Inspection on 22/10/09 for Cornwallis

This inspection was carried out on 22nd October 2009.

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

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

Other inspections for this house

Cornwallis 11/02/10

Cornwallis 28/07/09

Cornwallis 23/10/08

Cornwallis 02/11/07

Cornwallis 23/05/07

Cornwallis 22/05/06

Cornwallis 24/02/06

Cornwallis 05/09/05

Cornwallis 03/03/05

Cornwallis 20/09/04

Cornwallis 08/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report Care homes for older people Name: Address: Cornwallis Trewidden Road St Ives Cornwall TR26 2BX     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: Diana Penrose     Date: 2 2 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Cornwallis Trewidden Road St Ives Cornwall TR26 2BX 01736796856 01736797143 cornwalliscare@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Cornwallis Care Services Limited care home 51 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Cornwallis Nursing Home is a detached property located above the town of St Ives, Cornwall. It is a three-storey dwelling and is situated at the top of a hill. The home offers nursing care for up to fifty-one elderly residents with a dementia or mental health problem. Residents accommodation is spread over three floors. Private bedrooms are shared or single, with bedrooms on the first floor having en suite provision. There are two communal lounge / dining areas, plus a conservatory, which has sea views. All rooms have call bells and assisted bathing facilities are provided. The garden area is accessible to residents. There are opportunities for socialising and visitors are openly encouraged. Information about the home is available in the form of a residents guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from 530 to 750 pounds per week according to the manager, who supplied this information during this inspection. Additional charges are made in Care Homes for Older People Page 4 of 38 Over 65 51 51 0 0 2 3 1 0 2 0 0 8 Brief description of the care home respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Two Regulatory Inspectors visited Cornwallis Nursing Home on 22 October 2009 and spent nine hours at the home. This was a key inspection and an unannounced visit. The focus was on ensuring that residents placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection 34 people were living in the home, 2 of these were receiving respite care. The methods used to undertake the inspection were to meet with the manager, staff and residents to gain their views and information on the services offered by the home. Records, policies and procedures were examined and the inspectors toured the building. The manager returned an Annual Quality Assurance Assessment (AQAA) which was used to inform this inspection. The Manager did not receive surveys from the Care Quality Commission. This report summarises the findings of this key inspection. Care Homes for Older People Page 6 of 38 The management of this home are aware of the areas that need to be improved. Historically they have made improvements but have not consistently maintained the changes they have put in place. There is a new manager in post who intends to register with the CQC in the near future, she appears to be enthusiastic in her role and feels supported by the Operations Director and Facilities Manager. The manager is aware that there have been breaches of the Care Home Regulations 2001 and these were discussed during the inspection. She has agreed to ensure that shortfalls are addressed however requirements and recommendations have been set. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: The registered person must ensure that the home is suitably managed and that there is stability and leadership for staff. There must be a manager in post who is registered with the Care Quality Commission. Care Homes for Older People Page 8 of 38 Ensure the care plans are more detailed to direct staff on the specific care to be provided. The scoring system of risk assessments undertaken needs to be included in the care plans as it has an impact on the care provision. It should be clear who is involved and how consent is gained for people using restraints such as bed rails. Ensure staff converse with residents and offer reassurance when using equipment such as hoists. Staff should also interact with residents and respond to any agitation or anxiety. They should also ensure that they talk to residents and provide them with suitable activities to prevent them becoming bored. Make sure that the medicines keys are not left in the trolley locks but are held with a person authorised to hold them. Make sure that a copy of the guidelines for the use of medicines in social care is available for staff to refer to. Make sure that social activities take place each day that are suitable for each resident, this does not have to be organised games and so on, it can be reading to them or one to one time for example. Ensure that records are kept of the food offered to / eaten by residents each day. Ensure the cooks receive relevant training on preparing and cooking for diabetic residents and any others on special diets. Ensure the environment of the home is improved to make it a pleasant homely place to live in. Ensure the wet room facility is completed and the other bathing facilities are reviewed to ensure suitability for the elderly frail and to provide homely bathrooms. The registered persons must also ensure that toilet facilities are not locked so that residents can access them when they need to. Offensive odours should be eliminated to make the home a pleasant place to live and work in. Ensure that there are sufficient staff on duty to meet the needs of people using the service, in particular at mealtimes when assistance is required. The registered person must ensure that appropriate checks are made prior to staff being employed in the home, for example POVA, CRB and references. The management team must ensure that new staff receive