Inspection on 18/11/09 for Donnington House

This inspection was carried out on 18th November 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Donnington House 11/02/10

Donnington House 14/12/09

Donnington House 21/08/07

Donnington House 26/06/06

Donnington House 21/09/05

Donnington House 03/05/05

Donnington House 14/10/04

Donnington House 09/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

Key inspection report Care homes for older people Name: Address: Donnington House 47 Atlantic Way Westward Ho! Bideford Devon EX39 1JD     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: Susan Taylor     Date: 1 9 1 1 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 45 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 45 Information about the care home Name of care home: Address: Donnington House 47 Atlantic Way Westward Ho! Bideford Devon EX39 1JD 01237475001 01237424540 donnington@stone-haven.co.uk WWW.stone-haven.co.uk Stonehaven (Healthcare) Ltd care home 36 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 36. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: DementiaCode DE- maximum of 36 places Physical disability- Code PD- maximum of 36 places Old age, not falling within any other category- Code OP- maximum of 36 places Date of last inspection Brief description of the care home Donnington House is a large detached property situated in the seaside resort of Westward Ho! It has recently been extended and has increased its registration to 36 older adults who may also have dementia or physical disability. The accommodation is on three floors. There is access between the floors by stairs, chairlift and a passenger Care Homes for Older People Page 4 of 45 Over 65 0 36 0 36 0 36 Brief description of the care home lift. The majority of residents are accommodated in single occupancy rooms but there are two bedrooms which have shared occupancy. Fees charged ranged from £467.50 to £582.25 per week. Additional charges are made for chiropody, hairdressing, newspapers, private telephone lines and are variable according to individual needs. Care Homes for Older People Page 5 of 45 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 0 stars. This means the people who use this service experience POOR quality outcomes. This unannounced key inspection was brought forward as a result of the Annual Service Review and Safeguarding processes, which highlighted concerns about the quality of care that people living at Donnington House are receiving. We (the Commission) were at the home with people for 27 hours. We looked at key standards covering: choice of home; individual needs and choices; lifestyle; personal and healthcare support; concerns, complaints and protection; environment; staffing and conduct and management of the home. During this visit we spoke with or observed the majority of people living here. We could not speak with some people because they have communication difficulties such as dementia. We looked closely at the care, services and accommodation offered to 6 Care Homes for Older People Page 6 of 45 people living here. This is called case tracking and helps us to make a judgment about the standard of care, and helps us to understand the experiences of people who live here. We looked at the care and attention given by staff to these people and we looked at their assessments and at their care planning records. We looked at the environment in relation to their needs and how their health and personal care needs are met. We also spoke with visitors to the home, with staff and with one of the Owners who is the Responsible Individual. We visited some of the bedrooms of the people we case tracked and saw all service and communal areas of the home. Prior to the inspection the provider sent us their Annual Quality Assurance Assessment (AQAA) which gave us information about the home and its management and about the needs of people living here. This document asks for evidence in relation to what the home does well and what they think they can improve upon. In addition, we sent surveys to 15 people living here and 13 were returned. We sent 10 surveys to staff and 7 were returned. We also took an expert by experience to the home. CQC are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are now using a method of working where experts by experience are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term experts by experience used in this report describes people whose knowledge about social care services comes directly from using them. The expert helped to speak to people about their experiences of living at the home as well as making some general observations. Their comments are included throughout this report. Feedback and comments are included in the report. During this inspection evidence was taken under the Police and Criminal Evidence Act and this is being considered under our enforcement procedures. In November 2009, the fees ranged between £467.50 to £582.25 per week for personal care. Additional charges are made for personal telephone lines, chiropody, hairdressing, newspapers and toiletries and these vary. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk Care Homes for Older People Page 7 of 45 What the care home does well: What has improved since the last inspection? What they could do better: We have made legal requirements about the following: This home does not have a registered manager and is not being sufficiently well managed. This has resulted in peoples health and welfare needs not always being assessed or met. The assessment, care planning and communicating systems in place are not sufficiently robust to ensure that care staff have the information they need about peoples care needs and how these should be met. The legal requirements of the Mental Capacity Act are not fully understood and being followed, particularly in relation to giving medication in a covert way. This has resulted in some decisions being made that may not be in the best interest of that person. People are not always treated with dignity and their right to make choices or to be engaged and sociable are not always supported. Some peoples sense of self and personal identity is at risk of being eroded by a system that is not person centred and is sometimes institutionalised. Peoples needs are not being assessed in terms of occupation, interest and capabilities, which would ensure that activities are person centred and appropriate for the individual. Staff are well intentioned but are not always on duty in sufficient numbers, and do not always have the support, knowledge or skills they need, to meet peoples needs. Recruitment practices are not robust, which means that people are at risk of being cared for by inappropriate staff. Care Homes for