Inspection on 01/04/09 for Church View Nursing Home

This inspection was carried out on 1st April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church View Nursing Home 29/09/09

Church View Nursing Home 15/04/09

Church View Nursing Home 15/10/08

Church View Nursing Home 15/08/07

Church View Nursing Home 14/06/06

Church View Nursing Home 30/01/06

Church View Nursing Home 01/11/05

Church View Nursing Home 09/02/05

Church View Nursing Home 06/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Church View Nursing Home Church View Nursing Home Rainer Close Stratton St Margaret Swindon Wiltshire SN3 4YA     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Janice Patrick1     Date: 0 2 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. 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. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 44 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 44 Information about the care home Name of care home: Address: Church View Nursing Home Church View Nursing Home Rainer Close Stratton St Margaret Swindon Wiltshire SN3 4YA 01793820761 01793820180 churchview@hallmarkhealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Hallmark Healthcare (Swindon) Ltd care home 43 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: No more than 3 service users with a terminal illness may be accommodated at any one time The staffing levels set out in the Notice of Decision dated 1 December 2003 must be met at all times Date of last inspection 1 6 1 0 2 0 0 8 0 3 3 Over 65 43 0 3 Care Homes for Older People Page 4 of 44 Brief description of the care home Church View is a purpose built care home providing nursing care and accommodation for up to forty-three residents. The home is part of the Hallmark Healthcare Group. The registered manager post is currently vacant. The home is located within a residential development in Stratton St Margaret, situated on the outskirts of Swindon, and is within walking distance of a local shop. Accommodation comprises of twenty-nine single rooms and seven double rooms, located over two floors with all having en suite facilities. Residents also have access to a lounge and dining area on each floor and a ground floor conservatory, which leads out to an enclosed garden and patio area. As the home provides nursing care, registered nurses are on duty at all times and are supported by care assistants. Domestic, laundry, catering, maintenance and administration staff are also available. Current fees range from 469.44 pounds to 690 pounds. Information about the Funded Nursing Care Contribution (FNC) is provided by the company. Care Homes for Older People Page 5 of 44 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: This was an unannounced Key Inspection, which included a visit to the home The visit was completed by two inspectors and a pharmacy inspector over two days. Prior to the inspection we (The Commission) looked at various pieces of information to gather evidence in preparation for our visit which included the following: The previous inspection report. The homes inspection record which gives us an account of any information we have received about the home since the last inspection. The Annual Quality Assurance Assessment known as an AQAA. The home is requested annually to complete and return this assessment to us by a specified time. We received the AQAA on time which contained information about what the home considers it does well and what plans they have for further improvements in the coming year. We sent surveys Have Your Say to people who live in the home, staff, and health and social care professionals. Eighteen were completed and returned. Comments received Care Homes for Older People Page 6 of 44 from the surveys will be referred to throughout this report. During our visit we spoke with some of the people who live in the home, visitors, the manager, deputy manager, and other staff members who were on duty. We also looked at how effectively staff engage with people in the home and how they were interacting and communicating with each other. We looked at four individuals care files which included pre admission assessments, care plans, and risk assessments. We also looked at a number of records and files relating to the day to day running and management of the home. We spent time in all communal areas of the home and some of the bedrooms. We finished the inspection with a feedback session to the area manager, manager, and deputy. What the care home does well: What has improved since the last inspection? What they could do better: People living in the home are potentially at risk and their health, safety, and wellbeing is compromised. This is due to high levels of individual health and social care needs. The inadequate levels of staff in place means that the peoples needs are not met effectively. Provision must be made to adjust the levels of care staff throughout the home between 8AM and 8PM. By increasing the staffing levels people living in the home should be able to receive the care delivered to them as prescribed in their individual care plans in an effective, safe way. People in the home will benefit from the social stimulation and activities available when the coordinator is able to focus on her role and is not deployed to perform the roles of the carers. It would further help the improvements already made with regard to the home Care Homes for Older People Page 8 of 44 fostering an open door policy and making it easier for people to raise any concerns, if all staff received some training in what to do if someone raises a concern or makes a comment about something they seem unhappy about, so that this information quickly reaches the staff who can act upon this. The homes refurbishment process must look at ways of utilising space in the home so that people living there maintain privacy, dignity, and dont have their personal space impinged upon. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 44 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 44 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed prior to admission to determine the suitability of placement. Evidence: We looked at the pre-admission assessment format which were comprehensive covering all activities of daily living, a full health screen and personal history background. The information gathered pre-admission should provide a sound benchmark of the persons ability, state of health prior to admission and subsequent needs when they move into the home. The manager told us that people wishing to live in the home, family and carers are involved in the pre-admission assessment wherever possible and all information is used to determine the suitability of the placement. Where possible the manager also obtains comprehensive assessments and care plans from other health and social care professionals involved,for example, social workers and hospital staff. Care Homes for Older People Page 11 of 44 Evidence: The newly appointed manager clearly demonstrated the importance of thorough preadmission assessments in order to ensure that the home can meet individual needs. We also discussed the importance of ensuring that if the home admits people with high dependency needs then staffing levels must be increased in order to meet those needs effectively. Later in the report evidence will show that the dependency levels of the majority of people living in the home are very high. These people need support with personal care, continence management, eating and drinking and assistance with mobility and transfers at varying levels. The dependency levels in most cases are where people living in the home have deteriorated and not through poor pre admission assessment, however the home has failed to recognise that the staffing levels currently in place do not meet the needs of the people effectively and subsequently peoples care is compromised. Care Homes for Older People Page 12 of 44 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. People living in this home are not receiving the level of care they require and because of this they are being placed at risk. There were generally safe arrangements in place for the management of medicines although we found some weaknesses that need addressing in order to help reduce risks with medication for people living in this home. Evidence: We observed staff working and inspected various care records on each floor. The