, the Operations Manager, to staff and to residents. We spent time observing staff supporting residents and looked around the accommodation. We also looked at a selection of records. This report contains information gathered about the Home since the last Key Inspection (February 2009). It also includes information provided with the surveys that were returned to us. We received seven from staff, ten from residents and two from health/social care professionals. The registered Manager left the Home in September 2009 and a new manager, Leslie Horsefield has been appointed and started work at the end of September. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: The residents personal and health care needs are not being met. Residents are not able to have a bath on a regular basis and are waiting for a long time to be assisted with personal care. Some residents are left sitting in wheelchairs as there are not enough staff to assist them to use the hoist to transfer to armchairs. One of the comments made in the residents surveys was that sometimes I cant find anyone to help me. Residents told us that they try to help each other as they cant find staff to help them. At the time of the Random Inspection residents were not being offered hot drinks mid morning and were only able to have sandwiches for tea seven days a week. At the time of this most recent visit the residents were offered a hot choice at tea time that had been cooked at lunchtime and been left in the hot trolley until teatime. There are areas of the Home that are not clean and the domestic staff do not have time to carry out the necessary tasks. There is an unpleasant smell in some areas of the Home. At the time of the last Key Inspection it was noted that the Home would benefit from having a deputy manager. The Operations Manager said that they are currently recruiting for this position but that there are no plans for this role to be supernumerary. One of the reductions in staffing has been the loss of a qualified nurse on each shift during the day which means that the senior care staff now take on more responsibilities. There is a need for more training for all levels of staff to ensure that they all receive training appropriate to enable them to carry out their roles. There are health and safety issues that need addressing. There are outstanding requirements from the latest Environmental Health Officers visit, the main lift in the Home has not worked for several weeks. The company who provides pressure relieving Care Homes for Older People Page 8 of 36 equipment refused to provide equipment due to unpaid invoices and the company who service the hoists initially refused to do so until outstanding invoices were paid. These situations were addressed during our visit. 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 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home provides clear information about the service that it intends to provide but due to the current staffing situation this is not accurate. The Home cannot clearly demonstrate that it can meet the needs of residents. Evidence: At the time of the last Key Inspection this outcome group was assessed as being Excellent. The Statement of Purpose and Service User Guide were assessed as meeting the regulations and they were available in alternative formats. We did not reassess these documents during this visit to the Home. We looked at the pre admission assessment for the resident who had most recently moved in to the Home. This had been carried out by the new Manager and the previous Manager. They had visited the resident and had gathered information from a variety of sources. The pre admission assessment forms the basis of the care plan. Care Homes for Older People Page 11 of 36 Evidence: However, the Home are not able to clearly demonstrate that they are able to meet residents needs due to the shortage of staff on duty. This report will include examples of how residents needs are not being met. The services described to prospective residents in the Service User Guide/Statement of Purpose are not currently all being provided. Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents personal and health care needs are not always being met. The privacy and dignity of the residents is compromised on occasions due to their personal care needs not always being met. Medication is managed safely. Evidence: At the time of the last Key Inspection the Home was assessed as providing good quality outcomes to the residents in this area. In May 2009 we were informed that there were plans to reduce the staffing levels in the Home. We spoke to one of the directors of the organisation at that time who said that this was not the case although they were planning to review the staffing provision to ensure that it was effective. In August 2009 we were informed by the Manager that the staffing levels had been reduced with immediate effect by the directors of the organisation. The reductions were across all levels of staffing including nurses, carers, domestic, catering and activity staff. Care Homes for Older People Page 13 of 36 Evidence: In September 2009 we received two complaints from relatives about the reduction in standards of care for the residents. During this visit we looked at the Homes complaints records and can see that the Manager also received complaints about the same issue during September 2009. A safeguarding referral