Inspection on 15/09/09 for Charterhouse Residential Care Home

This inspection was carried out on 15th 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charterhouse Residential Care... 14/05/10

Charterhouse Residential Care... 11/02/10

Charterhouse Residential Care... 22/01/09

Charterhouse Residential Care... 11/11/08

Charterhouse Residential Care... 05/07/07

Charterhouse Residential Care... 27/07/06

Charterhouse Residential Care... 23/11/05

Charterhouse Residential Care... 08/06/05

Charterhouse Residential Care... 03/02/05

Charterhouse Residential Care... 02/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Charterhouse Residential Care Home Second Drive Dawlish Road Teignmouth Devon TQ14 8TL     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: Judy Hill     Date: 1 5 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 40 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 40 Information about the care home Name of care home: Address: Charterhouse Residential Care Home Second Drive Dawlish Road Teignmouth Devon TQ14 8TL 01626774481 01626774481 margaretbrett@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Stephan Barry William Brett,Margaret Louise Brett care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Charterhouse is registered to provide accommodation and care for a maximum of twenty people who are over 65 years of age and who may have dementia, physical disabilities or a mental illness. The home does not provide nursing care. The owners are registered as Mr Stephan and Mrs Margaret Brett. However, they have formed a limited Company, Brett Care Homes Limited, which was registered with Companies House on 21st December 2005, to carry on the business and Brett Care Care Homes for Older People Page 4 of 40 Over 65 20 20 20 20 0 0 0 0 1 1 1 1 2 0 0 8 Brief description of the care home Homes Limited is not registered with the Care Quality Commission. Mr and Mrs Brett live mainly in Spain so they are unable to manage the service on a day to day basis and there has been no registered manager in post since August 2008. The home is a large detached period property set in landscaped gardens. It is less than a mile from the town, which has a good beach, railway station and frequent bus services. The home provides accommodation and care for a maximum of twenty people who are over sixty five years of age and who may have dementia, a mental disorder of a physical disability. The fees range from 468.76 to 330.00 pounds a week. Extra costs include private hairdressing, private chiropody and items of a personal nature. Information about the home including a copy of the last inspection report can be obtained on request from the Home. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: Two inspectors carried out an unannounced visit to the home on 15th September 2009. The information contained in this report was gained during the site visit, when we spoke with some of the residents, the staff on duty and relatives of three of the residents. We also carried out a partial inspection of the premises, observed the interaction between the staff and residents and looked at records. The records we looked at included case tracking the needs assessment and plans of care of four of the people who use the service and how their care is delivered. We also looked at staff recruitment and training records and staff rotas, medication administration records and menu plans. Before the site visit we received a completed Annual Quality Assurance Assessment from the home and nine surveys that had been completed and returned to us by the staff. Care Homes for Older People Page 6 of 40 We gathered further information from the report of the last key inspection, which was carried out on 5th July 2007 and the reports of three random inspections, which were carried out on 28th January 2008, 11th November 2008, 22nd January 2009. We also looked at our records of complaints and notifications that had been sent to us from the home. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users Guides both need to be revised as they do not provide the reader with all of the information they need about the home and the service and some of the information they do provide is out of date. The needs assessments should pay more attention to identifying peoples religious needs and beliefs, their cultural needs and their social interests as these help to define who the person is and identify the diversity of their needs. The care planning process does not focus sufficiently on individual risk assessments and methods of working with people to reduce the identified risk. Insufficient staff training and low staffing levels prevent the staff from providing the level of individual care needed to meet the diverse needs of the residents. No provision is made to enable people to go out of their home and into the community. This means that if people need an escort to go out and do not have friends or families to take them out, they do not go out. Insufficient choice is available to the residents at mealtimes. Complaints are not always well received and staff training and recruitment practices do not protect people from the threat of abuse. There are no accessible communal toilets on the ground floor for people who use a wheelchair or walking frame. The lack of electric drying facilities, hand washing facilities and a washable floor Care Homes for Older People Page 8 of 40 covering make the laundry facilities unsuitable for the needs of the home. Care Staff begin to work at the home unsupervised before a Criminal Record Bureau check has been returned and without a POVA First check. This means that people are employed to work with the residents without having undergone checks to ensure that they are safe to do so. This puts people at risk. The staffs training needs are not being met. This means that they may not have the skills they need to meet the assessed needs of the residents. There is no registered manager in post. This means that the Care Quality Commission has not assessed the suitability of the person who is managing the home on a day to day basis. The limited Company that is operating the home is not registered with the Care Quality Commission to do so. Mr and Mrs Brett sent in an application form to register a company as the registered providers of the home. This had to be returned because many sections of the application form were not completed properly. By the time our report had been written, we still have not received a valid application. We are in discussion with our enforcement team about this situation. 