appropriate induction training when they commence work at the home. This should be in line with the Skills for Care standards when employing care staff. Ensure that all staff receive regular statutory training and training relevant to their role and client group. Ensure that suitable quality assurance systems are in place to continually monitor and improve the services provided. Meetings need to be regular to enable staff, residents Care Homes for Older People Page 9 of 38 and families to air their views. Ensure that the policy for the management of service users money and financial affairs is reviewed and updated so that staff are clear on the processes used in the home and what the out of hours arrangements are. Ensure at all times that the home is safe and free from hazards by making sure that relevant health and safety checks are carried out and potential risks are assessed and steps are taken to eliminate them. 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 10 of 38 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 38 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are assessed prior to admission to the home; to ensure that the home is able to meet their individual needs. Evidence: We did not see the statement of purpose on this occasion but the manager told us it had been updated and she would need to amend her details when her registration with the CQC is completed. We were told that the assessment documentation in use is the same as before. The manager told us that she goes to visit prospective residents prior to admission on her own, she feels she is competent to do this but would take an Registered Mental Nurse with her if she felt the need. She said she prefers the resident or their relative / representative to visit the home prior to the assessment taking place, to meet her and to look around. Care Homes for Older People Page 12 of 38 Evidence: We looked at the care files of two new people using the service. One of these contained an assessment form completed by the manager which was detailed, dated and signed. The manager told us that the other person was admitted from out of the county so she did not have the opportunity to visit him. His file contained a written assessment undertaken by a person at his previous home; it was detailed, dated and signed. We were told that information about this person was also gathered by telephone but there was no evidence to support this in the file. Information about people using the service from external healthcare professionals was seen in some of the care files we looked at. Care Homes for Older People Page 13 of 38 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health care needs of people using the service are met with the support of external professionals however care plans do not consistently direct and inform care staff of the action they must take to meet residents specific care needs. There is a suitable system in place for dealing medicines in the home however the keys to medicines storage facilities were not held securely to prevent the risk of theft. The privacy and dignity of residents is usually respected. Evidence: The manager told us that the format of the care plans has been changed since the last inspection and that almost all were now in the new format. We looked at four care files and saw that the format used is the same as at one of the other homes owned by the Company. The plans are based on the activities of daily living and are an improvement on those seen at the last inspection. Some personal preferences were included in the care plans along with life histories. We discussed the plans with the manager as some areas were not specific in their direction to staff. Words such as encourage and monitor were used, for instance, with no explanation on how this should be done for the individual resident. The word regular was also used rather than Care Homes for Older People Page 14 of 38 Evidence: specific timescales. One plan stated several times that the person was unable to communicate but did not inform staff on how they should communicate with this person; verbally or non verbally. We saw that several risk assessments were carried out but that the scoring system was not always referred to in the care plans to show the relevance of the scoring and consequently the level of care to be provided. Moving and handling was recorded under the plan for mobility; there needs to be a separate plan for this to record in detail the equipment required, for example the type of hoist, the size of the sling to be used and so on. We saw risk assessments for the use of bed rails and consent forms for their use. There was no evidence as to who is involved in the decision making for the use of bed rails. The manager told us that Mental Capacity Act assessments had been undertaken by the continuing healthcare staff and mini assessments were in the care files. She said the best interest assessor came in regarding deprivation of liberties and there is now a policy in place and request forms. We saw that some people had diagnoses or issues recorded in their documentation but there was no reference to these in the care plan. Some documents were not dated. Care plans were reviewed monthly and updated. Daily records were seen and were up to date, they refer to health issues and tasks undertaken; there is little reflection on leisure, emotions, interaction and visitors. There were records that show that doctors and other healthcare professionals visit. We spoke to a Community Nurse who visited during this inspection. We were told that specialist nurses visit when asked and that some staff have a special interests as well and act as links with the Community Nurses. Equipment was seen in use for moving and handling. We observed staff using a hoist; there were no instructions or words of reassurance given to the resident and they were left suspended in the hoist for rather a long time. Pressure relieving mattresses and cushions were seen in use around the home. We were told that one person has a