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Inspection on 10/05/10 for Deerwood Grange Nursing Home

Also see our care home review for Deerwood Grange Nursing Home for more information

This inspection was carried out on 10th May 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What the care home does well

People are supported to keep in touch with their family and friends so they can maintain relationships that are important to them. Relatives can visit at any time and are made welcome. Many of the staff that work there have worked there for a long time so they know the people living there well. Activity staff are employed so that people have an opportunity to be engaged in activities that they enjoy. There is a large garden at the back of the home so that people have a nice view from their lounge and if they want to can spend time outside.

What has improved since the last inspection?

Staff follow the advice of health professionals to ensure that people`s health needs are met. Staff were better at moving people regularly in to a suitable position so that the risks of their skin becoming sore are reduced. Incidents that affect the safety of the people living there are being reported more often to ensure that people are safeguarded from harm. New furniture has been ordered so the home is safe and more comfortable for people to live in. Staff are having more training and support so they know how to support the people living there to meet their needs and ensure their well being. Staff have had fire safety training so they know how to support the people living there if there is a fire. New fire safety equipment has been bought to help staff to fight a fire if needed. Fire risk assessments are being written with the help of the fire officer. This helps to ensure that the risks of there being a fire are minimised and staff know how to support individuals in an emergency. A new manager has been recruited who has the skills and experience to manage the home in the best interests of the people living there.

What the care home could do better:

Staff must have the information they need so they know how to support the people living there to meet their needs. Staff must monitor people`s weight to ensure they have no underlying health needs, which could affect their well being.Staff must ensure they administer creams appropriately to ensure that the risks of people`s skin becoming sore is reduced. People must be moved safely to avoid risk of injury to them and to staff. Medication must be given to people as prescribed to ensure their health and well being. People`s medication should be reviewed to ensure that it helps their well being and they are not over sedated. Staff should have more training in what medicines are prescribed for and how to manage people`s behaviour without the use of medication. Staff should support people in a way that maintains their dignity, so ensuring their well being. All the people living there should be given the opportunity to take part in a variety of activities that they enjoy. Clearer records of food eaten by each person should be kept to ensure they have a varied, nutritious diet and the foods they like to ensure their health and well being. All incidents that affect the well being of the people living there must be reported to us to ensure that people are safeguarded from harm. The environment should be homely, comfortable and clean for people to live in. Records of how staff are recruited must be available in the home to show that `suitable` people are employed to work with the people living there. Agency staff should have an induction to ensure the safety and well being of the people living there and staff. Hazardous substances must be locked away to reduce the risks of harm to the people living there. Hoists must only be used to transfer people and all staff must be competent in using these for the safety of them and the people living there. A representative of the provider must visit monthly to show that action is being taken to improve the home for the people living there.

Key inspection report Care homes for older people Name: Address: Deerwood Grange Nursing Home 22 Wentworth Road Four Oaks Sutton Coldfield West Midlands B74 2SD     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: Sarah Bennett     Date: 1 0 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Deerwood Grange Nursing Home 22 Wentworth Road Four Oaks Sutton Coldfield West Midlands B74 2SD 01213550060 F/P01213550060 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): BAMH (MIND) Name of registered manager (if applicable) Type of registration: Number of places registered: care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 23 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 23 Mental disorder, excluding learning disability or dementia (MD) 23 Date of last inspection Brief description of the care home Deerwood Grange is a large detached adapted nursing home in the Four Oaks conservation area of Birmingham. The home is approached from a driveway, and is set back from the main road. To the rear of the building are large gardens, which are utilised by the people living there in good weather. The building work to extend the Care Homes for Older People Page 4 of 36 Over 65 0 0 23 23 2 4 1 1 2 0 0 9 Brief description of the care home home has provided most people with single bedrooms apart from one that is shared. There are two large lounge areas, and a large dining room. The extension has also provided a new laundry, a disabled toilet and down stairs shower room. The upstairs bathroom has been converted into a new shower room. There is a new staircase to access the first floor of the extension, access to the first floor using the passenger lift is via the original building. The home provides nursing care to people over the age of sixty-five with a diagnosis of dementia and/or mental health issues. The home is staffed 24 hours a day and there is always a qualified nurse on duty. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is zero star. This means the people who use this service experience poor quality outcomes. This inspection was carried out by two inspectors over one day, the home did not know we were going to visit. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered including notifications received from the home. The home is required to tell us about incidents and accidents that happen there. The home returned to us their Annual Quality Care Homes for Older People Page 6 of 36 Assurance Assessment (AQAA) when required. This provides information about the home and how they think it meets the needs of the people living there. It also provides some numerical information about the service. We case tracked the care received by two people living there. This involved establishing individuals experience of living in the care home by meeting and talking with them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked at parts of the home and a sample of care, staff and health and safety records. The people living there, some of their relatives, the manager, the operations manager and staff on duty were spoken with. Due to their needs many of the people living there were unable to tell us what it is like to live there. To help us find this out we used the Short Observational Framework for Inspection (SOFI) tool. This involved observing four people in the lounge for one hour and how staff and the other people living there interacted with them. Following our visit we continued to have concerns about the safety of the people living there and the management of the home. We shared our concerns with social services and the contracts department. A formal suspension of contracts was placed on the home on May 13th 2010, which means they cannot admit any other people to the home. A contracts monitoring officer from Birmingham City Council will visit the home to monitor the progress being made in response to this. We served a Statutory Requirement Notice on 19th May 2010 regarding care plans, skin care and medicine management due to breaches of regulations 12 and 13. the compliance date for this is 30th June 2010 and we will be visiting to monitor compliance with this. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: Staff must have the information they need so they know how to support the people living there to meet their needs. Staff must monitor peoples weight to ensure they have no underlying health needs, which could affect their well being. Care Homes for Older People Page 8 of 36 Staff must ensure they administer creams appropriately to ensure that the risks of peoples skin becoming sore is reduced. People must be moved safely to avoid risk of injury to them and to staff. Medication must be given to people as prescribed to ensure their health and well being. Peoples medication should be reviewed to ensure that it helps their well being and they are not over sedated. Staff should have more training in what medicines are prescribed for and how to manage peoples behaviour without the use of medication. Staff should support people in a way that maintains their dignity, so ensuring their well being. All the people living there should be given the opportunity to take part in a variety of activities that they enjoy. Clearer records of food eaten by each person should be kept to ensure they have a varied, nutritious diet and the foods they like to ensure their health and well being. All incidents that affect the well being of the people living there must be reported to us to ensure that people are safeguarded from harm. The environment should be homely, comfortable and clean for people to live in. Records of how staff are recruited must be available in the home to show that suitable people are employed to work with the people living there. Agency staff should have an induction to ensure the safety and well being of the people living there and staff. Hazardous substances must be locked away to reduce the risks of harm to the people living there. Hoists must only be used to transfer people and all staff must be competent in using these for the safety of them and the people living there. A representative of the provider must visit monthly to show that action is being taken to improve the home for the people living there. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We did not assess this outcome area during this visit so a judgment cannot be made. Evidence: At the last key inspection in November 2009 the manager told us that they were updating the statement of purpose and service user guide. We did not look at these at this inspection. On March 10th 2010 the provider agreed that they would not admit anyone to the home without first talking to us because of our concerns and that of the the placing authority about this home. Therefore since then the home has not admitted any people. There were nineteen people living there, so four vacancies. We did not look at the assessment process during our visit. Since this visit we have met with the local authority contracts department and representatives from the Primary Care Trust (PCT). At that meeting it was agreed to Care Homes for Older People Page 11 of 36 Evidence: formally suspend the contract with this home. This means that there can be no further admissions until the required improvements are made. Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and health care needs of the people living there are not always met, which could impact on their well being. Evidence: We looked at the records for two of the people living there. The manager said that one persons care plans and risk assessments were being updated. This meant that their records had been split into two files, one that was being updated and one that showed staff how to support the person to meet their needs. The file that was being updated only included some blank forms and some information that had been copied from the other file. In the file that staff were using there was some old information, some of which was dated 2005 and no longer seemed applicable. These were at the beginning of the file. This should be removed so that staff do not get confused as to how to support the person now. This is particularly important as due to staff vacancies agency staff work at the home. We found that it would be difficult to find the current information as to how to support the person. Care Homes for Older People Page 13 of 36 Evidence: Some care plans had been updated. Some of these included more detailed information as to how to support the person. However, some still lacked detail. For example, one persons care plan for continence stated that staff needed to monitor the person for signs of urine infection. It did not state how staff should do this or what signs they would be looking for. A care plan for stimulation and relaxation stated what activities the person liked and enjoyed but not how staff are to support them to do these. One persons care plan for how to support them with their personal hygiene stated their oral hygiene needs should be met. Their previous care plan stated that the person wore dentures and these should be cleaned but this information had not been transferred to the current care plan. This would be helpful to staff so they know how to meet the persons needs in relation to their oral hygiene. We found for one person that staff had noticed when their skin was becoming sore. Staff had informed other professionals of this so that the person got the health care support they needed. This is an improvement from previous inspections and helps to ensure that peoples needs can be met. However, the persons care plans did not show staff how to care for the persons skin on their hands to help prevent them from being constricted. This could mean that staff do not know how to care for all the persons needs. One persons records showed that the tissue viability nurse had visited them to ensure that staff were supporting them appropriately to reduce the risk of their skin becoming sore. In their records were previous guidelines which had now been updated. These should be removed so that staff do not get confused as to which ones to follow. The persons updated care plan stated that staff should see the detailed tissue viability care plan but it was not clear where this was. We saw records that showed that people were being turned regularly and that people were positioned appropriately to stop their skin becoming sore. This had improved since the last time we visited. One persons records included records of measurements of their arm and leg. Staff do this as due to the persons needs they cannot be weighed on scales. However, a significant loss or gain of weight can be an indicator of an underlying health need. In April records showed that the measurement of the persons arm had increased but the measurement of their leg had decreased. There was no indication as to what the significance of this was or guidance for staff on how and where they should measure the persons arm and leg so that accurate measurements can be taken. The other persons records did not include a record of their weight. Their care plan for nutrition stated that their weight should be monitored monthly. Care Homes for Older People Page 14 of 36 Evidence: Staff write records on each person on each shift so they can monitor their health and well being. There is a separate sheet for each shift so three sheets over 24 hours. Records record when a person has a bowel movement. This is important when a person cannot communicate this, so that action can be taken to stop them becoming constipated. We tried to track for one person if there were any gaps, which could indicate they were at risk of constipation. We looked at nine days so there were twenty seven sheets to look at to find this out. This could make it difficult for staff to monitor this. We discussed this difficulty with the operations director and deputy manager at the random inspection in March. We found from the records that no bowel movements had been recorded for the person for a period of five days but no action had been taken. The person did not have a care plan for constipation and this was not identified as a risk for them. We found creams for one person in their bedroom to help prevent their skin becoming sore but there were no records in the persons bedroom or in their medication record that staff had applied these. The manager told us before the inspection that some people need to take their medication in jam or some other food to help them to swallow these. This is described as giving medication covertly, as the person may not know they are receiving tablets. The manager said that protocols were not in place for this but they would be developed with the GP to ensure that this was done in peoples best interests. For one person their protocol had not been developed so their medication was given to them with a small medication pot of water. This made it difficult for them to swallow and they were observed to be chewing the tablets. Their visitors asked staff for a glass of water which was given. Staff giving the tablets to the person were observed to give them with their fingers, which could put the person at risk of cross infection. We looked at the medication for three people. With the exception of giving creams this had improved since our last key inspection and we found that medication was being given as prescribed. A pharmacist inspector visited on March 11th 2010 and found that audits were being done to demonstrate that medicines had been administered correctly. The audit system was successful in identifying medicine errors. They also found that cream management was poor. Many creams were found on top of a metal trolley that had not been locked away. Some creams had been discontinued by the doctor but had not been discarded so could still be used. Not all external health care professional visits had been recorded, so it was not possible to see why a cream or tablet had been