was also made during September with regard to a resident having a pressure sore, possibly due to the lack of appropriate equipment. We carried out a Random Inspection on the 18th September 2009 and found many examples of poor standards of care being provided to residents. During that visit we spoke to staff, relatives and residents as well as looking at some records. We found that residents were waiting a long time for call bells to be answered, that residents were not able to have a bath weekly due to shortage of staff, that residents were not able to have a hot drink during the morning, that residents were being left to sit in wheelchairs as there were not enough staff to use the hoist to move them to a more comfortable armchair. Residents were having to wait to use the toilet. At the end of our visit we left an Immediate Requirement for their to be adequate staff on duty at all times to meet the residents needs. The timescale for this was 48 hours. During this visit we found that the only increase in staffing has been the addition of one extra care staff on duty during the morning shift. During this visit we found further examples of residents needs not being met. We spoke to five residents and eight staff as well as observing staff supporting residents. We also looked at the care records for four of the residents. We observed residents spending long periods of time in their wheelchairs and were told by staff that this is because they do not have the time to use the hoist to move them to armchairs. We observed residents still having breakfast at 11am as they had only just got up and did not want to have their breakfast in their rooms. One of the residents told us that she had had a bath last week after having had to make several requests. Another resident said that they had not had a bath for over a fortnight. One of the residents told us that another resident assists her to go to the toilet as I have to wait too long for the staff to come. Residents also said that the staff are kind and willing to help but that there are not enough of them to do so. Staff told us that they are very concerned about the quality of the care that they are able to provide currently. One said that residents are not dressed or washed properly Care Homes for Older People Page 14 of 36 Evidence: as we dont have time. Another said that residents sometimes have to wait for longer than a week for a bath. Comments within the staff surveys that were returned to us include the following: with low staffing levels things are deteriorating we need more staff to attend to the needs of residents residents are not getting the care they need when staffing levels are good then the level of care is great We received 10 completed residents surveys. Views are mixed with regard to whether their needs are met with the majority responding sometimes or usually to this question. The same mix of responses was given to the question about whether staff listen and act on what residents say. Additional comments were made such as: there are problems with some staff being untrained there is no-one in the lounge Sometimes I cant find anyone to help me We observed staff speaking respectfully and kindly to the residents. We received two completed surveys from health/social care professionals. These bot indicated that the residents needs are only met sometimes and that staff only seek advice and act on it sometimes. Additional comments in these surveys include the following: all staff appear very caring some staff are inadequately trained the carers appear to do their best The needs of some of the residents are high. There are currently 13 needing nursing care and 10 residents who have dementia. The other 39 residents are assessed as needing residential care. There are two residents who are fed via a feeding pump and several who need assistance with their meals. Many of the residents need assistance with mobility, including several who need the use of a hoist and two staff. One of the residents needs three staff to assist him with mobility. In September 2009 a referral was made by the Manager through the local Safeguarding procedures. This related to a resident who had acquired a pressure sore. The pressure relieving equipment that the resident needed was not available. The Manager said that this was due to the outstanding bill not being paid to the company who provided the equipment and so they refused to repair or to provide new equipment. We looked at four of the care plans. These are detailed and contain good information about how residents needs should be met. However, currently there are aspects of these that are not able to be met due to the staffing situation. Care Homes for Older People Page 15 of 36 Evidence: For example, the care plan for a resident who smokes in their rooms states that staff should be aware when the resident is smoking and ensure that the cigarette is extinguished. Two of the residents care plans that we saw state that they would like to have a bath at least weekly. Discussions with staff about these issues confirm that it is not possible to meet these needs consistently. We saw that in the shared rooms there are curtains to provide some privacy but there are other areas in which residents privacy and dignity is compromised. For example, some residents have to wait a long time for assistance to use the toilet. Some residents had food on their clothes after their