Pharmacy Inspector looked at a large selection of records pertaining to the safe administration of medicines and has made a separate report within this outcome. We identified shortfalls in peoples care and in the safe administration of medicines in October 2008 and outcomes for people living in this home were assessed as being poor. Various requirements were made of the Registered Provider following that Key Inspection in order to try and seek compliance with the Care Home Regulations 2001. Where these have been complied with we have acknowledged that in this report. More Care Homes for Older People Page 13 of 44 Evidence: recently however, the local funding authority identified serious concerns. They shared their findings with us and other healthcare professionals under recognised Safeguarding Procedures. These concerns relate particularly to the people living on the first floor where dependency levels are very high. During this inspection we inspected a mixture of care records, in detail, pertaining to the care of eight people on the first floor. This included written care plans for many areas of care such as eating and drinking, personal hygiene, safe moving and handling, wound care, pressure relief care and various risk assessments, to name some. We also inspected additional records such as fluid and nutrition intake charts. We observed the care routine and in some cases the actual care being given by the staff. On the first day we issued an Immediate Requirement. This was issued because we evidenced that peoples health and welfare needs were not being met and they were being placed at risk. A summary of our findings is given in this outcome. To fully understand the reasons for our initial action these findings need to be read in conjunction with those in the Staffing outcome found later in this report. Despite some immediate action being taken by the home, on the second day of this inspection it was evident that peoples needs were still not being adequately met and they were still at risk. We have already given feedback to the home management regarding our immediate concerns and further requirements have been made within this report to seek compliance with the Care Home Regulations 2001. A meeting with the Registered Provider or their representative has been made to further discuss these shortfalls. Any subsequent action by us will follow our enforcement pathways until compliance is successful and peoples needs are met. The immediate issue of peoples safety and the monitoring of the home and its practices will be are decided via under the Safeguarding Adults Procedures. On the first day at 11.15am we witnessed drinks of tea being delivered to people sitting in the lounge. There were nine people in this room and five were asleep. The television was on as it remained all day, on both days. These drinks were placed on the ends of peoples tables, in front of their armchairs without a word from the person carrying out this task. This meant that none of the five people asleep were woken up and only one person, who was clearly able to express the fact that they were hungry, had a choice in what to drink. We saw a plate of biscuits on the tea trolley but these were not offered around. The hungry person was later offered a piece of toast. This person was also able to say that they would like some sugar in their drink, which was provided and they were able to drink without help. We were later concerned, when looking at peoples weight charts, that some of these people, including the one that was hungry, were losing weight. We spoke to managers about this. They initially explained that there maybe a problem with the scales and that these may possibly be Care Homes for Older People Page 14 of 44 Evidence: giving false readings. The managers told us that the scales were due to be checked the week after this inspection. These records also recorded increases in other peoples weights. The Deputy Manager confirmed that the kitchen uses full cream milk and adds calories to food in other ways such as butter in potato and cream in sauces. Some people are also on prescribed, nutritional supplements. We saw nutritional assessments being recorded. Our concerns remain however, as clearly many of the people are very frail and require the staff to take every opportunity to get added calories and fluid into them. Clearly this was not the case during the above tea round. At a separate time of the inspection, a frequent visitor expressed their own concerns as to whether their relative was actually receiving adequate drinks when they were not visiting. This person also commented that the menu states that a piece of cake or biscuits is meant to be provided with afternoon tea, 3pm, but that on many occasions they have not seen this to be the case. We were very concerned with the provision of peoples drinks and the lack of support they were getting to drink them, also in what was actually being recorded as taken. Several times throughout the inspection we monitored what was being given to people and what was being recorded. Two clear examples of incorrect recording were, in the case of the first person, they were fed with their drink of tea at approximately 12.10pm. We observed this beaker of tea initially being delivered at approximately 11.30am and it was virtually full. The carer helped the person drink about half the contents. A similar amount was measured by us and was found to be 80 millilitres. When revisiting this persons fluid and nutrition intake chart at 2pm, an entry had been made alongside 11am for 200 millilitres. The second example, we observed a member of staff help one person have their drink in the lounge. All of the people in the lounge, except one person, were provided with half beakers of tea, approximately 80 millilitres. Again, in front of us, an amount of 200 millilitres was recorded. Another person managed to give themselves their drink and this was later seen as recorded correctly. By 12.10pm on the first day six of the people in the lounge still had not had their beaker of tea and looking at the records later, none had been recorded, so we presume these were not given. On the second day the teas were delivered in the lounge to eight people and to those in their bedrooms, most required the assistance of a member of staff to successfully drink these. The member of staff confirmed to us that it was her task to deliver the drinks; she has to then let the Deputy Manager know that this had been done. At this point the Deputy Manager was helping one person in the lounge with her drink. There were six further people in the lounge requiring assistance to drink and no other staff present so we helped two people to have a drink. It took us ten minutes to help one person have seven sips of tea. This was due to the persons frailty and their inability to hold small amounts of fluid in their mouths. This emphasised to us the dependency levels of these people and the time it takes to carry out a simple, but necessary task. Care Homes for Older People Page 15 of 44 Evidence: At 12 midday we asked how many people still needed to be washed and helped to get up. There were five. At 12.50pm one person was up and another had been washed. Three still required a wash and two needed help to get up, the third was remaining in bed. At 12.30pm lunch arrived for those that require soft or puree diets. All who require these diets require help to eat or at least some prompting. We spoke to one carer who we observed feeding one person. It had taken her 15 minutes so far to help the person eat half of her meal. This again emphasises the degree of care these people require and how long that care can take. She also confirmed that there were seven people who required puree, soft diets and that there were twelve people altogether that needed a carer to actually feed them. At 1.05pm we sat with a person who told us about the help she requires. This person said she was hungry and ready for her lunch. At 1.40pm a carer arrived with her pudding. The person was able to say that she had not yet had her first course, this was organised and arrived about 1.50pm. On the second day at 10.50am we visited some of the bedrooms on the first floor to see if the action the home had taken in response to the Immediate Requirement had improved things. We found seven people in bed with their curtains drawn closed. Two people had their legs over the