prescribed in all instances. Protocols that detailed when to administer medicines prescribed on a when required basis were developed and awaiting the doctor to review and sign off if accurate. The two nurses spoken with had a very poor Care Homes for Older People Page 15 of 36 Evidence: knowledge of the medicines they handled so they may not be able to fully support the clinical needs of the people they look after. A very high proportion of people currently living in the home (70 ) were prescribed anti psychotics and sleeping tablets often at the highest dose. The deputy manager stated that he couldnt manage their behaviour without medication. This is concerning as it is not in line with current thinking and guidelines and raised concern why the staff could not manage the peoples challenging behaviour without the need to sedate them. We shared this information with the lead pharmacist at the local PCT. During the SOFI observation we found that staff interacted with the people we were observing for 43 of the time. It was good that 80 of these interactions were positive, as this can help to improve the well being of the people living there. There were no negative observations so the other 20 were neither positive or negative but described as neutral. We saw that people were dressed in individual styles that reflected their age, gender and cultural background. A relative said that their relatives skin care had improved recently and they were pleased with this. We saw one persons finger nails were very dirty indicating that they needed more support with this. One person was seen wandering around with their skirt raised showing us that their continence pad needed to be changed. We assisted them to go to staff for support. Staff did support them immediately. We saw faeces in a bin in a shower room. The people living there cannot access the shower room without staff support so staff had not supported a person fully to ensure their personal care needs were met. Staff were observed talking to people in a respectful way to help ensure their well being. Care Homes for Older People Page 16 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living there are not always supported to experience a meaningful lifestyle or have a healthy diet, which could impact on their well being. Evidence: There are two activity staff employed at the home, one activity staff was working at the time of our visit. The manager said that activity staff were working on creating life histories for people so that staff knew more about the person as an individual and what they had achieved in their life. Care plans for what support the person needs to do activities and to meet their leisure needs stated what the person enjoyed doing. They did not state how staff are to support them to do these or how often they would need this support. Records sampled showed very little evidence of the person being offered any social stimulation on an ongoing basis. The records we looked at were for people who were nursed in bed so they are at a greater risk of social isolation than people who move around the home. Their care plans said they liked listening to classical music. Their records showed little evidence of this and when we visited their room, this was not playing on the radio. Staff spoken to knew what the individuals liked to do. Care Homes for Older People Page 17 of 36 Evidence: We observed one person wandering around for about an hour talking to us and visitors. They were holding table mats and seemed to want to be involved in an activity. There were no staff around for them to interact with so this interest could be developed into a purposeful activity for them that may have reminded them of tasks they used to do at home. One person said they did not like what channel was on the TV and that it was on all day. Staff were later observed changing to the Yesterday channel, which was more appropriate to the age of the people living there. Staff were observed to help one person do their knitting, which they seemed to appreciate. Staff said that some people went out with activity staff for local walks and to local cafes for a drink and snack to help them take part in the local community. Staff said that recently an entertainer had visited the home and that people had enjoyed this. They said it was planned that further activities like this would take place. Relatives said that they visit the home when they want to and are made welcome by staff. They said that the arrangements for visiting are flexible and they can also phone the home to ask how their relative is and keep in contact with them. We observed people who were able to make a choice being asked what they wanted to eat and drink. When people requested a drink this was given and staff ensured they were supported to drink it if needed. Regular hot and cold drinks were served to reduce the risk of people becoming dehydrated. Some people are not able to make choices about what they want to do or eat and drink. Records did not always clearly state what people liked or disliked so it was not always clear how staff made decisions for people. One persons food records did not show that they were having a varied and nutritious diet. In the first nine days of May where what they had eaten at tea time had been recorded they had corned beef three times and mash potato three times. Some records did not state what food the person had eaten. They stated whether they had 100 or 50 of their meal but it was not clear what amount they started with, so it was difficult to monitor their nutritional intake. Records showed and staff said that the person had a soft diet. Staff said that each type of food is separated on the plate so that food is not all blended together making it look more appetising to eat. When we visited in March 2010 to do a random inspection the dining room had been moved to a smaller room, which was used as a small lounge. It was intended that this would make it more homely and meals would be served in two sittings