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 40 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs assessment practices take most of the needs of people entering or considering entering the home into account but do not focus sufficiently on identifying their individuality and diversity. Evidence: We looked at the Homes Statement of Purpose and Service Users Guide. The Statement of Purpose needs updating as some of the information contained in it is out of date and could be misleading. The Service Users Guide does not include all of the required and recommended information. We looked at the needs assessments for three of the people who use the service. These showed us that where people were funded by the local authorities, copies of care management or joint assessments had been obtained. We also saw that the Home completes a basic pre admission assessment that contain Care Homes for Older People Page 11 of 40 Evidence: score or tick boxes covering mobility, hearing, sight, washing, communication, dressing, orientation, eating, behaviour, apatite, awareness, use of toilet, risk of falls, continence, risk of pressure areas, medication, sleeping, oral hygiene and foot care. There were also sections for religious and cultural needs, social interests, weight and dietary needs. These tended to be left blank or very little information had been inputted. These sections are an important part of assessment process as they help to define who the person is and identify the diversity of their needs. Ensuring these sections are completed would provide the home with a more complete assessment of peoples individual needs and allow more person centred care plans to be developed. The people we case tracked could not tell us what their experience of the admissions process was because they have dementia. Care Homes for Older People Page 12 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Poor care planning records mean that people are at risk of not receiving the care they need. Evidence: We looked at the plans of care for four of the people who use the service. Each of these included a basic care plan, but the care plans did not provide the staff with clear directions about how to meet peoples individual needs. We saw very few individual risk assessments and little evidence to show that regular monthly reviews are being carried out to record peoples changing needs. The care planning records we saw told us that one resident had a recent history of falls. Seven accidents or incidents had been recorded between 22nd August 2009 and 7th September 2009, three of these had no description about what had happened so it was difficult to establish a pattern. We did not receive any written notifications about these accidents or incidents, as is required under the Care Homes Regulations, even through one fall resulted in the resident sustaining a fractured hip. We saw no records Care Homes for Older People Page 13 of 40 Evidence: to tell us that any written risk assessments had been carried out in relation to the falls or to the residents mobility. The care planning records also told us that one of the residents was prone to wander and had on one occasion left the home and been brought back by the police. The Annual Quality Assurance Assessment tells us that the home does have a written procedure on what to do if a resident goes missing, but either the procedure needs amending or was not followed as the Care Quality Commission did not receive a written notification about this incident. We saw no evidence that a risk assessment had been carried out regarding this incident although we were told that the home had a locked door policy, which imposes a restriction on all of the residents, to prevent a re occurrence of this behavior. We saw no evidence that the Deprivation of Liberties Safeguards, which are part of the Mental Capacity Act 2005, had been taken into account when making this decision. The care planning records told us that one resident could become agitated and aggressive toward the staff. As the home is registered to care for people with a mental disorder as well as people with dementia we would expect to see a written risk assessment and detailed risk and behavioral management plans in the care planning records but did not do so. The Annual Quality Assurance Assessment tells us that the home does not have a policy, procedure or code of practice on dealing with violence and aggression. One of the plans of care we saw was contained very little information but it did contain a risk assessment on moving and handling and a radiator risk assessment. We did note that most of the radiators in the bedrooms did not have radiator covers on them to reduce the risk of people scalding themselves on a hot surface, even through we had highlighted the need for radiator covers on previous inspections. The Annual Quality Assurance Assessment tells us that twelve of the residents are incontinent of urine and that one is doubly incontinent. It also tells us that the home does not have a written policy, procedure or code of practice on continence promotion and the unregistered manager confirmed this. We saw no evidence in the staff files that training on continence control or continence management had been provided. When we entered the home we did detect the smell of urine and this was also evident in