meal and may have to wait a long time for staff to assist them to get changed. Staff told us that they do not always have time to ensure that the care records, such as records of turns, fluid and food intake and of baths are completed accurately and are kept up to date. We could see that there are gaps in the records that we looked at. The Manager is reviewing where the care records are kept as currently they are in the residents bedrooms which means that they may easily be overlooked during the day for residents who are not in their rooms. The staff are now not paid to attend handover and so not all staff receive a formal handover of information about the residents. The responses in the staff surveys are mixed with regard to whether they receive good information about the residents needs. We looked at the arrangements for the storage, administration and recording of medication in one area of the Home. The nurses and the senior care staff are responsible for all aspects of the management of medication in the areas in which they work. The senior care staff have all recently attended training with regard to the administration of medication as previously only the qualified nurses administered medication. There is now only one nurse on duty and so it is not possible for her to administer medication to all of the residents. We saw that there were appropriate records kept for the receipt and return of medication. Medication is stored appropriately and records are kept of administration. There is a need for clear guidance to be in place for the use of PRN (as required) medication. Care Homes for Older People Page 16 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are no opportunities for residents to take part in meaningful activities. Residents are able to have visitors whenever they wish to. The quality of meals has greatly reduced recently and residents are not always being offered hot drinks during the day. Evidence: At the time of the last Key Inspection the Home was assessed as providing good quality outcomes for the residents with regard to the provision of activities and meals. However, since then there has been a reduction in the hours that the activity organiser, the chef and the kitchen assistants work. The activity organiser left the Home two months ago. The Operations Manager confirmed that they are recruiting to this post but this will only be for 20 hours per week. During the Random Inspection and this visit to the Home we were told by residents that they are bored and that there is nothing to do. Staff confirmed that they do not have time to spend encouraging residents to take part in activities. The organisation runs a day centre in the grounds of the Home but only two residents from the Home attend this. They attend for approximately two days a week each. Care Homes for Older People Page 17 of 36 Evidence: Comments were made within the residents surveys such as: the loss of events coordinator is sadly missed we need entertainment Residents and relatives told us that they are able to visit at any time. The chefs hours have recently been reduced and there are less kitchen assistants employed. The complaints that we received in September included the fact that residents were only able to have sandwiches for tea seven days per week and that they were not being offered hot drinks during the day. At the Random Inspection it was confirmed that due to the fact that there is no chef or kitchen assistant on duty the residents were only having sandwiches for tea seven days a week. The chef was making the sandwiches before he left at 2pm and leaving them for staff to serve up at tea time. We also confirmed that residents were not being offered hot drinks mid morning and some times mid afternoon. We were told by the staff that this was because there were no longer kitchen assistants available to do this and the care staff do not have time. During the Random Inspection and this visit we saw that there were jugs of cold drinks available in each lounge. During this visit staff told us that the residents are now offered one hot choice at tea time as well as sandwiches. However, as there are no kitchen staff available during the afternoon the chef is having to make the hot option and it is then left in the hot trolleys for approximately 3-4 hours before being served to residents at tea time. Residents told us that the hot option is dried out and is not appetising or tasty as it has been in the hot trolley for so long. Staff said that residents have complained to them about the quality of the hot option. Residents said that the quality of the food used to be much higher and that the chef used to make lovely meals. The chef has a good understanding of the individual residents nutritional needs and prepares separate meals if needed. We were told by residents and staff that usually the residents are now offered a hot drink during the day but that if staff are called away to do other things then there may be occasions when this does not happen. One of the consequences of the reduction in kitchen staff is that the care staff are having to undertake some of these tasks. In the afternoons the care staff are now responsible for providing hot drinks and for preparing and serving tea. A kitchen assistant is responsible for clearing up in the kitchen after tea. We also observed care Care Homes for Older People Page 18 of 36 Evidence: staff hoovering