pressure sore that is healing and one of the nurses oversees tissue viability in the home. It concerns us that we saw some residents sat on pressure relieving cushions but they were not stood up or their position changed for over three hours. One person we were told had had a stroke in the past and we observed that she was sat in a chair leaning against the chair arm and wing, on her affected side, for over three hours. The manager told us that the annual continence assessments are due soon. She said that a carer, currently on night duty, is responsible for overseeing continence and for ensuring the correct pads are used and so on. Risk assessments were seen in the care files for those people at risk of falling and some information for staff was recorded in Care Homes for Older People Page 15 of 38 Evidence: the care plans. We observed two residents that had toe to knee bandages in situ but they were not wearing footwear, their toes were bare. Nutritional assessments were seen along with records of peoples weight. When staff interacted with residents we saw that this was good, staff were friendly and kind towards the residents. It is of concern that we observed a person who had no interaction from staff for two hours. Other residents appeared agitated and anxious but little was done to alleviate this. Many of the residents could not express their views on the service provided to them to the inspectors. The manager said she did not receive the surveys from the CQC to give to staff or relatives for us to gain their views on the service. One resident said the staff are very kind and she is well cared for at Cornwallis; she was observed comforting another resident who was agitated and crying out. Two nurses explained the medicines system to an inspector. It is a monitored dose system and medicines are only administered by registered nurses. The medicine administration and disposal records we saw were satisfactory. There was a photograph of the resident with their medicine records for identification purposes. All hand written orders that we saw on the medicine charts were witnessed with two signatures recorded. The storage of medicines was appropriate. It is of concern that the keys to the medicines trolleys were kept in the trolley locks, the keys to the controlled drugs cupboard were held on one of those key rings. The door to the medicines room was locked however the medicine keys must be held by an authorised person. The nurses told us they would deal with this straight away so a requirement has not been set at this time. We saw that the medicines fridge temperature was monitored daily and was within the safe limits. The medicines policy was available to staff and the manager told us she had updated it since the last inspection to include the issues discussed then. The Guidelines for the use of medicines in social care was not seen; the manager said she would ensure a copy is obtained and available to staff. A report written by the pharmacist and dated 19 August 2009 was seen and satisfactory. We were told that all of the nurses and one carer had received medicines training recently and certificates were awaited. This information was not included on the training matrix we saw. The Annual Quality Assurance Assessment (AQAA) told us that the manager hopes to improve relationships with the local surgery so that medication reviews are completed regularly. We saw staff knocking on doors prior to entering rooms. When residents were not in their rooms the doors tended to be locked; we saw that some doors did not have a Care Homes for Older People Page 16 of 38 Evidence: lock fitted. We were told that none of the residents have a key to their room but could have one if they were able. We did not see any risk assessments in respect of key holding. We noted that some rooms could not be locked from the inside. Screens were seen in the shared rooms. People were seen wearing clean clothes and we saw the laundry person putting clothes back in peoples rooms. Staff said that clothes are usually labelled and they dont often go astray. We saw notices on the walls of bathrooms giving information to staff; this sort of information should be held in a drawer or cupboard for staff to access and not be displayed on the walls of their home. The manager removed some notices during this inspection. We observed one resident who was moving in her chair and her blanket kept slipping; her skirt was pulled up and her bare legs were exposed, we could see she was wearing an incontinence pad. Staff did cover her after a while but this happened several times. We were told that this resident does not like wearing trousers and there is a problem keeping her covered up. Care Homes for Older People Page 17 of 38 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities are provided for 15 hours per week and some entertainers visit the home, the manager intends to develop this further to enable all people using the service to have opportunities for leisure and recreational activities according to their needs and capacities. People using the service benefit from a nutritional diet, further choices and attention to special diets will help to ensure their needs are fully met. Evidence: We spoke to the person employed to co-ordinate activities in the home. She told us she has been employed since September 2008 and works 15 hours per week on a flexible basis. She said she had been on a training course for one day, which she enjoyed and is going to attend a massage course in two weeks time. She said she also hopes to do an NVQ as well. It was evident that she has developed the activities since the last inspection and has sought the views of people using the service on what is provided. She appeared motivated in her role and seemed to know the residents well. Since the random inspection in July 2009 she has improved the individual record keeping to ensure that the date includes the year and that there is information as to what people gain from the activities and whether they demonstrate any emotional