some of the bedrooms, one of which contained a commode that had been used but not emptied or covered. The home is registered to provide care for people with physical disabilities but the Annual Quality Assurance Assessment tells us that there are no policies, procedures or Care Homes for Older People Page 14 of 40 Evidence: codes of practice on moving and handling and we saw no evidence that all of the care staff had received moving and handling training. There is a fixed hoist in the bathroom on the first floor to enable the staff to help people to bathe safely. There are no communal toilets on the ground floor that are accessible to people who use wheelchairs or walking frames. The home is registered to provide care for people with dementia and the Annual Quality Assurance Assessment tells us that sixteen of the residents have dementia. The unregistered manager does have a National Vocational Qualification in Dementia Care but the training records showed us that most of the staff have not received any training in dementia care. One of the residents is confined to bed. We were told that she is receiving regular visits from the District Nurses and saw that the staff were recording her fluid intake, food intake and bowel movements. The Annual Quality Assurance Assessment tells us that the home has a policy on the control, storage disposal, recording and administration of medicines. The medicines are stored in a locked cabinet and wall cupboard in the dining room. We inspected the medication administration record sheets and found a number of gaps where medicines had either been given and the records had not been initialed or not given and the coding system had not been used to indicate why. We were told that records were signed retrospectively and not as the person assisting the residents to take their medication saw it being taken and this did explain why some of the gaps occurred on the day of the site visit. As we were inspecting the medication we asked the unregistered manager if she could tell us what the medication was needed for. In most cases she could. However, no written information was available to identify what the medication was needed for, possible side effects that the staff need to look out for or the possible consequences if an item of medication is not administered as prescribed. Throughout the inspection we saw a lot of social interaction between the staff and the residents. One resident said The staff are lovely, I like them here and another said We are lucky the staff are nice. A visiting relative said The staff are very good. I have never had to worry, they treat people well. Care Homes for Older People Page 15 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given the opportunity to engage in organised activities within their home, but no provision is made to take people out. Choices at mealtimes are limited. Evidence: Care staff were accessible to the people sitting in the lounge throughout the day of the site visit and there were several activities seen taking place, including a spelling quiz, a game of skittles and bingo. People were encouraged to participate by the staff, who worked hard to keep them engaged. A record book is kept to record all of the activities that take place. The unregistered manager said that this was not always filled in, but when it was the entries included information about how much people had enjoyed the activity and this helps the home to plan future activities for the residents. We also saw that a meeting had recently been held with the residents. The minutes had been posted in the home and showed that people had been asked what activities they would like to try. The Annual Quality Assurance Assessment told us that the staff were committed to Care Homes for Older People Page 16 of 40 Evidence: ensuring that people were provided with stimulating activities within their home and this is recognised as good practice. As previously stated, the residents individual needs assessments and plans of care that we saw had not paid sufficient attention to identifying what peoples social interests were before entering the home. This could be done retrospectively. A clergyman visits the home regularly to provide a service for the residents. However, as previously mentioned, the sections on the individual needs assessments on peoples religious needs had not been given sufficient attention and so people may have religious needs that are not being met. The relatives of three of the residents told us that people are not given the opportunity to engage in activities outside the home, in the garden or in the community unless they have friends or families to take them out. The Annual Quality Assurance Assessment and staff surveys also told us that the staff are not able to take people out because there are not enough staff on duty to enable them to do so and continue to provide supervision for the people who wish to remain at home. The residents are able to invite their friends and relatives to visit them at the home at any time, but they are asked to avoid mealtimes. The staff were seen encouraging people to drink fluids throughout the day and as well of tea and coffee, squash and water were available to them. There is a board in the dining room which is intended to show what meals will be served each day. The information seen on the board during the site visit was out of date. The Annual Quality Assurance Assessment told us that people choose their meals, but we saw no evidence of this during the site visit. For the lunchtime meal only one option was served, fish pie with vegetables, followed by profiteroles and ice cream. Everyone was given the same meal and one person complained that she wanted meat. The staff knew that this was her preference, as they later told us she always wanted meat, yet this was not anticipated. She was eventually given an alternative meal but only after she complained loudly. All but two of the residents had their dinner