the dining rooms after lunch. Some residents have their breakfast quite late due to getting up late and are then offered the main meal of the day a short time later. Staff did say that residents are able to have their breakfast in their bedrooms but that some residents prefer to have it in the dining room. We observed a resident having breakfast in the dining room at 11am. The tables were already set for lunch. The Home has three separate dining rooms and some residents choose to have their meals in their rooms. Several of the residents need assistance with having their meals. We observed the main meal taking place in two separate dining rooms during our visit. In both dining rooms the residents were sitting at the table for quite considerable time, some for over half an hour, before the meal was offered to them. In both dining rooms there was a lack of staff available for general support. In one dining room we observed a resident tipping over her drink and that belonging to another resident. They then pulled the apron away from another resident causing some distress to the resident. Staff were in and out of the dining room getting the meals from the kitchen. There is a hot trolley in the dementia unit. This is very large and is located in the corridor. This becomes extremely hot during use and could cause a risk of burns/scalds to the residents. Care Homes for Older People Page 19 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are dealt with appropriately by the Manager. The current staffing levels and the lack of staff training with regard to Safeguarding reduce the protection for residents from abuse. Evidence: The staff surveys that were returned to us all state that the staff know what to do if anyone wishes to make a complaint about something. The Manager maintains a complaints record which shows that there have been six complaints about the staffing situation in the last month. Records show that the Manager has responded to complaints appropriately. The Commission has received three complaints in the last month about the care provided at the Home. The Manager has worked well with the Commission when asked for any information relating to complaints. The Manager has made appropriate referrals to the Safeguarding team as they have occured. One referral was made last month with regard to a resident acquiring a pressure sore. During our visit we were given a copy of the training matrix. This shows that only 24 out of 36 care staff have received Safeguarding training and that some of this was provided over two years ago. Only 4 out of 12 auxillary staff have received this Care Homes for Older People Page 20 of 36 Evidence: training and that was provided in 2007. The current staffing levels mean that there are often times when staff are not available in the communal areas which means that there is a lack of supervision for residents whose behaviour may be challenging to other residents. The responses within the residents surveys indicate that not all residents are aware of the complaints procedure. Care Homes for Older People Page 21 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home provides individual and shared bedrooms which the residents are encouraged to personalise. There is a range of communal lounge and dining areas. There are areas in the Home which are not kept clean. There are some health and safety issues which need addressing to ensure the safety of residents. Evidence: At the last Inspection the Home was assessed as providing good quality accommodation for the residents. However, there are now issues which are affecting the residents and which are in need of improvement. We have received complaints from relatives about the fact that residents bedrooms are no longer kept as clean as they used to be. During our Random Inspection we were told by residents that they were concerned about the lack of cleanliness in the Home. At that time, and during this visit to the Home, we saw areas of the Home which were not clean. For example, we looked around the Home during the morning and in one of the dining rooms there was food on the floor which had been there from the previous evenings meal. We spoke to domestic staff during both of our recent visits and were told that they only have enough time to do basic cleaning rather than the proper cleaning that needs to be done. Care Homes for Older People Page 22 of 36 Evidence: The domestic hours provided in the Home have been reduced as part of the overall reduction of staffing in the Home. There are now only two domestic staff on duty during the morning and if one of these is on leave or off sick no additional cover is provided. We observed care staff hoovering the dining rooms after the lunchtime meal rather than spending time assisting residents. The Home has three lifts. The larger lift has been out of order for several months and was still not working on our last visit to the Home. The Operational Manager said that the company responsible for maintaining the lifts was having trouble obtaining the right part to mend the lift. The Home is a large building which has been extended. Although there are no physical divisions within the Home it has recently been designated into three separate areas. There is a 13 bed dementia unit on the ground floor known as the Grant Hadley unit. The additional 19 beds downstairs are designated for residents in need of nursing care. The 39 beds