bedrails, clearly indicating that they wanted to be up. One of these people had their underwear lowered and indicated, by holding out their hand, as they could not speak, that they needed help. One persons bedroom smelt strongly. On investigation they had had their bowels open in the continence pad they were wearing. We observed two people being washed on their beds, each by only one carer. In one case the carer was holding the persons upper body up off the mattress, by their neck. Managers later confirmed that staff had been told not to wash people on their own. We considered what we were observing to be extremely poor care and asked the acting manager and the Regional Manager to also witness what we had found. This they did and could not understand why the care delivery was so behind in time. We inspected one persons pressure relief care and wound care records. This persons care plan told us that they needed a special mattress on their bed and that a pressure relief cushion was required when sitting in the armchair. On the first day this person was helped into an armchair in the lounge. For sometime they called out saying that their back hurt and they wanted to get out. This person had not been placed on a pressure relief cushion. Despite her calls and a member of staff being in the immediate vicinity, her discomfort was not being acknowledged. Eventually the Deputy Manager came into the room to investigate and asked staff to return her to her bed where she thought the person maybe more comfortable. Due to the level of Care Homes for Older People Page 16 of 44 Evidence: this persons discomfort we asked her permission if we could check the skin on her bottom. We did this with the assistance of a qualified nurse. We saw that a dressing was in place and asked for this to be removed as it was very wet anyway and required a change. The wound records recorded a shallow wound in February 2009. We were not looking at a particularly shallow wound but the bed of the wound was clean. The nurse explained that the area of skin around the pressure sore had healed well and we could see this by looking at previous photographs of the area. The Tissue Viability Nurse, an external healthcare professional who specialises in wounds, had visited last on the 17th February 2009. This shows that the staff of the home are utilising the skills of specialist healthcare professionals, however, this specialist had written in the records during her last visit asking staff to make sure the person was seated on the appropriate pressure relief cushion whilst in the lounge. We also noted that special pressure relief gutters were being used for this persons feet, designed to relieve pressure from the heels. The purpose of which was completely defeated as thick socks and slippers were being worn whilst the feet and legs were resting in the gutters. We asked staff how they thought the gutters worked. They said they were not sure but thought if they put everything on something had to be right. During feedback to senior managers they told us that staff have had training relating to pressure relief care and should know what was required. We were informed by one of the nurses that this persons heels had healed. Our concern is that through staff not using the equipment appropriately or at all, they are placing this person at unnecessary risk and putting them in danger of either the existing pressure sore and surrounding area deteriorating or from developing sores again that have already healed. The home had requested a doctors visit on the day of our inspection so that this person could be prescribed some pain relief. This persons wound care plan was not reflecting the current treatment being provided. The Deputy Manager explained that the specialist comes in and tells them what to use and that sometimes this changes. This shows that this person is having access to a specialist that is treating the wound as required each time she reviews it. It is however then important that this advice and instruction is then written in the associated care plan so that all staff are aware of what treatment is being used and so that the rationale behind the change in dressing material is recorded. Another person had been assessed as being at high risk of developing pressure sores on 10th March 2009. In February, care records indicated that this person had the beginnings of a pressure sore. The relevant care plan said that the person must be turned regularly and have a change of position. This offers staff no specific guidance as to how often they should be turned. Crucially, there was no documented follow up information regarding the condition of this persons skin indicating that staff were monitoring this persons skin. There was no turn chart for this person at night and on both days of our inspection they were one of the people getting up very late, having spent all the morning on their back. They were however, Care Homes for Older People Page 17 of 44 Evidence: on a special air mattress, but this is not adequate pressure relief used on its own. This persons relative said that they had raised concerns before about the length of time their relative was being left in bed and also about their relative never actually being taken to the toilet to have their bowels open, instead a continence pad being positioned and the person being left to defecate into the pad. This persons care plan says, take to the toilet every four hours. This would help to encourage some kind of bowel habit and would also maintain a degree of dignity for this individual. We noted that none of the people in the lounge, that were there when we arrived, were taken to the toilet before lunch. Hence none moved position either throughout the morning, although some were sitting on pressure relief cushions. Staff were honest and explained that they did not have time to toilet people in the mornings. Another person was assessed as being at a high risk of developing pressure sores and on the 4th March 2009 records again implied that there was a pressure sore beginning to develop. A care plan explains the use of a specialised mattress and that continence pads should be changed regularly. There was no further record telling us of the current condition of this persons skin. Again this person did not move from her chair during the morning, but a turn chart was seen completed for turns occurring during the night. We were also unable to determine when people last had a bath or shower. We noted that one persons hair was particularly greasy. We understand their relative had expressed concerns about their relatives lack of bathing and had requested, that because of the persons continence problems, they be showered daily. The relevant care plan for this person says give weekly bath and hair wash. Due to the wording and design of the tick charts used to record baths, showers washes and bed baths, we could not tell from this if this person had had a recent shower. We also read through the daily record, unable to find an entry. In the last two months a general bath had only been recorded for 28th February 2009, 13th March 2009 and 18th March 2009. We asked four members of staff if they had recently showered or bathed this person, or knew if anyone had done this and they were unable to help. The same was evident in other peoples records. We were informed both by managers of the home and by external healthcare professionals that the content of care plans had generally improved. We still found however non specific terms being used such as regularly or for example if she doesnt eat for long time and in the example of the wound care plan, no relevant guidance at all. The fluid and food intake charts in places are being completed incorrectly. It is the responsibility of the Registered Persons to ensure that there are suitable arrangements in place for the accurate recording of care. For qualified nurses, who are ultimately responsible for the care people given, it is within the Nursing and Midwifery Councils, NMC Code, Standards of Conduct, performance and ethics that each Registered Nurse must ensure an accurate record of care. Care Homes for Older People Page 18 of 44 Evidence: As part of this key inspection, one of our (The Care Quality Commission) pharmacist inspectors looked at some of the arrangements for the management of medicines. This included looking at some stocks and storage arrangements for medicines and