Older People Page 8 of 45 Concerns are being investigated by the local safeguarding team. Whilst this investigation is ongoing, admissions to this home via health or social care services have been suspended by Devon Adult and Community Services. Some working practices and systems are not ensuring peoples safety. This includes prevention of accidental falls, prevention of pressure sores and the prevention of malnutrition. Maintenance of equipment is not always up to date nor are risk assessments or actions in relation to the use of restraint by medication. Peoples rights in terms of data protection of confidential information about them is not being met. The Commission has not been kept informed in relation to all incidents, accidents and deaths in the home, as we should be, so that we can monitor this type of activity in the home. We have made recommendations about the following: Peoples independence would be better promoted if equipment such as plate guards are used for people with physical disabilities. Additionally, best practice guidance should be implemented to ensure that the needs of people with dementia are taken account of and gives them the best chance of orientation to the environment they live in. Assessment of current infection control management should take place using the Department of Health Guidance to ensure that measures protect people that live in the home and staff that work there. Financial management systems do not fully take account of the needs of people that lack capacity. Best practice would be to involve advocates in monitoring how money is spent on an individuals behalf. 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 45 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 45 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. Peoples needs are not always adequately assessed, so the provider cannot be sure that individual needs are being met. Evidence: Donnington House has a statement of purpose and service users guide providing prospective residents with information about the service. We spoke to an individual about their experiences moving into the home and asked them about how well their needs were known and being met by staff. The person told us that the staff know what they are in respect of their needs and went on to tell us that they had diabetes. This was documented in the persons assessment and highlighted that the persons diabetes was controlled through diet and medication. The individual told us they have a healthy diet. Staff working in the kitchen were clear about the persons needs and provided a well balanced meal of shepherds pie with plenty of vegetables at lunch time for the individual. Care Homes for Older People Page 11 of 45 Evidence: We spoke to 2 relatives visiting their relation at Donnington House about their experiences of the admission procedure. They said when she first came we had a package of information about the home providing a good picture of what to expect and [we] were asked a lot of questions about her needs. We read a letter on file confirming that the service was able to meet this persons needs at the point of admission to the home. Contracts had been agreed with people and/or their advocates on admission. This demonstrates that the team involve relatives, when an individual does not have the capacity to obtain information about their life, health and social care needs which is good practice. We looked at 5 other care files to consider how risks are assessed to meet peoples needs. Staff told us that the manager and deputy manager were responsible for assessing people prior to admission to ensure that individual needs could be met at the home. However, the manager and deputy manager are currently absent from the home and this responsibility has been delegated to the two Senior First care staff. In all of the care files we looked at we saw that assessment information had been obtained from the placing authority. However, important information is not always translated into the risk assessments and care plans completed for individuals. For example, a hospital discharge assessment stated that a person had been diagnosed with vascular dementia. The Alzheimers Society website highlights that whilst the symptoms for a person may be similar to those of other types of dementia. People with vascular dementia may particularly experience problems concentrating and communicating, depression, symptoms of stroke, such as physical weakness or paralysis and a stepped progression, epileptic seizures and periods of acute confusion. The care plan for the individual stated type unknown next to dementia and did not adequately take account of the persons capacity. A Mental Capacity test had been carried out with the person. This test asks the correct questions regarding comprehension, retention, consideration and communication of information, however it did not relate to a particular decision. A broad conclusion was made in the persons file XXX does not have the mental capacity to make the decision. Entries in the daily records also tell us that staff have not recognised that the person has periods of acute confusion and judgemental statements have been made. For example, we read comments like refused to get undressed and was very rude and was very rude and refused to change her clothes ... she was being very awkward. Therefore, staff do not have access to the right information and some staff lack the skills needed to fully understand and meet the needs of people with dementia. The responsible individual verified that Donnington House does not provide an intermediate care service. Care Homes for Older People Page 12 of 45 Evidence: Care Homes for Older People Page 13 of 45 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 most vulnerable people living at Donnington House are being put at risk because their health and welfare needs are not being met. Some people do not have their care planned in a person centred way that treats them as individuals and are not always treated with dignity. Evidence: In a survey, 84 percent (11) people responding verified that staff listen and act on their wishes. We observed mixed interactions between staff and people living in the home. More experienced staff responded well to people and engaged them in conversation when otherwise they might have been isolated and withdrawn. However, we observed that some of the less experienced staff did not always maintain the dignity of people. For example, a carer joked going up in the world when an individual was moved by hoist from the chair she had been sat in. The person was moved as she still rambled, which could have indicated distress or alarm. Her dress became runched up around her thighs, exposing her stocking tops and