upstairs are designated for people in need of residential care. The Home has several lounge areas, including large conservatory. There are also three dining rooms. There are communal bathroom and toilets. The majority of the bedrooms have en suite toilets. The shared rooms have curtains to assist with privacy. There are some areas of concern that we noted during our walk around the Home. One of the shared rooms on the ground floor has large patio doors which were unlocked. These lead out on to a raised concrete area with steps down to the garden. The concrete has a lot of moss on it which could be a slip hazard. There are no restrictions to the residents in accessing this area. There was a hosepipe causing a trip hazard and the handrails on the steps are not adequate. The stair carpet on one of the staircases is frayed at the edges and could cause a trip hazard. Some of the baths are stained and would benefit from being replaced. There is a large heated trolley which is located in the corridor in the dementia unit. When this is turned on it becomes extremely hot. During our Random inspection we were told by the Manager that the company who usually service the hoists had refused to make arrangements to do so as they were waiting for payment for an outstanding invoice. The Operations Manager contacted the company whilst we were there and confirmed that this was the situation. He arranged Care Homes for Older People Page 23 of 36 Evidence: for payment of the invoice and during this recent visit to the Home we saw the records confirming that the hoists were serviced within the timescales in which they were due. The Manager told us that the company who provide and maintain the pressure relieving mattresses and beds had refused to do so due to unpaid invoices. As a consequence of this one of the residents was not able to have the pressure relieving mattress and developed a pressure sore. A referral was made to the Safeguarding team about this. During our recent visit to the Home the Operations Manager said that he had dealt with this situation. We were told that the company had delivered the equipment on the morning of our visit. At the time of our Random Inspection we saw the report relating to the recent Environmental Health Officers visit. Requirements were made at that time and a further visit had taken place to monitor compliance. Two requirements were outstanding and the Home had been given a further timescale in which to meet these. The oustanding requirements related to replacement of the seal on one of the fridges and to replace part of the kitchen floor which is torn and presents a possible infection control hazard. At the time of our Random Inspection neither of these requirements had been met. However, during our recent visit the Operations Manager said that the fridge seal has been replaced and that a company is due to visit to complete the work needed for the flooring and that this will be done within the revised timescales given by the Environmental Health Officer. We saw that residents have been encouraged to bring in personal items to personalise their bedrooms. The majority of the bedrooms have lots of packets of incontinence pads stacked on the floor which detracts from the homeliness of the rooms. Care Homes for Older People Page 24 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are working hard to meet the needs of residents but the staffing levels are not sufficient to do so. The Proprietors have not taken sufficient action to meet the Immediate Requirement that was issued. Staff do not receive adequate training to ensure that they are able to carry out their roles effectively. Evidence: We spoke to several members of staff during our Random Inspection and during this visit to the Home. We have also received several staff surveys. We spoke to residents and relatives during both of our recent visits to the Home. As previously stated in this report we were initialy told by the Manager that the Proprietors had plans to reduce the staffing levels at the Home in May 2009 but at that time the Proprietors said that this was not their intention. However, in September 2009 we were informed by the Manager that the Proprietors had reduced the care, activity, domestic and catering staff with immediate effect. During September we received several complaints from relatives about the reduced standards of care that the residents were receiving. Examples of these are included in the section of the report regarding personal and healthcare. The staff who spoke to us were all very concerned about the fact that they were Care Homes for Older People Page 25 of 36 Evidence: unable to meet residents needs consistently. Staff are working additional hours as the previous Manager had been told that she was not able to use agency staff. During our Random Inspection the Operations Manager said that the Manager is able to use agency staff if there is a need to do so. We received seven completed surveys from staff. They all stated that appropriate recruitment checks had been carried out when they applied for the job. All of the completed surveys state that there are never enough staff on duty. The responses were mixed with regard to questions about whether the staff receive appropriate training. Additional comments were made such as: staff dont have time to cook we need better training with low staffing levels things are deteriorating we need more