response. She told us that when the sheets are completed they are transferred to the care files. Care Homes for Older People Page 18 of 38 Evidence: The activities coordinator told us about the activities on offer and there was a monthly programme on the notice board. Activities include knitting, cooking, bingo, art and craft, flower arranging, music and movement, hand massage and 1:1 sessions. We were shown photographs of residents involved in activities. We were told that the residents made the decorations for last years Christmas tree and that work will commence on cards and decorations again soon. She told us that entertainers come in to the home, for example, a clothes shop, music for health and other musical entertainers; but these are not regular events. There have been no outings since last Christmas when a trip to the lights was arranged. We were told by staff that some people are taken to the shops occasionally and some go out with their families. During this inspection we saw a visitor with a pat dog and residents seemed to enjoy this very much. The activities coordinator was planting bulbs with some residents in one lounge but nothing was taking place in the other lounge. We were told that some people are not able to take part in activities. The television was on all day in the lounge we sat in and in the morning music was also playing. As previously mentioned there was little staff interaction in this lounge but we observed that this was better in the other lounge. There is no programme of activities for when the coordinator is not there but we were told that the new manager would like one put in place. The AQAA told us that whilst there is an activity programme this could be further improved so it is easily readable by the client group with in the home. It also states that a schedule of outings is to be planned and displayed around the home to encourage both service users and relatives to participate. We saw that visitors were welcomed to the home and the visitors book shows that the home receives regular visitors. The front door is not locked and gives access to the office and laundry areas. Visitors are assisted by a staff member to get in and out of the door to the residents area as it is secured and opened by a key pad. People were still getting up late in the morning and having breakfast. There was evidence that people can bring personal possessions into the home but some bedrooms were very bare with little to show that they were occupied. There were some records of personal preferences in the care files and food likes and dislikes were recorded in the kitchen. There was little to show that people choose when to bath or shower but staff said this is generally once a week; this seemed to be the case from looking at the care files. The AQAA told us that clear concise documentation on the individuals preferences and choices are easily accessible to care staff in the home. We saw the menu that spans four weeks, the menu was varied but there was no Care Homes for Older People Page 19 of 38 Evidence: choice of main meal. The chef told us that alternatives are available and the care staff let him know which people would like an alternative. The meal on offer was written on white boards in the lounges. We saw that it was lasagne with vegetables for lunch and we saw one person offered fried eggs instead. The chef said he does not keep a record of the meals offered/eaten and this was discussed with the manager, who agreed to address it. He also told us that there are diabetic residents but none are insulin dependant. He said they have the same diet as the other residents he does not use any sugar substitutes or special jams and so on. The manager told us that this issue was being addressed by the facilities manager. There were good food stocks in the home that included fresh fruit and vegetables. Fresh fruit salad was on the menu weekly. The chef said that cakes were homemade and chocolate cake was on offer in the afternoon as well as fresh fruit. We saw that refreshments were available in the lounge/dining rooms and we were told that some snacks are available in the kitchen overnight. We observed lunch in one lounge and saw that some people sat at a table while others sat in armchairs with a small table in front of them. It was the same in the other lounge. People seemed to enjoy the food, one resident said she always enjoys the food. Clothes protectors were used but there was little interaction from staff when putting these over residents heads. They were not all removed after the meal and we saw one resident take hers off an hour and three quarters after lunch began and put it on the floor. Appropriate assistance was given to those who needed it; plastic gloves were worn by staff. We noted that the desert was served an hour after the main meal which could mean that there were insufficient staff on duty over the lunch period. Feedback was given to the manager at the end of this inspection. Care Homes for Older People Page 20 of 38 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has suitable complaints and adult protection policies however all staff must attend suitable training in respect of adult protection to ensure that people using the service are safeguarded. Evidence: We saw that there were suitable complaints and adult protection policies in the home at the last inspection so these were not looked at during this inspection. We spoke to staff who knew about the policies and where to access them. The manager told us there have been no complaints to the home since the last inspection. She said that thank you letters and cards are held and showed us some of the recent correspondence. The Commission received concerns in relation to staffing, the lack of a manager and qualified nurses and there being inexperienced care staff on duty. Further concerns were the recruitment of staff, the assessment of prospective residents, care planning and nutritional assessments. A random inspection was carried out by two inspectors on 28/07/09 when some if the