undergarments. The carers continued to talk over the person as she still rambled Care Homes for Older People Page 14 of 45 Evidence: when she was sat in the wheelchair, with her skirt still up. The Expert by Experience wrote in her report Whilst most people were dressed appropriately, some of the women had bare legs and were wearing just slippers on their feet, which probably meant their legs were cold. Everyone was wearing slippers, which appeared to be mainly well fitting. I observed members of staff placing blankets on the knees of two people, also providing extra cardigans for two people who said they felt cold. Everyone in the room appeared to be suitably dressed, with hair well groomed. People were able to tell me how much they enjoyed having their hair done when the hairdresser visited. A member of staff gave nail care to one person. There was a relative in the room visiting and I sat with her and asked how satisfied she was with the care their relative received, her reply was I think the staff are marvellous, my relative is well fed, clean, and comfortable, I cant ask for more. Conversely, we met other relatives who told us that their relations nails were disgusting yesterday, I had to clean them. On the second day of the inspection, we also observed that some of the more dependent people had dirty nails. Therefore, the quality of care people receive in respect of their personal grooming is inconsistent. We looked in depth at the care plans of 6 people, 1 person had been transferred to another home. We found that each person had a plan of care and that these contained a large number and range of documents relating to care needs. However, these documents were written in the first person giving the impression that an individual has mental capacity when clearly some people did not. For example, the care plan for a person with advanced dementia stated I have no sight problem. This is false and misrepresents people. We found instances of where contradictory information had been recorded, for example a persons care plan stated that the individual wanders frequently day and night. However, no instructions had been entered for how this should be managed for that person. The Expert by Experience stated in her report one person said I enjoy a shower, but really prefer to have a bath. This was not documented in the persons care plan. Therefore, care plans do not always provide care staff with the correct or detailed information that they need to meet peoples needs. We case tracked a person with complex physical care needs who was at risk of malnutrition. The persons weight had been regularly taken, however this showed that the individual was gradually losing weight. Reviews of the assessment had taken place and the most recent highlighted that the level of risks for this person had increased and would necessitate a change in care for the person to have additional supplements and increased monitoring of their nutrition. We spoke to staff who confirmed that no specific instructions about food and drink had been given to them about this persons Care Homes for Older People Page 15 of 45 Evidence: needs. One member of staff said we try to encourage her to eat and I have noticed she hasnt been eating that much at lunch. After speaking with this member of staff later that morning we observed them pouring out some squash. They then woke the person we were case tracking, who was seated in a chair and saw her put the cup to the individuals mouth and asked the person to drink. They took a couple of sips. We then observed the member of staff get a side table and put the drink on it and the indivdual was asked to drink. The member of staff then left the lounge and person closed their eyes and went back to sleep. We spoke to another carer about the persons weight loss and they were not aware that the individual had been losing weight. We concluded that the known risks for this individual are not being minimised and their needs are not being met. We saw in care plans that people are assessed to see if they are at risk of developing pressure sores. The people we had case tracked are at risk. Some of these people are cared for on pressure relieving mattresses and cushions as is good practice. Some people are also nursed on adjustable beds which is also good practice. We were told that one person has developed a pressure sore since coming to live at Donnington House and that one person came to the home having already developed a pressure sore. We looked at pressure relieving equipment in one persons bedroom. We found that the mattress had been set to the maximum pressure indicating that the person using this mattress is heavy. When we looked in care records we found that this person is very light. We asked staff how they work out the pressure that the mattress should be set to. One person said they did not know, another said the person setting it up does it. We looked in care plans, to see if staff have access to instructions about the pressure each mattress should be set at. We did not find any instructions. As part of the safeguarding investigation, we decided that a more in-depth examination of a persons records was needed after the site visit to the home. This person was no longer living at the home. We seized a number of records relating to that person and have examined them in detail. From this we have established that a risk assessment highlighted that the likelihood of the person developing pressure sores was in place on admission. However, the assessement stated that the individuals risk score was 14, which highlighted that the person was at risk of developing pressure sores. Corresponding instructions stated that the person did not need pressure relieving equipment when sitting in a chair or in bed. Additionally, the persons care plan had not been adjusted to take account of the higher risk of developing pressure sores due to immobility. This contradicts the assessment. Within 10 days of admission the individuals records stated that the person was not walking and whilst the care plan was reviewed and altered to reflect increased nutritional needs there was no alteration with regard to minimising the risk of skin breakdown. Care Homes for Older People Page 16 of 45 Evidence: We can find no record that professional advice was sought from either the tissue viability nurse specialist or District Nursing Team. Within 7 days of the person not walking, entries in the daily records highlighted that the persons skin had broken and a black, small hole was recorded. An observation like this might indicate that there is significant pressure damage underneath that is not yet visible. Records tell us that staff were instructed to commence turning the person every 2 hours and