in the dining room. They were served in an unhurried and relaxed manner and those who needed assistance were given help in a supportive and caring way. One residents had her dinner in her bedroom and was Care Homes for Older People Page 17 of 40 Evidence: again helped and supported in a caring way. One person was given her dinner in the lounge and we were told that this was because she did not like eating in the dining room. We noted that she left most of her meal and we were told that she had not eaten very much on the previous day either. This person should have been given support, but was not. Care Homes for Older People Page 18 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are not always dealt with in a timely manner and the people who use this service are not adequately protected from the threat of abuse. Evidence: Both the Service Users Guide and Statement of Purpose tell us that the Complaints Procedure is displayed in the entrance hall of the home, but neither document includes either a copy or a summary of the complaints procedure. The AQAA tells us that the home does not have a policy, procedure or code of practice on concerns and complaints. The Annual Quality Assurance Assessment tells us that two complaints had been received in the twelve months up to 3rd June 2009, which was when the AQAA was completed, and that both were dealt with within twenty-eight days. Three complaints have been made to CQC within the last twelve months. In each case the person contacting us told us that they had discussed their concerns about the quality of care provided with the home and, in particular, about the staffing levels, the ability of the home to meet the needs of the residents and the environment in which people live and had not been satisfied with the initial response that they received. Surveys received from the staff told us that the staff would know what to do if someone raised concerns or complaints, however, they also told us that concerns Care Homes for Older People Page 19 of 40 Evidence: raised by or on behalf of the residents are not always dealt with as quickly as they could be. We saw no records to tell us that the staff had received training on the Protection of Vulnerable Adults. The AQAA tells us that the home has a policy on Whistle blowing, but that there are no policies, procedure of code of practice on Safeguarding Adults and the Prevention of Abuse. One safeguarding referral has been made in the past twelve months. This was about a named former member of staff who was alleged to have handled a resident roughly, causing bruising. This was investigated under the Safeguarding Adults procedures and the home cooperated fully with the proceedings. Care Homes for Older People Page 20 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not well maintained and does not meet the specific needs of people with dementia or people with poor mobility. Evidence: Charterhouse is a large detached house that is set in its own grounds in a private road. The home benefits from being in a prime location and has uninterrupted views of Teignmouth bay. There is a large, well maintained garden to the front of the house. This is level and mostly lain to lawn and could provide a very nice outdoor area for the residents. A relative of a resident told us that the garden was out of bounds to the residents unless they are accompanied and this was confirmed by the unregistered manager. We were told that this is because it can only be accessed using a steep slope or from the driveway and because it is not safely enclosed and people could wander off. The residents do have access to a patio area, which is accessible through the conservatory, when the conservatory door is not locked. The main entrance to the home is from the side of the building. We had difficulty gaining access because the door bell was broken and taped up and nobody responded when we used the door knocker. We were eventually able to attract the staffs Care Homes for Older People Page 21 of 40 Evidence: attention by knocking on a window. The second time we entered the home the front door was not locked and although an inner door has a key pad on the inside we were able to open it from the outside and walk into the home without attracting the staffs attention. This puts people at risk of having unwelcome intruders entering their home. There is a large and impressive entrance hall. This contains a pay phone for the residents to use to receive and make telephone calls. Part of the entrance hall has been sectioned off to provide a reception and office area. Care plans are kept on a shelf area, which is not satisfactory they contain personal information about the residents. There is a large lounge and most of the residents were seen in this room. Next to the lounge there is a large conservatory. Although the conservatory is a communal room, it is also being used as a staff sleeping in room. This arrangement is not satisfactory as it prevents the residents from using their conservatory if they wish to do so from 9pm and 7am. The dining room is spacious and would appear more homely if alternative arrangements were made for the storage of the medication. This room is a little dark and gloomy, due to an overgrown shrub which is blocking the light from the main window. The carpets in the communal rooms and entrance hall are very heavily pattered and not suitable for a home that is registered to provide care for people with dementia and who may, at times, hallucinate. The kitchen is next to the dining room and has a hatch to enable food to be passed through. This room is well equipped and adequate for the needs of the home. The residents bedrooms are on the first and second floor and there is a passenger lift to aid the residents mobility. The first floor is on two levels and a stair lift has been fitted between the two levels to aid the residents mobility. We inspected some of the bedrooms and found them to be basically but adequately