issues were substantiated. One requirement and four recommendations were set in the random inspection report; all bar one recommendation have since been met. The remaining recommendation is in progress. There have been no safeguarding issues regarding this home since the last inspection. Care Homes for Older People Page 21 of 38 Evidence: The manager told us that staff have received training in respect of abuse and that further training is in hand that will cover the Mental Capacity Act and Deprivation of Liberties as well. The training matrix we were shown had no records to show that staff had received any training regarding the safeguarding of adults. We have spoken with the Operations Director who has details of training facilitators. There is a risk assessment process for the use of bed rails in the home, this needs to be extended to other forms of restraint such as recliner chairs. We did not see any evidence as to who is involved in the decision making for the use of bedrails. Care Homes for Older People Page 22 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean but not all areas were warm, there were unpleasant odours around the building and there was a great deal of redecoration and refurbishment to be done to make it a pleasant, homely place to live in. A more varied colour scheme would enhance the appearance and benefit residents with dementia. Improvements must be made to ensure there are appropriate bathing and toilet facilities for people who are frail and disabled. Evidence: We toured the building and the manager showed us some unoccupied bedrooms on the second floor that had been refurbished and decorated. These rooms have been decorated in very pale colours. but they are an improvement on the white paint used around most of the home. Many rooms do not have bedside/over bed lighting which needs to be addressed. Some en-suite cupboards on the second floor need new doors; the manager was aware of this. The home is very clinical and institutionalised with white walls, lack of colour and lack of pictures and other decorative objects. All of the bedrooms were kept locked apart from those with people in them and those that had no locks. Some bedroom doors were alarmed as were fire exits. Staff arrived promptly when the fire doors were opened and the alarm activated. All of the bathrooms were locked; this was discussed with the manager as people using the service should be able to access the toilet Care Homes for Older People Page 23 of 38 Evidence: facilities. There were two toilets near the lounges that were unlocked and almost all residents seem to spend their time in the lounges during the day. Most of the occupied bedrooms need decorating and refurbishment. Some appeared to have had new carpets fitted but others had carpets that were stained or worn and frayed. Furniture in these rooms was generally old and in need of replacement. Many rooms lacked personalisation, colour and pictures; some of the rooms looked unoccupied. Several bedrooms felt cold although the corridors felt warm. Not all of the radiators were guarded, to prevent the risk of scalding, we were told that those without guards were turned off. We noted that a portable electric heater was in use in one bedroom with a trailing lead; this is not safe practice. There were strong urine odours in some bedrooms. We ran the hot water in several rooms and found it to be very hot, there were some signs in place indicating that the water was very hot but little evidence of risk assessment for the facilities or the people using them. Toilet and bathroom facilities are still in need of improvement. Currently assisted bath facilities are very limited, with a bath chair on several of the baths but the baths are domestic in type, and not appropriate for those who are very frail or have a physical disability. We were told that these bathrooms are not used very often. The assisted bathroom that is used regularly is very bare, painted white and again looks very clinical; it is not at all homely. We were told that this room is going to be the wet room shower as the other room is now going to be a disabled toilet. We were told that this is the next job to be done. We talked to the manager and the facilities manager about reviewing all of the bathing facilities as removing this bath would leave people with no bath or shower facility whilst work was in progress. The communal rooms were reasonably decorated and furnished. There are two lounges with dining facilities incorporated, there is no separate dining room. The nurses station in the corner of one lounge looks very clinical and takes up part of the living space. There were notice boards in the residents lounge containing memos for staff and other staff information. We saw one resident reading these; more suitable and interesting and relevant notices could be available for residents to read. Additional portable heaters were seen in use in one lounge on shelves; one above the television and one above the filing cabinet. There was an offensive odour downstairs which was unpleasant. The conservatory on the first floor was comfortably furnished and the manager told us that blinds are to be purchased as it can get very hot. She said that this room can be used independently but tends to be used for one to one sessions with residents, meetings with staff or relatives and for training. Skirting boards in the corridors were scuffed and in need of painting. Care Homes for Older People Page 24 of 38 Evidence: A new call system was being installed during this inspection which staff said would be a great improvement. The manager told us she has been in all rooms and has made a list of things that need to be done; we saw her hand written notes. A full action plan needs to be in place , with timescales to address the poor environment in the home. Improvements we were told about include a hairdressing salon, redecoration of the lounges, repair of the flat roof and rendering the outside of the home. Most of the fencing had been removed from the garden and