various records about medication. We saw how staff administered some medicines to people living in the home. The pharmacist spoke to the manager, the deputy manager and two nurses. We spoke to one person living in the home and visited several bedrooms. We gave full feedback after the inspection to the manager and deputy manager about the medication issues we found. Since the last inspection in October 2008 it was apparent the newly appointed manager has worked hard on making improvements to the arrangements for the management of medicines in the home and to address the issues we raised then. At the time of this inspection nobody living in this home was assessed as able to look after and administer some medicines themselves. Staff told us that in the past some people have looked after their medicines if they assessed this as safe and arrangements would be made for this. All people living in the home were therefore totally dependent on the staff for this part of their care. Registered nurses administered medicines (except for certain skin products that carers applied under the direction of the registered nurses). We saw that some medicines had recently been administered using a syringe driver. The deputy manager told us that the district nurse had provided some support to start this treatment. As this is a specialist procedure staff training for this must be up to date. It was not clear if the nurses training for this was up to date but the manager told us she had already identified this as a priority. During the inspection we saw a nurse taking one of the medicine trolley and records around the home to administer medicines to some people and following a safe procedure. Since the last inspection the home have made some changes to the times that medicines are administered and we saw during this inspection that medicines were given to people within an acceptable period of the required times. Medicines also were not administered during meal times. There was a better spread of doses throughout the day so that people should benefit from a better effect from the medicine. Also doses were not given too close together, which can sometimes put people at risk. We pointed out one person was having two different tablets at the same time but where these must be taken at least two hours apart in order to prevent the action of one tablet being made less effective by the other. The deputy manager changed the time for administration of one medicine on the chart during the inspection. Staff need to be aware of issues such as this and ask for any further advice Care Homes for Older People Page 19 of 44 Evidence: from the pharmacy. We noted staff had been advised by the hospital that a particular capsule could be opened up to disperse the powder from inside in some water before administration. Staff had to wear gloves as protection when doing this. We advised the deputy manager to discuss this with the pharmacy to see if any alternative was available. We also strongly recommend that the home ask the Pharmacy to provide the official manufacturers Patient Information Leaflet so that they can check that they have in place the correct arrangements for safely doing this and staff are aware of any hazards. There were arrangements for keeping records about medication received, administered and leaving the home or disposed of (as no longer needed) for each person in the home. Complete and accurate records about medication are very important in a care home where there are a number of different staff involved with medication and people in the home are totally dependent on these staff for their medicines and are often taking a complicated regime of medicines. Proper records help make sure that people are not at risk from mistakes, such as receiving their medicines incorrectly, and there is a full account of the medicines the home is responsible for on behalf of the people living here. We strongly recommend that the home sees the monthly prescriptions to check before they are sent to the pharmacy. This should help to make sure that the new prescriptions include the medicines that the home have ordered and the directions can be checked with the surgery immediately where these are different from what has been ordered. We saw occasional examples where directions were not up to date. Most of the sample of medicine records we looked at appeared to be order so that there were clear records about the medicines people living in the home need and had taken. We pointed out very occasional examples where records were missed. We saw however a number of examples where the doctor had prescribed a range of a medicine dose (5 to 15ml for example) but the records did not provide the information about what dose staff had given or why they had given that dose. Some dose directions for eye drops need to clearly state which eye or eyes were to be treated. Some other medicine charts needed to made clearer as they included medicines that were not signed as administered and the pharmacy had printed as none supplied. Staff explained to us that this was where treatment was completed and no longer needed. Arrangements should be made with the pharmacy to correct the records and in the meantime staff must make notes on the records to explain this with reference to the care plan or doctors visit as appropriate. Care Homes for Older People Page 20 of 44 Evidence: We looked at the medicine records for one person who was admitted in January 2009. There were records for new medicines received 10 days after this person came to the home yet during the period immediately following admission the medicine chart was signed as though the medicines were administered. In addition we looked at records for 1mg tablets of one medicine prescribed to use as required. 28 tablets were signed as received on 2nd February 2009 and since then we found records for 37 doses administered yet there were more tablets remaining than should be. The deputy manager thought this person had brought medicines with her when admitted and these were not recorded. When we visited this persons bedroom we found two different types of creams that were not recorded on the medicine chart or care plan. The use of another type of barrier cream was included in the care plan but we found no container in the bedroom and there was no record for this at all on the medicine chart so there was no evidence that this treatment was being provided. A number of medicines were prescribed to use as required. For a number of people in the sample of records we looked at we found there was additional written information in care plans that provided further guidance to the nurses to help understand what the direction as required meant for this person and medicine. This should help make sure people receive this type of medicine in a consistent way and to meet identified needs. We pointed out examples of some other medicines where this information was still needed or the where the plan already written needed better information so that there would be clearer guidance for staff. Another care plan for administering medicines by a feeding tube needed improving by adding the specific information about administering medicines in this way. The deputy manager made some additions to some care plans during the inspection. Consideration of peoples capacity and how they consent to taking their medicines must also be included where needed in accordance with the provisions of the Mental Capacity Act 2005. We saw in two care plans where peoples choice about where their medicines were taken was included. This is good practice and should be put in place for everyone. We saw that prescribed food supplements were in stock and there were records for these on the medicine charts where staff signed as having given this feed. We pointed out to the deputy manager that the records for one person on a more complex treatment needed clear direction about the rate of administration on the medicine chart even though this was in the care plan. The records for the volume administered also needed to be clearer as some people were signing for the whole volume when first started at 7am and others appeared to be signing in two stages at 3pm. This was confusing and not a clear record. Our checks on a sample of medicine stock and records showed that the medication Care Homes for Older People Page 21 of 44 Evidence: people needed was available in the home and the