so that people Care Homes for Older People Page 18 of 36 Evidence: did not all have to eat together in one large group. Relatives said that this room is not suitable, as there is carpet on the floor and there is an offensive odour which does not make it pleasant to eat in. They also said that there was not enough room for people to move around in there. They said that they used to use the room as a quiet place to meet with their relative and now the only place they can do this is the persons bedroom, which is not always suitable. Relatives have discussed this with the manager who is listening to their views and agreeing with them and the people living there the best action to take. Some relatives said the food is good. The cook said that they talk to the people living there and their relatives to see what foods the person likes to help them to develop the menu. We observed this during our visit. Some relatives were there at lunch time and supported their relative with eating their meal. The choice for lunch was chilli con carne and rice or fish cakes and chips. One relative asked if there were any vegetables to go with the fish cakes but staff told them there were not. Sauce was not offered at first but was given when the relative asked. The relative was disappointed that for the main meal of the day no vegetables were offered although they said this was unusual. It does not ensure that people have the recommended five portions of fruit and vegetables a day to have a healthy diet. Care Homes for Older People Page 19 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements ensure that the the views of the people living there are listened to but do not always ensure that they are safeguarded from harm. Evidence: The AQAA stated that there are effective policies in place that show people how to complain, show staff how to report safeguarding incidents and how to report whistle blowing. The home has received one complaint since the last key inspection in November 2009 regarding the care of one person from their relative. This had been recorded and the manager had responded appropriately. They ensured that action was taken to address the concerns raised. We received a complaint in May this year that we investigated as part of this visit. The complaint related to no induction for agency staff, high use of agency staff, lack of choice at meal times, inappropriate techniques and equipment to move people, people not being given personal care when needed, lack of stimulation, dirty environment, lift not working and care planning. We found that regulations had been breached in relation to staffing, moving and handling and care planning and these are addressed in the relevant sections of this report. We observed the manager listening to the views of the people living there and their Care Homes for Older People Page 20 of 36 Evidence: relatives. Relatives told us that the manager listens to them and they think she will take action to make improvements where needed. Following our visit we received concerns regarding the safety of people when there are no staff in the lounge. We were told that two people had been hurt by another person living there who was agitated that day. Staff were allegedly not around to witness this to ensure that people are protected from harm but were told this had happened. We referred this to the local authority as safeguarding and it is being investigated by them. The home has got better in reporting incidents to us that affect peoples well being. Therefore, it was disappointing that the home did not notify us of these incidents until after the social worker had contacted them regarding the safeguarding. They did not think it was necessary as we had referred the safeguarding. However, if we had not received this information we may not have been informed of these incidents as is required. This does not show that the home is proactive in ensuring that people are safeguarded from harm. Staff spoken to showed an understanding of what they would do if they witnessed a person living there being abused by another member of staff to ensure that the person was safeguarded from harm. Staff training records given to us during the visit showed that eleven staff had received training in safeguarding in January 2010. The manager said that further training in this was booked so that all staff have this training. Care Homes for Older People Page 21 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements do not always ensure that people live in a homely, comfortable and safe environment that meets their individual needs. Evidence: We saw that the chairs in the lounge were worn and old and would not be comfortable for people to sit in. The manager said that new chairs had been ordered for the lounge to improve this. They also said the flooring in the room that is currently being used as a dining room is to be replaced. This carpet was stained, worn and torn in parts. Relatives said that there is often an offensive odour in the room which does not make it pleasant for people to eat in. One relative said that the home had been run down. The flooring in the hall was worn and the manager said they had identified it as a trip hazard. They said the deputy manager had been on a health and safety course and was doing an assessment of the home to identify what needed to be done to improve it. This needs to be done and action taken so to ensure the health and safety of the people living there, their visitors and staff. We looked at three bedrooms, one of which was shared by two people. We saw this room at a previous visit and again at this visit found that the decoration was worn. One person spends some of their time in a position facing the wall to relieve the pressure on their skin. This wall is in need of redecoration and when we last visited Care Homes for Older People Page 22 of 36 Evidence: had no pictures that could be seen by the person. Since then a pin board had been put up with colourful cards and pictures for