there was temporary metal fencing in place. The manager told us that work was in progress to extend the home. We were told there had been no changes to the laundry system and dedicated laundry staff are employed. We saw one sluice with a washer disinfection the ground floor, there needs to be another facility upstairs, as there used to be in the past, for health and safety reasons. Hand washing facilities with liquid soap, paper towels and hand sanitising gel were seen in use throughout the home. We also saw that protective gloves and aprons were in use. Care Homes for Older People Page 25 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were generally sufficient staff employed to meet the needs of people using the service; however lunchtime was prolonged and maybe due to insufficient staff on duty at that time. Recruitment is generally robust but some areas require attention to ensure that appropriate checks are undertaken to safeguard people using the service. The skills for care induction programme is not in use and there is little evidence to show that training for staff has been taking place regularly to ensure staff are knowledgeable and skilled in their roles. Evidence: There has been a high turnover of staff since the last key inspection and further management changes. We were told there are not enough Registered Mental Nurses (RMN) to have one on duty at all times, however the manager said that the Registered General Nurses (RGN) have been deemed competent to be in charge of the floor. The rota showed that staff generally work twelve hour shifts, 08.00 - 20.00 and 20.00 08.00. We saw that there were two nurses (one an RMN) and five care staff on duty during this inspection. The rota showed that there are not always two nurses on duty but there are generally five care staff. At night there is usually one nurse and three care staff and we were told they stay awake. The manager told us she works from 08.00 - 16.30 Monday to Friday and sometimes works on the floor. Other staff on duty during this inspection included an activities coordinator, two kitchen staff, two housekeepers and a laundry worker. There was an administration person in the office Care Homes for Older People Page 26 of 38 Evidence: and the facilities manager came in to assist with this inspection. Staff told us they are happy working in the home and that there are sufficient staff to care for the residents. From our observations it appeared that there were not enough care staff to cover the lunchtime workload. We also observed that nursing staff did not get involved in assisting care staff with care tasks. Six staff files were inspected, one person employed since April 2009 had not had a CRB check undertaken by Cornwallis Care Services. The CRB in her file had been undertaken by another employer. There was no evidence of the supervision arrangements for this person in the file and she was not supervised during this inspection. One file for a new employee lacked a reference from her previous employer; another had a reference marked To whom it may concern with no evidence that this was followed up with the referee. No interview records were seen and there were no job descriptions in the files. The only training certificates in the files were from previous employment. These issues were discussed with the manager. The AQAA told us that recruitment and retention of staff has improved. We were told that eleven of the sixteen care staff have an NVQ qualification at level 2, in care (69 ). We were also told that two of these staff are qualified to level 3 and that five are working towards level 3. We saw completed induction checklists in staff files but there was no evidence that the Skills for Care induction standards are still in use. We were shown a training matrix which recorded mainly recent training. It showed that all bar six staff have undertaken moving and handling training in the past year. Staff told us that more moving and handling training was imminent and we saw a memo that listed certain members of staff and stated they must attend. The matrix showed that eighteen staff have received health and safety training in the past year. Only one of the kitchen staff has food hygiene training recorded and this was done in 2007, some of the care staff have food hygiene training recorded. Seven staff have first aid training recorded. Six staff have infection control training recorded for the past year and only one person has fire training recorded for this year. There is no evidence on this matrix of any training taking place in respect of adult protection, Mental Capacity Act, Deprivation of Liberties, equality and diversity, challenging behaviour or dementia awareness. The AQAA states that the manager intends to promote and facilitate in depth dementia training. No training and development programme was seen for staff although we were told that supervision was taking place and some training needs had been identified. The manager told us that training had not been kept up to date when she arrived and she has identified priorities and is booking courses for staff. Care Homes for Older People Page 27 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements for home have lacked stability for a significant time; a manager is now in place who intends to apply for registration with the CQC, she hopes to improve systems in the home and establish stable leadership for the staff. Some Quality Assurance monitoring takes place but the system needs to be developed. There is a system for dealing with residents personal money but the policy does not reflect the processes in place. Statutory training has been lacking and some health and safety issues need to be addressed. Evidence: The registered manager resigned in August 2008. There have been various arrangements in place for the running of the home since then. A new manager has been in post for seven weeks and she told us that she is going to apply to the Care Quality Commission for registration. She said she is a Registered General Nurse with