furnished and decorated. Some of the bedrooms we saw were not very clean. Around midday we saw beds that had not been made, carpets that had not been vacuumed and commodes that had not been emptied. We were told that the cleaner was on holiday and the rotas confirmed that she was on leave the previous week and the week of the site visit. We were told that the care staff were covering her duties but saw that the care staff were too busy looking after the residents to do so. Care Homes for Older People Page 22 of 40 Evidence: Most of the radiators in the bedrooms have not been fitted with radiator covers to protect the residents from scalding themselves on hot surfaces. A bulb had been removed from a socket over a hand basin and this should be replaced to protect the resident whose room it is from getting an electric shock. Some of the curtains in peoples bedrooms were coming away from their rails and some were thin or badly worn. Some of the bedding was not adequate for the needs of the residents. We saw one bed that had a sheet placed directly onto a plastic sheet. This would make the bed uncomfortable to sleep in. We also saw a bed with a sheet placed directly onto the mattress. Washable mattress protectors should be used to help keep the mattresses clean. Some of the bedrooms did not have call bells that were accessible to the residents from their bed or from their chairs. We were told that this was because the sockets that are generally used to provide extension leads were being used to provide pressure mats so that the staff would be alerted if a resident got out of bed during the night. We accept pressure mats are only being used where they are needed but these should be provided in addition to and not instead of call bells. Some of the bedrooms have en-suite toilets and some have en-suite bathroom or shower facilities, however, we saw commodes in several bedrooms which indicates that the en-suite toilet facilities are not always accessible to the residents. There are two communal bathrooms, one on the ground floor and one on the first floor. The bathroom on the first floor has a hoist. There are two communal toilets on the ground floor. One is not accessible to the residents because they would have to negotiate steps and a combination lock to get to it. Although the toilet in the ground floor bathroom is accessible to people who are ambulant, the home is registered to accommodate people with physical disabilities and people who use wheelchairs or walking frames are not able to access this toilet safely because there is not enough room for them to take their wheelchair or walking frame in with them. The bathroom on the second floor is a little larger and could accommodate mobility aids. There is a separate toilet on the first floor that is designated for staff use only. This toilet is not suitable for staff or resident use as it does not have a hand wash basin. The laundry is in the basement and is not accessible to residents. This facility is not suitable as although it contains two washing machines, there are no hand washing Care Homes for Older People Page 23 of 40 Evidence: facilities and there is no drier. There is a drier close to the managers office on the ground floor but this is not close enough to an electrical socket to use and the staff surveys told us that they had been told not to use it as part of an economy drive. Laundry is dried in a room next to the laundry room or on an outside washing line. The floor in the laundry room has a carpet on it. This is not appropriate because it means that the floor cannot be easily cleaned. Care Homes for Older People Page 24 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff are committed to providing the residents with the best service they can but are hampered by low staffing levels and a lack of training. Poor recruitment practices put people using the service at risk. Evidence: The turnover of care staff has recently been high and we looked at the recruitment records of five of the most recently recruited members of staff. Two of members of staff had been recruited from India through an agency and a further two were from Poland and had been recruited through an agency and one had been employed directly. Application forms had been completed and contained employment histories, references had been taken up and training and qualification certificates were on the files. However, we were told that POVA First checks are not carried out routinely and saw that although Criminal Record Bureau check forms had been completed, these had not been processed but sent back to the home because some of the information that was needed had not been provided. The staff rota was seen and this provided clear evidence that the staff whose CRB checks had not been carried out are working day shifts with other staff and are covering the waking night shifts, when they are working alone. We looked at staff training records and discussed the provision of staff training with Care Homes for Older People Page 25 of 40 Evidence: the unregistered manager. We were given a copy of the new staff induction sheet, the contents of which do not meet the Common Induction Standards recommended by Skills For Care. Although the AQAA told us that on-going training was being provided, many of the staff who benefited from this have left and the only evidence of training we saw for the newer staff were certificates for training on Parkinsons Disease and Sensory Deprivation. The unregistered manager has completed her Registered Managers Award and NVQ at Level 4 Care and the deputy manager has completed an NVQ at Level 2 Care and is working towards completing an NVQ at Level 3 in Care. Prior to the inspection we sent surveys to the people who work at the home. Nine surveys were completed and returned to us and eight of the staff who responded told us that there were not always enough staff on duty to meet the residents needs. We requested and were given copies of the