the person to look at. The paint was peeling off the wall and one part of the wall was a different colour to the rest. A shelf was broken in the book case in the room and the things that were on the shelf had fallen down to the bottom. The bedding on the two beds was worn and had some holes in it. Both of these people spend all their time in bed and this does not ensure that the room is comfortable for them. One of the other bedrooms looked at was well decorated but not personalised and quite bare. It was not clear whether or not this was the persons taste. The other bedroom was more personalised and had a memory box on the wall by their door. This is a box with a clear front so that pictures and photographs important to the person can be put in there to remind them where their room is and of these important things. We received a complaint, part of which alleged that the lift was not working. The manager said she had not been aware that the lift had broken down. The lift was working on the day we visited. The manager could not find evidence that the lift had been serviced but sent this to us following our visit. This showed that the lift was serviced in April 2010. The home employs cleaning staff so that care staff do not have to do this. In one shower room we noticed an offensive odour and saw faeces in the bin. Staff have to support the people living there to use this room, as it is locked. The manager asked staff to ensure this was cleaned appropriately. The other bathrooms and toilets were clean and no other offensive odours were noted. The home generally needed care and attention as it did not look clean, comfortable and homely for people to live in. Care Homes for Older People Page 23 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for staffing, their recruitment, support and development are variable, which could impact on the well being of the people who live there. Evidence: The manager said that there were vacancies for four nurses and four care staff. One nurse was suspended pending investigation. Care staff vacancies were being recruited to and the nurses vacancies were to be advertised. Bank and agency staff are used to cover vacancies where needed. Rotas sampled showed that there were enough staff to meet the staffing levels that the home has assessed are needed but most shifts included some bank or agency staff to cover. There were two agency care staff on in the morning, both of whom had worked at the home before and one bank care staff in the afternoon who works there regularly. This helps to have some consistency of staff for the people living there. Staff said that most times agency staff work with permanent staff and this was observed during our visit. One part of a complaint we received stated that there is no induction for agency staff when they first work at the home. The manager stated that there is no specific induction for agency staff. We were told that there had been an occasion when there were no permanent staff on duty and rotas seen confirmed this. The manager said that they and the deputy are going to work alternate weekends to ensure that there is sufficient cover on all shifts to ensure that the people living there are supported by Care Homes for Older People Page 24 of 36 Evidence: people who know them. We looked at staff meeting minutes. These showed that three staff meetings had been held since July 2009 and there had not been a meeting since the new manager had started at the end of March. However, there was a meeting planned later that week. This does not ensure that staff have an opportunity to discuss how they support the people living there and can be kept updated with best practice. The AQAA stated and staff said that all care staff have completed training in National Vocational Qualification (NVQ) level 2 in care and some staff are now doing NVQ level 3. This exceeds the standard that at least 50 of staff have this training and should ensure they have the knowledge and skills to meet the needs of the people living there. We asked to look at two staff records relating to their recruitment and training. The operations manager was at the home sorting out staff records but neither they nor the manager were able to find records for the staff requested. Therefore it was not possible to assess whether or not staff are being recruited appropriately and suitable to work with the people living there. These must be available in the home so that this can be assessed. Staff spoken to said and training records showed that staff had recently had training in safeguarding, fire safety, moving and handling, pressure area care, using the hoist and dementia. This is an improvement from our last visit. Staff said that training in other areas is booked and some of them are refresher training so they can keep updated in their knowledge. Care Homes for Older People Page 25 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements do not ensure that the health, safety and welfare of the people living there is promoted and protected, which could impact on their well being. Evidence: Following the last key inspection the manager, who had been in post less than six months, left the home. The operations director managed the home until a new manager could be found. The current manager has been in post since the end of March. The manager has several years experience of managing homes for older people. This is a nursing home but the manager is not a registered nurse. The deputy is a registered nurse and therefore takes the clinical lead over the nursing care for the people living there. Staff spoken to said that the home had been unsettled by the changes of managers. Staff and relatives spoken to said that the current manager is supportive, listens to their views and wants to change things for the benefit of the people living there. The manager said she gets a lot of support from the deputy manager but he also has Care Homes for Older People Page 26 of 36 Evidence: a lot of administrative tasks to