next months supply had arrived in plenty of time. There were arrangements in the home to store medicines safely and securely. The storage of controlled medicines was correct and the requirement about this from the last inspection was actioned. We advised moving the medicine fridge from below a medicine cabinet as the heat from the back of the fridge was making the cupboard warm. Some of the dressings in the main store room needed sorting out. We found two open packs of sterile dressings with part of the dressing missing. It is unsafe practice to keep these as they would not be sterile if used in the future and so put people at risk if used. We saw that the right lancing devices were in place to use where staff take blood to test for sugar levels. This requirement from the last inspection had been actioned. We advised that the wrong lancets still in the cupboard are removed to prevent these being used by mistake. The arrangements for monitoring creams that are kept in bedrooms must be checked as being effective. We visited a bedroom and found two tubs of prescribed cream one of which had no label from the pharmacy and the other where the name of the person had been torn off. There was no date of opening on either pack. In another bedroom we found a tub that was labelled and correctly dated when opened. It is good practice to write the date on medicine containers when first opened to use but we found this was not always done. This helps to make sure stock can be rotated properly particularly where there are good practice guidelines or the manufacturers give a limited shelf life after opening. It also helps with audit checks to show if the medicine stocks agree with the records. These can indicate whether people have received their medication correctly. We did see that remaining stock balances were often recorded on medicine charts which is another check. The deputy manager showed us the type of audit checks of medication that she or the manager makes each month. The manger showed us a company medicine policy dated June 2008 contained within a large policy folder. We had only seen a very small part of this policy on each of the medicine trolleys during the inspection. It is important that this sort of information is readily available to all the nurses so that they are provided proper guidance about how the home expects them to safely handle and manage medicines. As this was a company wide policy there should be additional information inserted with specific information applicable to this home. Care Homes for Older People Page 22 of 44 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. Peoples choice and lifestyle is compromised because of the insufficient hours of staff deployment. People maintain family contact and staff encourage family and friends to join in with activities and any outings. The home produces a varied and wholesome diet that people living in the home are able to influence. Evidence: There does not appear to be any unnecessary rules in the home and it was clear that the manager and staff are working towards empowering people and encouraging them to maintain independence, autonomy and choice. The care files give good detailed accounts of how people want to live their lives. Daily routines are flexible within the home, the care files indicate that people can get up and go to bed when they like, have their meals in their bedrooms, they can go out when they wish and participate in activities they have a particular interest in. However because of the high dependency levels of individuals needs some people are not Care Homes for Older People Page 23 of 44 Evidence: always able to live the life they choose because there are not enough staff on duty to accommodate their wishes. We saw several examples where choice is compromised which are detailed throughout the report. This includes being not being able to enjoy and pursue hobbies, personal interests and activities provided by the home. This is due to various factors including the full time activities coordinator having to assist in duties usually performed by care staff, for example assisting with people when food is served. We also saw during our visit that one lady wanted to go out for some recreation. The activity coordinator took the lady out but this meant that the remaining people living in the home received no social stimulation that day. Many of the people living in the home are unable to participate in group activities and require one to one stimulation. The activity coordinator does try to see people individually and we did witness her talking with individuals, but this was usually when she was also trying to encourage them to have the drink that had been put in front of them or as said above during lunch. We did observe her mid morning painting the nails of two people on the first floor. Her ability to provide designated social interaction, on a one to one basis is limited due to the amount of people she has to accommodate. One visitor told us that they were very happy with the care that their relative received but that on many occasions they would visit for two hours and staff had not checked on their relative throughout their visit. They told us that they were concerned that their relative, Didnt have enough people just popping into the bedroom for a chat every now and then. People in the home will benefit from the social stimulation and activities available when the coordinator is able to focus on her role and is not deployed to perform the roles of the carers. Because the majority of the peoples needs are complex, they would benefit from 1- 1 interaction. The amount of hours deployed for this are not sufficient. The home has a receptionist to greet visitors on arrival to the home and assist with general enquiries and this is often the first point of contact for visitors to the home. We saw the receptionist greet people in a warm, friendly, professional manner throughout our visit. The home operates an open door policy for visitors and people are able to see visitors in the privacy of their own rooms and there are some semi-private seating areas around the home and in the gardens.We spoke with a few visitors during our visit who told us that they are always made to feel welcome by all the staff in the home. We Care Homes for Older People Page 24 of 44 Evidence: saw several visitors speaking with staff in a friendly, familiar way. The size and layout of the dining rooms makes it difficult for everyone to enjoy the social advantages of dining together. As we mention later in the report Hallmark are in the process of a redecoration and refurbishment plan, where the plan is to utilise all available space and additional dining room suites will be provided. We met the head cook who had worked at the home for ten years, she was very happy in her work and demonstrated good awareness of individual needs and preferences of people in the home. Although there is a four week menu plan for people living in the home, everyone is asked daily about what they would like to eat and they dont have to have whats on the menu if they dont like it. People told us that they usually liked the food offered to them and that they ask for something else if they didnt like what was on the menu. All food is freshly prepared in the home on a daily basis including, cakes, pastries, bread, soup and fruit salad. The kitchen was well organised and seemed to run efficiently and effectively. The food is home cooked offering various choices of hot and cold alternatives and fresh fruit is available at all times. The menu rota displays traditional meals and menus are reviewed to reflect seasonal trends and availability of produce. Extras are ordered on request for birthdays and special occasions. Any visitors to the home are welcome to stay for lunch. The kitchen was well equipped, spacious and clean. Stores exhibited a good range of foods. Food hygiene training was up to date for staff. Documentation was provided to show that the required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked. Care Homes for Older People Page 25 of 44 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good policies and procedures in place to manage complaints and people can be confident that their concerns will be listened to and acted upon. There are good arrangements in place for staff training and awareness of protecting vulnerable adults so that people living in the home are