previous management experience. She told us she had successfully completed the Leadership and Management for Care Services Award. There was a copy of her CV in her file but no copies of any certificates for her nursing or management qualifications. Care Homes for Older People Page 28 of 38 Evidence: She told us that she has no job description as yet and told us she is working a probationary period. She said she works alongside the Facilities Manager. She also said she keeps herself up to date on issues related to the client group. Staff told us that the new manager seems to be settling in well. One person said she has lots of ideas and is trying to get things changed. Staff said they are hopeful that the manager will stay as most managers have changed things and then left. It is clear that there are areas that require improvement and they stem from before the recruitment of the current manager. The environment and the bathing facilities in the home have required improvement for a considerable time; some efforts have been made but the issues have not been fully addressed. Recruitment of staff has not always been robust with appropriate checks undertaken and appropriate staff training, including induction training has not been taking place. We have observed residents sat in chairs for long periods of time during this inspection without being moved and with little interaction from staff. Some activities take place but these are limited to the more able residents and restricted due to the number of hours allotted. The facilities manager told us she is responsible for housekeeping, catering, maintenance and the management of residents money. We were told that the Operations Director visits the home regularly and is supportive to the management team. The manager told us that she had sent quality assurance questionnaires to approximately twenty five relatives, she has had five returned and we saw that these were positive about the services provided by the home. We were told there is no annual development plan for the home. The manager said she has undertaken an audit of the medicines and the environment. She also said she has action plans for care planning, pharmacy, supervision and a keyworker system. We were told that a relatives meeting took place at the beginning of October 2009 and that staff and nurses meetings are starting to take place. The manager said she intends for these to be held on a regular basis. The Operations Director compiles reports in line with regulation 26 and sends them to the Commission, but this is not on a regular monthly basis. The manager provided an Annual Quality Assurance Assessment (AQAA) prior to this inspection which was in reasonable detail considering the length of time she has been in post. The information provided was supported by evidence seen in the home. We were told that the dataset section of the document was sent to the Commission by post as there was a problem with the online form. This has not yet been received by the inspector and a copy was not available in the home during the inspection. We were given a copy of the policy for the management of service users money and Care Homes for Older People Page 29 of 38 Evidence: financial affairs. The document was signed by the manager and dated as being reviewed on 09 September 2009. The policy refers to the CSCI which needs to be amended. The policy also refers to what staff should do, not what they actually do and this has been reported at previous inspections. It states that staff will ensure that safeguards are in place, but does not specify what these are or how they are managed. It refers to the manager holding the safe keys; it does not specify this is the facilities manager. The policy needs to be reviewed again to state the actual processes used in the home and who holds responsibility. We were told that none of the residents control their own money and the home does not manage any bank accounts on their behalf. We were told that the home holds personal money for some people so that they have access to cash to buy personal items. Money was seen stored in the safe in separate wallets. The monies of five people were checked and were correct with the records. Varying amounts of money are held there is no stipulation in the policy as to how much should be held or how much the safe is insured to hold. There was an audit sheet for each person and two members of staff signed and dated the transactions. Receipts were seen for purchases and were numbered for auditing purposes. The system for the purchase of toiletries for residents was changed while we were in the home. Money is now taken from the residents wallet prior to shopping and recorded; the change and individual receipt is returned and double signatures recorded on the transaction sheet. The facilities manager said she holds the safe key and would come into the home out of hours if needed. She said the manager would also have a key when she is comfortable and has got the nursing side done. The fire records were examined and the last fire alarm test was dated 29/01/09. Other checks, including the emergency lighting were recorded as taking place weekly, give or take a day or two, the last recording was 17/10/09. There was one record of a fire drill and it took place on 29/09/09. Ten staff were recorded as attending. The record stated that the nurse in charge was unaware of the correct procedure for locating the fire zone. Fire training records show that only one person has attended training in 2009. We were told that the Facilities Manager is organizing fire training for staff. As reported in the previous section not all statutory training has been kept up to date and staff have commenced work prior to receiving statutory training. Service and maintenance certificates were seen and most were up to date. The last testing of small electrical appliances was dated 29/10/08. There was no record of any Care Homes for Older People Page 30 of 38 Evidence: asbestos or Legionella testing taking place. Hot water temperatures were