staff rota for the weeks commencing 7th September 2009 and 14th September 2009. These showed us that that unregistered manager, who has been appointed as manager in February 2009 but had not applied to be registered when the site visit was carried out on the 15th September, works from 8am to 5pm from Monday to Friday. From the rotas we calculated the care staffing levels as to be as follows. From 8am to 2pm the care staffing levels varied on three days there were four care staff on duty, on seven days there were three care workers on duty and on three days there were only two care workers on duty. On one day there were three care workers on duty from 8am to 11am and two from 11am to 2pm. From 2pm to 8pm, on seven days there were three care workers on duty and on the other seven days there were two care workers on duty. One care worker provides waking night cover from 8pm to 8am. One care worker is employed on a sleeping in basis and works from 8pm to 9pm and from 7am to 8am. We have not included the appointed manager in our calculations but were told that she regularly covers care shifts herself in the mornings at the expense of focussing on her role as manager. For the two weeks that we inspected, the cleaner was on holiday and the care staff Care Homes for Older People Page 26 of 40 Evidence: were doing the cleaning as well as looking after the residents. Two cooks are employed and they work from 9am to 3pm on different days. One of the cooks was on holiday during one of the weeks we inspected and although the second cook did cover some of her days, there was no cook on duty on two days and the care staff provided cover. The AQAA tells us that no shifts have been covered by temporary staff or by staff from an agency in the past three months. We were told that all but two of the sixteen people living at the home at the time of the site visit had been placed by the local authorities, thirteen by Devon County Council and one by Cambridge County Council. All of them had been assessed by the local authorities as having high dependency needs and our own observations told us that all of the people living at the home require a high level of support and attention. All but one of the residents has dementia, one person has a mental disorder and one is bedbound. At least three people need help or supervision to eat their meals. The AQAA tells us that all of the residents need help washing and bathing, that fifteen of them need help dressing and undressing and twelve people need help to use the toilet. The AQAA also tells us that four people need two members of staff to assist them with their care. From the evidence seen during this inspection we regard the care staffing levels to fall far short of the staffing levels that are needed to meet the assessed needs of the people who use the service. Care Homes for Older People Page 27 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements at the home are Insufficient, meaning that people living at the home are at risk. These include poor recruitment practices, poor care planning, insufficient staffing levels and staff training and attention to health and safety arrangements. Evidence: The certificate of registration that is displayed in the entrance hall of the home is not current. This certificate states that the registered manager is Mrs Margaret Brett, who is one of the directors of Brett Care Homes Limited, which is the Company that owns the business. This certificate was reissued when Mr and Mrs Brett registered a manager in June 2008 and again when the registered manager left her post in August 2008. The certificate of registration tells us that the registered service providers are Mr Stephan and Mrs Margaret Brett. However, they formed a limited company, Brett Care Homes Limited and registered the Company with Companies House on 21st December Care Homes for Older People Page 28 of 40 Evidence: 2005. Mr and Mrs Brett are aware that they need to apply to the Care Quality Commission to register the Charterhouse under the Company name but to date they have not submitted a valid completed application to do so. Mr and Mrs Brett are not able to manage the home on a day to day basis because, although they have retained a flat at the home, their main residence is abroad. We were told that Mr Brett visits the home approximately every six weeks and stays for a week but that Mrs Brett is an infrequent visitor. Following the resignation of the person formerly registered as manager in August 2008 a new manager was appointed. She resigned from her post in January 2009 and the current manager was appointed in February 2009. To date the current manager has not submitted an application to be registered. This means that Care Quality Commission has not been given the opportunity to formerly assess her suitability for the post, which is a requirement under the Care Standards Act. During the inspection it became clear that the unregistered manager had not been employed to manage the day to day running of the home on a full-time basis, but that she was expected, as part of her duties, to supplement the low staffing levels. Because the home does not have a manager who can devote all of her energy into managing the service and ensuring that the administration work is brought and kept up to date, the overall management of the service is poor. In previous sections this has been made evident by the quality of the care planning, the poor staffing levels and lack of staff training, recruitment of staff and the condition of the premises. There is no annual development plan for the business and no evidence that a quality assurance or quality monitoring system is in place. Regular staff meetings do not take place and regular one to one supervision is not being provided for the care staff. The AQAA tells us that there are very few written policies, procedures or Codes of Practice in place and this was confirmed by the unregistered manager during the site visit. The home