further protected from abuse. Evidence: When the home was inspected six months ago a requirement was made because complaints and concerns were not being acted upon effectively and the home was not following its policies and procedures. Because of the nature of some of these concerns it meant that people were not safeguarded. Since the appointment of the new manager we saw evidence that complaints and concerns have reduced considerably. We receive details from the home about any internal complaints investigations and safeguarding referrals, the outcomes have shown us that these have been dealt with openly and effectively. The manager told us that she is committed to encourage an open culture within the home so that people feel comfortable and able to make a complaint or a suggestion without fear of reprisals. The current manager makes every effort to see people living in the home Monday to Friday, her office is by the main reception area which means that visitors can see and Care Homes for Older People Page 26 of 44 Evidence: talk to her on a regular basis. Being available has meant that people can discuss any concerns or issues with the manager before they potentially escalate into complaints. One visitor did tell us about concerns they had regarding their relatives care. They said they had raised these concerns in the past with several staff but felt that they had not been successfully acknowledged. We spoke with the manager about this particular persons care and she seemed unaware of these concerns. She could relate to these concerns, particularly as we had identified similar concerns at this inspection. It was thought that concerns had obviously been discussed in the past with care staff who did not always pass communicate this to senior staff and management. The issues raised by us during this inspection were taken seriously by the manager and we will continue to monitor the actions taken by the home to address these concerns and any future concerns. Holding meetings for people living in the home, relatives and staff has meant that communication and sharing information has improved. This further promotes people becoming less frustrated, thus relieving anxieties and any potential complaint referrals. Ten out of eleven people living in the home stated in our surveys that they did know how to make a complaint. People also told us that they knew who to speak to if they were not happy. There are policies and procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse. The availability of this information should increase staff awareness and the understanding of their role in protecting vulnerable adults who live at the home. We were told that the home actively promotes staff training and education in the protection of vulnerable adults on induction and on an annual basis the staff receive an update. We spoke with staff who confirmed that they had received this training in the last six months and they were able to demonstrate its effectiveness when discussing the content of the training. A number of staff have either completed or are enrolled on the National Vocational Qualification in care award, and a component of the award which addresses issues around the topic of the protection of vulnerable adults from abuse. Care Homes for Older People Page 27 of 44 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. At present the home is clean and comfortable. The additional work outlined in the homes refurbishment and redecoration plan should provide a safe, peaceful and wellmaintained environment for everyone. In general the bedrooms, communal rooms and facilities are suitable to meet the needs of people living in the home, however by revising some areas in the home will mean that peoples privacy and dignity will be further respected. Evidence: The home has a number of aids and adaptations throughout the premises to enable physically disabled people to maximise their independence. This includes wide corridors and pathways, passenger lifts, specialised bathing facilities, grab rails and assisted toilet facilities. We walked around the inside of the home and viewed most of the bedrooms and the communal areas including the dining rooms, lounges and bathrooms. The communal lounges, dining rooms, hallways and corridors are due to be redecorated and refurbished this year. The manager told us that they were waiting for paint charts and colour swatches to show the people living there what options were available. We saw that throughout the home any furniture that was looking tired and shabby had been marked for replacement. Care Homes for Older People Page 28 of 44 Evidence: Bedroom sizes are quite spacious for their stated purpose and have en suite facilities provided, communal bathing areas, showers and toilet facilities are located throughout the home. People had been supported to personalise their bedrooms with pictures and ornaments and they are able to bring items of furniture should they wish. Rooms are lockable so that they can maintain their privacy and keep their personal possessions secure. All rooms had profiling beds and two people living in the home had chosen to have a divan bed. Good quality matching bedroom suites, lounge chairs and a small tables are provided in each room. A small number of bedrooms are shared, which provide adequate space and good screening facilities in order that peoples privacy and dignity is respected. Bedrooms were bright and clean with matching soft furnishings, the manager told us that some of the lampshades were outdated or broken and were going to be replaced. The maintenance operative told us that he redecorated rooms when they were vacated and also has an ongoing programme for peoples rooms to be re painted as and when required. Two lounge areas allow for people to be seated together enjoying the entertainment systems on offer and any group activities or events. Although the rooms are quite small the home has tried to set the rooms up in a homely fashion particularly down stairs where there is more space to play with. The home was purpose built by the previous owners and although most areas are suitable for the people who use the service, the home does lack space. Storage can be a problem and wheelchairs and hoists are left in hallways and in other communal areas impinging on peoples space. Incontinence pads are also stored in wardrobes and in the en suites which effects peoples personal space. There is no facility for training which is largely done in house. At present the training takes place in vacant bedrooms. The manager told us that training does not take place in communal areas such as the lounge or dining room. At the last inspection it was noted that the hairdresser was having to cut and set peoples hair in the lounge, which means that individuals privacy and dignity was compromised for both the people having their hair done and the people using the lounges/dining rooms for their stated purpose. At present the hairdresser is using one of the vacant bedrooms, however when the rooms are not vacant there will be limited space for this service to be provided. Care Homes for Older People Page 29 of 44 Evidence: We talked about the above issues with the manager, who told us that Hallmark as part of the refurbishment programme are looking at various ways that space within the home can be modified to accommodate the lack of space as detailed above and we will look at any progress in future visits. In general the overall cleanliness of the home received positive outcomes from our surveys. People living in the home felt that the home was clean and fresh. During our visit we were not aware of a general offensive odour in the home, but shortly after this inspection we were told by visiting healthcare/social care professionals that offensive odours within the home had been evident. The acting manager confirmed that regular carpet cleaning takes place and wondered if any past deposits of urine etc may have been agitated during this process and said this is possibly what had been smelt in the past. We did note that several chairs had staining on the seats, this may have been caused by people having been incontinent, but as we mentioned above many pieces of furniture had been identified as requiring replacement. This staining and other smells may originate from problems discussed within the health and personal care outcome within this report where there have not been enough