staff to attend to the needs of the residents residents are not getting the care they need its hard to work in this environment we work well as a team when staffing levels are good then the level of care is great During the Random Inspection we issued an Immediate Requirement for the Home to provide sufficient staff to meet the residents needs. The timescale for this was 48 hours. Within the 48 hours we were informed by the Operations Manager that an additional care staff would be on duty during the morning shift. During our most recent visit we found plenty of examples to show that this increase in staffing hours has not been sufficient to ensure that the residents needs are being met. The one additional care staff in the morning does not even increase the care staffing to what it was prior to the cuts in September 2009. In addition, it does not even start to address the situation regarding the provision of catering and domestic staff. The reduction in hours which means that there is no handover time factored into the rota has also not been addressed. Residents told us that the staff are all nice and that they work very hard. They told us that they have to wait too long when they ring the bell and need assistance. We looked at a selection of recruitment files and could see that appropriate checks are carried out prior to staff starting work. Staff told us that they had received an induction from more experienced staff when they had first started work at the Home. We spoke to staff about training and were given a copy of the training matrix. According to the training matrix 21 of the 46 care and nursing staff have achieved a qualification to at least NVQ Level 2. Care Homes for Older People Page 26 of 36 Evidence: The majority of staff have attended Moving and Handling training in the last 12 months. However, the provision of other training such as First Aid, Fire Safety, Dementia Care, Infection Control, Safeguarding and pressure care has been inconsistent with many staff not having attended training. The Operations Manager confirmed that another change with regard to staffing is that staff are now not paid to attend training. This will have an effect on whether staff attend training as if they are not paid to do so they may be unwilling to attend. In addition to this there are not enough staff on duty to take staff from the floor to attend training. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The previous Manager has provided good leadership and day to day management of the Home. The needs of the residents are put first by the Manager and the care staff. There are concerns about the financial situation that the Home is in and also about the management of the Home by the organisation. Evidence: The Home is owned by Brunswick Care Home Ltd and the Responsible Individual is Dr Sondhi. The previous Manager, Karen Senior, has recently left the Home and a new Manager, Leslie Horsefield has been appointed. Mrs Horsefield started work at the Home the week prior to out visit and had a weeks handover from the previous Manager. Mrs Horsefield is a qualified nurse and has appropriate experience to undertake the management of the Home. She has already identified areas in need of improvement and has started to talk to the staff team and the residents about these. Care Homes for Older People Page 28 of 36 Evidence: Dr Sondhi and Dr Uddin are the Directors of the company and visit the Home approximately twice a month. They own other Homes across the country, including another Home in Norfolk. In order to improve management support to the Managers they appointed an Operations Manager two months ago. At the time of the last Key Inspection the Home was considered to be providing good quality outcomes with regard to management. At that time a requirement was made to recruit a deputy manager. One of the nurses has been taking on this role on a temporary basis. The Operations Manager said that he is currently recruiting to this role but there are no plans for this role to have supernumerary hours. It is difficult to see how a deputy manager in a Home this size would be able to carry out their roles without any time away from nursing duties. In May 2009 we were informed that there were plans to reduce the staffing levels in the Home. We spoke to one of the directors of the organisation at that time who said that this was not the case although they were planning to review the staffing provision to ensure that it was effective. In August 2009 the Manager informed the Commission that the staffing levels had been reduced with immediate effect. This report includes examples of the poor outcomes for residents of the reduction in staffing. We carried out a Random Inspection on the 18th September 2009 and at that time an Immediate Requirement was issued which required the company to increase the staffing to ensure that residents needs are met. During this visit to the Home we have found that this has not taken place. We will be discussing this situation with the Commissions enforcement team to consider what further action we will be taking. There are concerns about the health and safety of the residents. As previously mentioned in this report, the standard of cleaning and hygiene in the Home has reduced due to a reduction in numbers of domestic staff employed. Also, pressure relieving equipment has not been provided when needed due to the fact that outstanding