recorded monthly for baths and weekly for handbasins. As previously mentioned the hot water in the home is very hot. Some radiators were observed to be unguarded and all radiators were turned off, portable heaters were seen in use with leads trailing. The facilities manager said she has the maintenance plan which included re-decoration in the home, rendering of external walls, wet room facility and new call system. A maintenance book was seen for staff to report jobs to be done. We were told that the maintenance person works five hours a day. Care Homes for Older People Page 31 of 38 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 18 12 All staff working in the home 25/01/2010 must receive relevant training in respect of safeguarding adults. To ensure that they are knowledgeable on what to do to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 2 19 23 The home must be suitably heated. To ensure that ambient temperatures are maintained and people are kept warm. 07/12/2009 3 21 12 Appropriate bathing facilities 29/03/2010 must be provided, that are suitable for elderly people including those requiring assistance. Care Homes for Older People Page 33 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure peoples health and welfare is provided for in an appropriate manner. 4 29 19 The recruitment system 30/11/2009 must be reviewed and the vetting and selection of staff made robust, all of the documents required by legislation must be held in the home and appropriate supervision arrangements must be in place for new staff. This will ensure that new staff have been assessed as fit to work in the care home and that steps have been taken to safeguard people using the service. 5 30 18 All staff must receive training appropriate to the work they perform and the client group including structured induction training. To ensure that at all times suitably qualified, competent and experienced persons are working at the care home. 29/03/2010 Care Homes for Older People Page 34 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 6 38 23 All staff working in the home 29/01/2010 must receive suitable training in fire prevention and fire drills must take place at suitable intervals. This will ensure so far as practicable that staff know what to do in the event of a fire to protect people using the service, staff and visitors. 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 7 Care plans should be further reviewed to ensure they include all information about the persons care needs and they fully inform and direct staff on the individual care provision People using the service who cannot mobilise independently should have the opportunity to move frequently to ensure that they have exercise and to prevent the risk of pressure sores developing People using the service should be appropriately dressed to ensure their privacy and dignity are respected. Activities should be increased to ensure that all people using the service have the opportunity for stimulation through leisure and social activities that meet their needs and capacities. Training should take place as necessary to ensure that special diets can be provided for those that need them. The home should be decorated with more use of colour and rooms should be personalised to make it less clinical and more homely for people using the service. 2 8 3 4 10 12 5 6 15 19 Care Homes for Older People Page 35 of 38 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 7 8 19 19 The nurses station should be reviewed to ensure that it does not encroach on the residents living area. A thorough environmental audit of the home needs to be undertaken with a detailed action plan developed, that includes timescales for actions to be taken and work to be done. This will ensure that the home is a pleasant, safe place to live and work in. The wet room shower facility should be completed as soon as possible. This will ensure the needs and choices of elderly frail people can be met Toilet facilities should not be kept unlocked to enable residents to use the facilities when required. There should be a second sluicing facility with a washer disinfector situated upstairs. This will help to eliminate health and safety risks to staff having to take all equipent to be disinfected to the ground floor. Recruitment interview records should be maintained to ensure that recruitment is fair and that issues arising have been discussed. A training and development plan should be in place to ensure staff receive training appropriate to them and relevant to meeting the needs of people using the service. The manager should have a job description to ensure she knows what her role entails and what is expected of her. The manager employed should apply for registration with the CQC, to fulfil legal requirements and to give stability to the management of the home. An annual development plan should be developed to indicate what the home intends to improve over the next year The poilcy for the management of service users money and financial affairs needs to be reviewed and updated to ensure it directs staff on the processes in use in the home. Rooms should be centrally heated and portable heaters not used. If used in an emercency situation thorough risk assessments should be in place to reduce the risk of fire, burns and falls by tripping on leads. 9 21 10 11 21 26 12 29 13 30 14 15 31 31 16 33 17 35 18 38 Care Homes for Older People Page 36 of 38 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 19 38 Unguarded radiators and should be risk assessed, they should be guarded or thermostatically controlled to reduce the risk of burning rather than not be used and the rooms be cold. Staff should receive regular statutory training, for example infection control, food hygiene, fire, health and safety and moving and handling to comply with the law and to ensure staff are updated on their knowledge and skills to protect people using the service. 20 38 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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