staff to attend adequately to peoples toileting needs. We will continue to monitor this along with infection control practices generally, in future visits to the home. Care Homes for Older People Page 30 of 44 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 home does not promote staffing levels and skill mix of staff in order to help ensure that people needs can be met. The recruitment policies and procedures set up in the home should help ensure that people living in the home are supported and protected. The training provided to staff should help ensure that staff have the skills and resources to meet peoples needs. Evidence: We spoke with the manager towards the end of the first day of our visit about current staffing levels in the home. We had gathered strong evidence that peoples needs were not being met due to the high dependency levels and the lack of staff deployed to be able to meet those needs. Having had previous management experience in care homes the manager told us that she understood that staffing levels should be indicative of the needs and levels of care required and confirmed that levels of staff should increase when dependency levels increase. Only one out of eight people living in the home confirmed in our surveys that staff are Care Homes for Older People Page 31 of 44 Evidence: always available when needed, the remaining seven people felt that staff were sometimes available. We asked health and social care professionals in their surveys, How do you think the service can improve?. They told us that there had been a subsequent increase of people living in the home with more challenging medical needs with increased demands for care. Concerns were expressed regarding the homes general organisation and whether there were enough staff to meet the increased needs of people living there. Through observation, discussions with people living in the home, the manager and staff it was evident that there were major shortfalls in providing personal care in the mornings and that fluid and nutritional needs were also compromised. We saw on both days of our visit that some people had still not received any personal care by 1.40pm, many people were being brought down for lunch after 12.30pm and looked like they had just woken up. Staff confirmed that this was a regular occurrence. Many staff felt that they rushed when delivering personal care and that they had to cut corners in order to get all the work done. Other staff felt that it was better to take your time and not rush people but this meant that some were often offered lunch having only just got out of bed. Comments from staff included, It is becoming a regular occurrence that all residents are not washed and ready until 12.30pm, Staff are sometimes under pressure due to the client type and not the right amount of staff on duty, and Residents are being kept waiting for long periods to use the toilet as the staff are too busy. We examined some of the dependency levels of individuals by looking at their care files. We also looked at the information given to us in the AQAA. The information told us that at least thirty people needed help with washing and dressing, twenty nine people were incontinent of urine and/or feaces, thirty people required two carers to help with their care, just under thirty had a physical disability and required help with mobility and eighteen required help, supervision or prompting to eat their meals. An immediate requirement was made at the end of the first day of the inspection to increase the staffing levels in order to meet peoples needs effectively as prescribed in their care files. On the second day of our visit staffing levels had been increased by two carers, however we saw no improvement in the care being delivered in a timely acceptable manner. Care Homes for Older People Page 32 of 44 Evidence: We discussed this with the Area Manager and Manager at the feedback session at the end of day two. We were told that some of the problems were related to lack of direction from the RGNs on the floor and that organisation of the workload and allocation needed to be reviewed, for example, carers should be allocated people to care for and work in pairs. We have requested that Hallmark send us an action plan providing us with details on how they intend to make proper provision to ensure that the health and welfare of people living in the home is met. A sample of staff recruitment records were looked at and showed us that the home follows a good recruitment procedure. This will help ensure that the right people are employed to work at the home, and people living in the home will be further protected. Records contained completed application forms with a full employment history, two written references and Criminal Records Bureau (CRB) disclosures. Qualified staff nurses, are required by law to register annually with the Nursing and Midwifery Council (NMC) to be able to practice, these registrations are checked annually by the manager to ensure that the staff have done this. There is an induction programme, which covers all mandatory training, including Fire, Manual Handling, Health and Safety and the Protection of Vulnerable Adults. The home has a mentor system where all new staff are linked with and shadow a senior staff member during each shift to enable continuity and continued training throughout the induction process. One health care professional told us, I have some concerns over the palliative care provision by the home. Recent experience has highlighted the need for further training in palliative care and other complex medical needs. The manager told us that since commencing her post she has identified shortfalls in additional training. She has researched and made extensive plans for the next year with regards to accessing more training and development for staff tailored to individual needs. The manager and staff are pleased to be attending future training relevant to the care needs of the people they are looking after and those relevant to the roles they perform. We will look at the courses the staff have attended and the effectiveness of the training received at the next visit. Care Homes for Older People Page 33 of 44 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although we have identified serious concerns detailed throughout this report we are satisfied peoples needs and best interests are central to the management approach in the home. Good accounting methods are adopted and policies and procedures are followed correctly when handling peoples personal money so they can be sure their finances will be managed correctly. Staff feel that they receive supervision and support that is appropriate to their roles and responsibilities in the home. The health and safety checks within the home will help protect the people who use this service. Evidence: The manager was appointed six months ago just after the last inspection where the Care Homes for Older People Page 34 of 44 Evidence: home was rated poor, the home has also appointed a full time deputy manager. Throughout our visit the manager demonstrated good, effective leadership and management skills that relate to the aims and purposes of the home. The manager has submitted her application to CQC to be the Registered Manager of the home and is waiting for her interview appointment with us. Although this inspection has identified serious breaches of regulations and the consequent impact on the quality of care being delivered to people in the home, they have with the support of the staff team worked extremely hard since the last inspection in meeting previous requirements and in improving some of the outcomes for people who use the service. She has shared various new initiatives with us in order to further develop standards for the people who use the service. The manager and staff are developing into a stable team that supports a commitment to providing quality care for the benefit of the people living in the home. Staff made very positive comments about the manager and deputy and that things had been improving since they had been in post. The home completes an annual audit to assess the satisfaction of people with regards to the service that the home provides by asking them to complete surveys. The results and comments from the surveys were generally very positive. Information from the surveys is collated and documented effectively, this information is on