invoices had not been paid to the company who supply the equipment. At the time of the Random inspection we discovered that the company who service the hoists had refused to come as their invoice had not been paid. The Operations Manager addressed this situation at the time of our visit and during this visit we could see that the hoists had been serviced before the end of September which is when they were due to be serviced. As previously mentioned, there is still an oustanding requirement from the Environmental Health Officers inspection. The Home does not have a fully developed quality assurance system. The Manager has identified areas in need of improvement but these have not been addressed by Care Homes for Older People Page 29 of 36 Evidence: the Proprietor. The Operations Manager has recently started to carry out the monthly visits as required of companies. The latest report does not sufficiently consider the serious concerns raised at the Random Inspection. The staff said that they feel that the previous Manager provided them with good support. They said that although they did not always receive formal supervision they could go to speak to her at any time. The staff who spoke to us were clear that they had received good management support from the previous Manager. The staff are also positive about the new Manager and are keen to work positively with her to make improvements for the residents. Care Homes for Older People Page 30 of 36 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 8 12 That the residents personal 23/09/2009 care needs are met in a way which promotes their privacy and dignity To ensure residents needs are met 2 12 16 That meaningful activities are available for the residents to take part in if they wish to To ensure that residents have a choice to take part in meaningful activities 30/10/2009 3 22 23 That the necessary 30/09/2009 equipment is provided for the residents and that this is well maintained To ensure that the residents needs are met 4 27 18 To increase the staffing to ensure that the needs of the residents are met To ensure that the needs of the residents are met 22/09/2009 5 38 13 That action is taken to address the outstanding health and safety issues To ensure that the residents are safe 09/10/2009 Care Homes for Older People Page 31 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 27 18 To increase the staffing to ensure that the needs of the residents are met PLEASE NOTE THAT THIS IMMEDIATE REQUIREMENT WAS ISSUED ON 18TH SEPTEMBER 2009 DURING THE RANDOM INSPECTION AND HAD A TIMESCALE OF 48 HOURS IN WHICH TO BE MET. THE DATE FOR THIS HAS NOT BEEN EXTENDED. To ensure that the needs of the residents are met 20/10/2009 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 7 15 The records within the care plans need to be kept up to date To ensure that accurate records are kept of the care provided to the residents 30/10/2009 2 8 12 That the residents personal 23/09/2009 care needs are met in a way which promotes their privacy and dignity THIS REQUIREMENT WAS MADE DURING THE RANDOM INSPECTION ON 18TH SEPT 2009 Page 32 of 36 Care Homes for Older People 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 To ensure residents needs are met 3 8 12 It is required that the care home is conducted so as to poromote and make proper provision for the health and welfare of residents To ensure that the residents personal and healthcare needs are met 4 9 13 It is required that clear guidance is available for the administration of PRN medication To ensure that residents receive medication at appropriate times 5 12 16 That meaningful activities are available for the residents to take part in if they wish to THIS REQUIREMENT WAS MADE DURING THE RANDOM INSPECTION ON 18TH SEPT 2009 To ensure that residents have a choice to take part in meaningful activities 6 15 16 That residents are offered 16/10/2009 meals which are wholesome, nutritious and properly prepared. 30/10/2009 30/10/2009 30/10/2009 Care Homes for Older People Page 33 of 36 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 To ensure that residents are offered a choice of meals which are nutritious and which they enjoy 7 18 13 That all staff receive Safeguarding vulnerable adults training To provide increased protection to residents from abuse 8 22 23 That the necessary 30/09/2009 equipment is provided for the residents and that this is well maintained THIS REQUIREMENT WAS MADE DURING THE RANDOM INSPECTION ON 18TH SEPT 2009 To ensure that the residents needs are met 9 26 23 That all areas of the Home are kept clean and that infection control procedures are in place To ensure that the residents live in a Home which is clean and risks of infection are reduced 10 30 18 that the staff receive training which is relevant to their role 31/01/2010 30/10/2009 31/12/2009 Care Homes for Older People Page 34 of 36 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 To ensure that the staff have appropriate skills to carry out their roles effectively 11 38 13 That action is taken to address the outstanding health and safety issues THIS REQUIREMENT WAS MADE DURING THE RANDOM INSPECTION ON 18TH SEPT 2009 To ensure that the residents are safe 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 09/10/2009 Care Homes for Older People Page 35 of 36 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. 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