does look after small amounts of personal spending money for the residents. This is kept securely in the office. The records of money used by or on behalf of the residents were seen in their case files. It is suggested that these records are kept with the residents money so that these can only be accessed through a senior member of staff. Very little training has been provided for the staff and few of the staff have attended the basic training courses that we would expect the staff in a care home to have Care Homes for Older People Page 29 of 40 Evidence: attended. These include Infection Control, First Aid, Health and Safety, Basic Food Hygiene, Manual Handling and Fire Safety. We would also expect to see training provided in Tissue Viability, Safe Handling of Medication, Continence Control and Dementia Awareness. Stickers on the fire extinguishers told us that the Fire fighting equipment had been serviced within the past year. The AQAA tells us that Premises electrical circuits, portable electrical appliances, lift and stair lift and Hoist have been serviced within the last year. The AQAA also tells us that the gas appliances have not been serviced for three years. This should be done annually. The Devon and Somerset Fire and Rescue Service carried out an inspection at our request on 20th February 2009 and issued the home with a letter of non compliance. We are aware that some work has been done to rectify matters since this visit but still have concerns about fire doors which do not close firmly into their recesses. As reported on earlier, people are put at risk because robust recruitment procedures are not in place. Care Homes for Older People Page 30 of 40 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 19 23 The premises must be 27/03/2009 maintained in a good state of repair. To ensure that the residents live in a safe environment. 2 22 13 Suitable arrangements must be made to provide a safe system for moving and handling residents. To protect the residents and staff from harm. 27/03/2009 3 27 18 Having regard to the size of the home and the number and needs of the residents, suitably qualified staff must be employed in sufficient numbers to meet the needs of the residents at all times of the day and night. To ensure that the needs of the residents can be met. 27/03/2009 4 30 18 Ensure that the staff are 15/03/2009 given training that is appropriate to the work they are to perform. To ensure that the staff have the skills they need to meet the needs of the people who use the service. Care Homes for Older People Page 31 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The registered persons must 30/12/2009 ensure that the residents care plans are regularly reviewed. Monthly reviews are recommended. This is to ensure that peoples care plans can be adjusted to meet their changing needs. The registered persons must 30/10/2009 give written notification to the Commission without delay of the occurrence of the death of a resident, including the circumstances of his or her death, any serious injury to a resident, any event that adversely affects the well being or safety of a resident, such as a missing person and any accident within the home. 2 8 37 Care Homes for Older People Page 32 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to enable the Care Quality Commission to regulate the service between inspections. 3 8 18 The registered persons must 30/12/2009 ensure that the staff receive the training they need to carry out their duties safely. This refers specifically to training in continence control and continence management, lifting and manual handling, dementia care, medication administration, safeguarding and managing aggressive behaviour. This is to ensure that peoples assessed needs can be met safely. All of the staff who 30/10/2009 administer medication to the residents should receive training to do so and a regular audit of the medication administration record sheets should be carried out to ensure that there are no gaps in the records and that every item of medicine that enters the home can be accounted for. Also written guidance should be available to the staff telling them what each item 4 9 13 Care Homes for Older People Page 33 of 40 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 of medication is needed for, what possible side effects to look out for and the possible consequences if an item of medication is not taken as prescribed. This is to reduce the risk of errors and protect the residents. 5 10 13 The registered persons must 30/11/2009 ensure that none of the residents are subject to physical restraint unless it can be demonstrated that this is the only practical means of securing their welfare. This refers specifically to the locked door policy, which impacts on the freedom of all of the residents when other measures, such as a door alarm could be considered. This is to protect peoples rights to enter and exit their home. The registered persons must 30/12/2009 ensure that accessible toilet facilities are available for people who use a wheelchair or walking frames. This is to preserve peoples dignity 6 10 23 Care Homes for Older People Page 34 of 40 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 7 12 23 The registered providers must ensure that the external grounds are suitable for and safe for use by the people who use the service. This is to ensure that people can use the gardens when they wish to safely. 28/11/2009 8 16 22 The registered persons must 28/10/2009 ensure that the complaints procedure is accessible to the residents and their representatives and that all concerns and complaints are recorded and dealt with in accordance to the homes complaints procedure. This is to ensure that peoples complaints and concerns are taken seriously. 9 19 23 The registered provider must provide accessible call bells in all of the bedrooms. This is to ensure that people have access to staff support at all times. 