display for people to see. The results have enabled the home to identify strengths and weaknesses within the service they provide and are acted upon in their development plan for the coming year. Progress of any outcomes are discussed with the people living at the home and relatives at their meetings. As mentioned previously in the report the home completes an AQAA for us which provides us with information about where the home feels it has improved and their plans to improve in the next twelve months. The areas identified include monitoring staff performance in equality and diversity, staff training and improvements to the environment. The policy and procedure for holding peoples personal money was examined and four individual accounts were looked at. We could see that good accounting methods are adopted and receipts for sundries were available. At the last inspection we found that the home did not have a consistent system in place for supervision of staff. There is now an annual appraisal process, which ties in with the supervision arrangements. We saw an established formal recorded Care Homes for Older People Page 35 of 44 Evidence: supervision procedure for all staff. Discussions include things relating to the people who live in the home, work issues, staff issues, personal development and training. The manager told us that in general staff felt that the sessions were useful although some didnt quite see the value of them, the manager has introduced other ways of supporting and supervising staff whereby they feel that the sessions are more productive, for example group supervisions where people can share information, knowledge and ideas and practical supervisions. We spoke with the maintenance operative and looked at some of the Health and Safety records in the home. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms, equipment and emergency lighting. The homes records showed all necessary service contracts were up to date including, gas and electrical services and the passenger lift. The fire logbook evidenced compliance to the weekly, monthly and annual checks alongside records of staff training and drills completed. Care Homes for Older People Page 36 of 44 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 37 of 44 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 8 12 People living in the home are 02/04/2009 potentially at risk and their health, safety and wellbeing is compromised. This is due to high levels of individual health and social care needs. The inadequate levels of staff in place means that the peoples needs are not met effectively. Provision must be made to adjust the levels of care staff throughout the home between 8AM-8PM, effective from 8AM on 02/04/09 By increasing the staffing levels people living in the home should be able to receive the care delivered to them as prescribed in their individual care plans in an effective save way. 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 Person must 08/07/2009 ensure that there is a written care plan that shows how each need is to be met and ensure that these are kept under review. This relates to shortfalls in the instructions within care Page 38 of 44 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 plans for wound care, pressure relief care and the monitoring of nutritional risk. This is so that the guidance given to all staff is clear and specific, thus avoiding any confusion in its interpretation through vague and non specific wording or because the care plan has not been updated following changes in care. 2 8 17 The Registered Person must 08/07/2009 make suitable arrangements to ensure accurate records are kept of peoples conditions, their healthcare and nutritional care. This is so that an accurate audit trail of someones care can be demonstrated and inspected by other healthcare professionals if required. This is also necessary so that qualified nurses meet their responsibilities under the Nursing and Midwifery Council Code. 3 8 18 The Registered Person must ensure staff are appropriately trained to be able to carry out their work competently. This relates to 08/07/2009 Care Homes for Older People Page 39 of 44 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 completion of fluid intake charts correctly and the use of pressure relief equipment. Accurate records of peoples fluid intake enables the appropraite staff to reach a decision about the degree of risk the person is in, how much further support and supervision in this area is required, what other healthcare factors need to be considered and helps demonstrate that staff are giving support and monitoring intake. A good understanding of why and how pressure relief equipment should be used correctly will help reduce the risk of people developing pressure sores through poor practice. 4 8 12 The Registered Person must conduct the home in such a way that promotes proper provision of peoples health and welfare needs. This is relates to peoples fluid intake, some nutritional needs, personal hygiene needs, continence needs, pressure care and their dignity. 08/07/2009 Care Homes for Older People Page 40 of 44 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will help people get the care they require and the appropriate level of supervision in order to keep them healthy or at least to avoid their health deterioating as a result of poor care. 5 9 13 When medicines are 08/07/2009 administered to people living in the home you must keep complete and accurate records about the medication. This particularly refers to always recording the actual dose given where a variable dose is prescribed and to keeping records about all medicines received into the home when people are first admitted. This is to make sure that all medicines are accounted for and that people living in the home receive the correct levels of medication and are not at risk of mistakes with medication because of poor recording arrangements. 6 9 13 Review all medicine records 08/07/2009 for people living in the home to make sure that for all medicines prescribed with a Care Homes for Older People Page 41 of 44 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 direction when required there is clear and detailed written guidance available to staff on how to reach decisions to administer. Also include how staff are to reach the decision to administer the medicine or a particular dose in accordance with the provisions of the Mental Capacity Act 2005. This particularly relates to some care plans not including all medicines prescribed when required or some not including enough information to guide staff. This will help to make sure that there is some consistency for people in the home to receive medication when necessary and in line with planned actions. 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 9 Make sure all of the homes medication policy and procedures are easily available to staff and that any local information specific to this home is also included. When medicines are administered to people living in the home via a syringe driver make sure that all registered nurses who are responsible for the management of this treatment have up to date training (by a professionally Page 42 of 44 2 9 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 recognised trainer) in the setting up and use of syringe drivers. This is to help make sure of the health, safety and wellbeing of people living in the home is maintained when this type of device is in use. 3 4 9 9 Arrange to see and check all prescription forms in the home before they are sent to the pharmacy for dispensing. Write the date on all containers of medicines when they are first opened to use to help with good stock rotation in accordance with the manufacturers or good practice directions and to help with audit checks that the right amount of medicines are in stock. Hours need to be deployed so that peoples lifestyles match their expectations and preferences. They must be satisfied that their social, cultural, religious and recreational needs can be met. The homes refurbishment process must look at ways of utilising space in the home so that people living maintain, privacy, dignity and dont have their personal space impinged upon. 5 12 6 19 Care Homes for Older People Page 43 of 44 Helpline: Telephone: 03000 616161 or Textphone: or 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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