do, which means he is not always at the home. A part time administrator has been appointed and it is hoped this will reduce the administrative work load of the managers. The operations manager was working at the home looking at records on the day of our visit. The manager said this was the first time they had visited since the manager had been in post however, the operations director had still been at the home regularly. We were told that the operations director was leaving the organisation later that month. The manager had encountered some resistance from nursing staff to changes in practice. It was disappointing to note that the manager had not been formally introduced to staff by senior managers and they had not been formally informed of her role. This may have helped staff to acknowledge her as the manager and accept what changes need to be made for the benefit of the people living there. The manager told us that there were no specific quality assurance systems in place. Given the concerns that have been raised about this home by us, social services contracts and the fire officer, it is disappointing that there are no systems in place whereby the organisation can monitor what improvements are being made. A representative of the organisation is required to visit the home monthly to monitor the service provided and make a report of that visit available so the home know what improvements need to be made. We saw two reports for 2009 and two for April 2010. Again given the concerns about this home it is disappointing that the organisation are not monitoring the service as they are required to do. Since the random inspection in March where we identified some issues about fire safety a fire officer has visited the home. They served a fire safety order which required that the home make improvements to providing appropriate fire extinguishers, staff fire safety training, keeping fire exits clear, reviewing of fire evacuation plans and holding regular fire drills. The fire officer informed us that the home had complied with the necessary parts of the order and further work was continuing regarding fire evacuation plans. We looked at the fire records which showed that staff test the fire alarm weekly to make sure it is working. Staff test the emergency lighting monthly to make sure it is working. In May they had identified there were three faulty lights. There was no further information to show this had been followed up. The manager said the deputy manager had reported these. The fire equipment had recently been serviced by an engineer to ensure it is well maintained. We twice observed people being pushed along the hall in a hoist. This equipment is Care Homes for Older People Page 27 of 36 Evidence: not intended to transport a person from one area to another but to transfer them from one position to another such as from bed to a chair. The hoist being used was rusty and the manager was not sure when looking at the hoist servicing records which hoist this was. The manager said as two new electric hoists had been provided that this hoist would be taken out of use. Staff had received training in using the new hoists provided. We observed staff using the hoists in the lounge. Some staff seemed unsure how to use it and where to position individuals slings, which meant that people were hoisted up a bit and then back down until the position was right. Being in a hoist can be frightening for people so this could have added to the stress of this. Relatives told us that they had rarely seen the hoist used but on the day of our visit it was used several times in the space of one hour. We made a requirement relating to staff moving people safely at the last key inspection. Findings of this inspection show that this requirement remains outstanding. We observed staff using handling belts to move people, which helps to reduce the risk of injury to people. We observed people being moved but staff did not always plan moves which could have put them and the person at risk of injury. We saw one persons feet, who only had socks on, be narrowly missed by the wheels of another persons wheelchair. We saw staff having to climb over the recliner part of a chair, that was positioned outwards, while moving a person from one chair to another. Staff moved a person into a chair but forgot that the person needed a cushion to sit on, so had to move them up again to put the cushion under them. Staff said and records showed they have received training in moving and handling in the last few months. On the window sill in the lounge near to where people were sitting we noticed a Christmas gift bag that contained toiletries including two tubes of denture tablets. We gave these to the manager who said they were not aware of who they belonged to. The contents of this could pose a risk of harm to the people living there. Care Homes for Older People Page 28 of 36 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 12 Care plans must clearly state 28/02/2010 how staff are to support the person. So that people are supported in the way they need and ensuring their well being. 2 8 12 Staff must support people appropriately to ensure the risk of their skin becoming sore is reduced. To ensure peoples health and well being. 31/12/2009 3 9 13 All nursing staff must be 05/05/2010 trained in the indications and side effects of the medicines they handle. This is to ensure that they can fully support the service users clinical needs. 4 9 13 A system must be installed 05/05/2010 to check the prescription prior to dispensing and to check the dispensed medicines and Medicine Administration Record (MAR) charts against the prescription for accuracy. All discrepancies must be addressed with the healthcare professional. This is to ensure that all Care Homes for Older People Page 29 of 36 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 medicines are administered as prescribed at all times 5 9 13 All medicines must be stored 05/05/2010 securely. This includes creams and ointments. This is to ensure they are safely held on the premise to prevent mishandling 6 38 12 People must be supported to 31/12/2010 move safely. To ensure their safety and well being and that of the staff supporting them. Care Homes for Older People Page 30 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 29 19 Records of staff recruitment must be available in the home. To ensure that recruitment procedures are robust and suitable staff are employed to work with the people living there. 