01/11/2009 10 26 16 The registered providers must ensure that the home is kept clean. This is to reduce the risk of 01/11/2009 Care Homes for Older People Page 35 of 40 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 the spread of infection and provide a safe and pleasant home environment for the residents. 11 26 16 The registered persons must 01/11/2009 ensure that safe and hygienic laundry facilities are provided by ensuring that the staff have use of a clothes drier, facilities to wash or rinse clothing by hand and a facility to wash their hands. The flooring in the laundry should be none porous and easily cleanable. This is to reduce the risk of the spread of infection. The registered persons must 28/10/2009 ensure that enough staff are employed at all times to meet the assessed needs of the residents. This is to ensure that the people living at the home have the care they need. 13 29 19 The registered persons must 28/10/2009 ensure that a completed Crinimal Records Bureau check is carried out before new staff are allowed to work unsupervised at the home. 12 27 18 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to reduce the risk of people being cared for by unsuitable staff. 14 30 18 The registered persons must 28/12/2009 ensure that the staff receive the training they need to enable them to carry out the duties that they are required to perform safely. This is to ensure that the people living at the home receive the care they need. 15 33 24 The registered persons must 28/12/2009 establish and maintain a system for reviewing and improving the quality of care provided at the home. This should be done by consulting the residents and their representatives and by producing an annual development plan for the home. This is to enable the people using the service and their representatives to influence the way the service develops. Care Homes for Older People Page 37 of 40 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The Service Users Guide should be redrafted as it does not contain all of the required and recommended information about the home and the service provided. Copies of the revised Service Users Guides should be given to each of the residents and a copy should be sent to the Care Quality Commission. The Statement of Purpose should be revised as it does not include all of the information that the Care Homes Regulations require to be included and the information that the National Minimum Standards recommend are included. Some of the information that is included is out of date and could be misleading. When completing peoples needs assessments, their religious and cultural needs, social interests, weight and dietary needs should be included as these help to define who the person is and identify the diversity of their individual needs. The registered persons should ensure that unnecessary risk to the health and safety of the residents are identified and as far as possible eliminated by carrying out individual risk assessments as part of the care planning and review processes. This refers specifically to the absence of individual risk assessments in relation to falls, mobility, lifting and manual handling, missing persons, aggressive behaviour, the locked door policy and the lack of provision of radiator covers to prevent scalding. Peoples religious needs should be identified as part of the needs assessment process and arrangements should be made to ensure that their individual needs are met. The social, occupational and recreational interests should be identified as part of the needs assessment process and included in their plans of care. People should be given the opportunity to engage in group or individual activities outside their home with the assistance of staff if necessary. People should be offered a choice of at least two different dishes at each meal time and offered alternatives if they do not want either of the set meals. Care plans should be stored in a secure location which is accessible to the staff. This is because they contain Page 38 of 40 2 1 3 3 4 7 5 12 6 12 7 13 8 15 9 19 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations personal information about the residents. 10 19 Alternative accommodation should be provided for staff providing sleeping in cover as the residents should be able to access and use their communal rooms at any time of the day or night if they choose to do so. Alternative storage facilities should be found for the medication cabinets as they detract from the homeliness of the dining room. The large shrub outside the dining room window should be pruned or removed as it is blocking natural light from the room and making it gloomy. Heavily pattered carpets are not suitable in home that specialise in providing care for people with dementia and should be replaced with plain carpets. This is because some of the residents may experience hallucinations and see the patterns as obstacles that need to be climbed over or removed. Thin and worn curtains should be replaced and curtains that are coming away from their rails should be re hung. Washable mattress protectors should be used to help keep the mattresses clean and additional bedding should be used with plastic sheets to ensure that people are comfortable in their beds. The gardens could be a major asset to the home and should be made safe for the residents to access and use. As the registered providers have formed a limited Company. The limited company is carrying on the business but is not registered to do so. In view of this the limited company should submit an application to register with the Care Standards Commission. An application should be submitted to register a manager for this service. This is to enable the Care Standards Commission to ensure that the person appointed is suitable for the role of manager. 11 19 12 19 13 19 14 15 19 19 16 17 19 31 18 31 Care Homes for Older People Page 39 of 40 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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