31/07/2010 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 12 Ensure that care plans clearly reflect individuals needs. So that staff know how to support them to meet these. 30/06/2010 2 8 12 Peoples weight must be regularly monitored and action taken where there is a significant loss or gain. To ensure their health and well being. 18/06/2010 3 8 13 Ensure that staff know how to support people appropriately to ensure the risk of their skin becoming sore is reduced. 30/06/2010 Care Homes for Older People Page 31 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action So ensuring their health and well being. 4 9 13 Make arrangements to ensure that medication administration records are accurately maintained. So that people are given the medication they need to ensure their well being. 5 18 37 Any event that affects the well being of a person living there must be reported to CQC without delay. To ensure that measures are taken to safeguard the people living there. 6 19 13 People must live in a safe environment. To ensure the risk of them having an accident is reduced, so ensuring their well being. 7 33 26 A representative of the organisation must visit the home monthly and write a report of that visit. To monitor the service provided to ensure it is being run in the best interests of the people living there. 30/06/2010 30/06/2010 13/06/2010 30/06/2010 Care Homes for Older People Page 32 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 8 38 13 Hoists must only be used to 31/05/2010 transfer people not transport people from one area to another. To ensure that people are not at risk of being injured. 9 38 13 All hazardous substances 31/05/2010 must be kept securely in the home. To ensure that people are not at risk of ingesting them. 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 Information no longer required in peoples files should be taken out so that staff have the information they need to know how to meet peoples current needs. Daily records should be helpful to staff in monitoring peoples health needs in a timely way so that action can be taken to ensure peoples well being. It is advised that all discontinued medicines (including external preparations - creams and ointments) are removed and discarded so that people are not at risk of being given medication they are no longer prescribed. It is advised that further training is completed to enable staff to manage challenging behaviour without the need to administer sedating medicines. It is advised that all the people living there have a medication review to reduce the reliance of sedating medicines used in the home. Medication protocols for giving medication covertly, where Page 33 of 36 2 8 3 9 4 9 5 9 6 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 needed, should be developed to ensure this is in peoples best interests. 7 8 9 10 Staff should administer medication appropriately so not to put people at risk of cross infection. Staff should ensure that they support people to meet their personal care needs with dignity so ensuring their well being. All people should be offered regular activities to ensure they have opportunities for social interaction and to promote their well being. Care plans should state how staff need to support people in doing activities and to meet their leisure and social needs so ensuring their well being. Records should clearly state peoples likes and dislikes so they can be more involved in choices in their day to day lives. Food records should state what the person has eaten and the portion sizes so it can be monitored whether or not the person is receiving the nutrition they need to be well. People should be offered a varied, healthy and nutritious diet to ensure their health and well being. Rooms should be redecorated where needed so that people live in a homely and comfortable environment. Furniture should be replaced where needed to ensure that people live in a homely environment that meets their individual needs. Bedding should be provided that is clean and comfortable to enable people to be as comfortable as possible. Staff should support people appropriately so they live in a clean environment that reduces the risk of cross infection. Rotas should be flexible to ensure that there are always staff on duty who know the people living there and how to support them to meet their needs. There should be an induction process for agency staff so they know how to support individuals they are working with and are aware of safety procedures, if needed while working there. 9 12 10 12 11 14 12 15 13 14 15 15 19 19 16 17 18 24 26 27 19 27 Care Homes for Older People Page 34 of 36 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 20 27 There should be at least six staff meetings a year to ensure that staff have an opportunity to discuss the needs of the people living there and are kept updated with best practice. The manager should be well supported in her role to ensure the home is well run in the best interests of the people living there. Quality assurance systems should be in place to ensure that the home is regularly monitored and improvements can be made so it is run in the best interests of the people living there. Records should show that repairs have been reported so that action can be taken to ensure that equipment is working well to ensure peoples safety. 21 31 22 33 23 38 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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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