then later that same day to increase this to every 1.5 hours. The district nursing team were asked to assess this person the following day and treatment commenced to heal the wounds. Records demonstrate that staff were instructed to turn the individual hourly after the District Nurse had assessed the person. Therefore, peoples needs in relation to nutrition and tissue viability are not effectively managed and may place them at risk. The home uses a monitored dosage system. Senior staff are responsible for stock taking. Records of ordered drugs and a register of controlled drugs were seen and tallied with those being stored. The responsible individual told us that a member of staff had been suspended in relation to allegations of falsifying the controlled drug register. The Commission had not been notified about this incident before, however, the provider had taken appropriate steps to safeguard people. Additionally, they had established that people on controlled medication had been given it as prescribed. All medication was kept in a secure place; controlled drugs were stored in accordance with legislation. The system was easy to audit and we tracked medication given to 6 people. Records accurately reflected medication having been given as prescribed by the GP. However, medicines had not consistently been reviewed regularly. For example, one person last had their medicines reviewed in March 2009. We observed medicines being administered during the evening on the Primrose Unit and the first day of inspection. The carer put these into pots, with the individuals name on it, some of which were illegible. The member of staff said that they were potting up medicines for 12 people. We then observed the member of staff take the tray of medicines to people in the lounge. People were quite vocal and some appeared distressed. The member of staff was alone in the lounge whilst 2 other staff were in other parts of the unit providing care to people, in what was becoming a chaotic atmosphere. This meant that the carer giving out medications was constantly distracted, attending to other peoples needs and at the same time having difficulty coaxing the first individual to take the medication. We discussed the practice of potting up with the member of staff and told them that this was unsafe. If the care worker giving the medicines does not have the container with the label they cannot be sure that each person receives the right dose of the right medicine at the right time, as prescribed. The following day we spoke to 2 other staff, one of whom had been Care Homes for Older People Page 17 of 45 Evidence: trained to give out medicines. Both staff told us that there are two different procedures that operate in the home. One person explained why this was and said we cannot take the cabinet to them for safety reasons. Stonehaven admininstration of medication procedure states it is essential to minimise the potential for drug administration errors by using the minimum number of steps in the administration process and do not attempt to administer medicines to more than one service user at a time. We discussed our observations with the provider who verified that the normal procedure had not been followed and would take this up with the individual concerned through the disciplinary process. A mental health risk assessment for an individual we were case tracking highlighted that the person was not always compliant in taking their medication. The assessment about the person highlighted XXX does not have the mental capacity to make the decision. However, the assessment was not explicit about what decision this related to. We read a letter from the individiduals GP, which gave permission for medicines to be given covertly in food. We discussed Deprivation of Liberty Safeguards with senior staff and the responsible individual and they verified that a referral had not been made to request a Best interests assessment to be done. Such measures might be considered to be forms of restraint without careful assessment and agreement from all stakeholders, including the individuals advocate. We discussed this with the responsible individual who is aware of requirements in the Mental Capacity Act 2005 for there to be ongoing assessment of an individuals capacity at an exact moment about a particular decision or issue. The Expert by Experience wrote in her report from my discussions with three members of the staff, I found most of them had only worked at the Home for a very short time and were still undertaking NVQ training, I feel that it could have been difficult for them to have a great understanding of issues around mental capacity and their role in aspects of decision making for the people at the Home. We observed that staff always knocked on doors before entering peoples rooms. People told us that care was always done in the privacy of their room and that staff treated them with respect and kindness. One person said they all treat you nicely. Care Homes for Older People Page 18 of 45 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. Some peoples quality of life is enhanced by continued links with their families and friends and by the activities they take part in. However, not everyone is having their individual social needs and rights to make choices met. Evidence: Responding in a survey a relative wrote our communication with Donnington House is on going and we have no problems in that area. Surveys from service users and relatives indicate that the home has a good level of activities and that they have a good level of choice about what they do during the day, evenings and at weekends. Information (AQAA) sent to us by the provider tells us that people are encouraged to make their own choices about their personal lives, when they come and go from the home either with or without family, as per risk assessments and Mental Capacity Test results. Their hobbies are encouraged, visits from families and friends and trips out with them. In-house activities include Jigsaws, games, Music, PAT dog visits, Bingo, Library books including talking books and quizzes. The provider tells us that they know the faiths and beliefs of 83 percent of people living in the home and that the majority are Christian and 1 person has spiritualist beliefs. People that we met tell us that they have monthly services of Holy Care Homes for Older People Page 19 of 45 Evidence: Communion and a methodist minister visits. We observed 1 person organising hymm books on the first day of the inspection and they and another person told us that there was some confusion as to whether a service would be taking place or not. We checked this out with the Responsible Indivdual who said that they had contacted the minister about this, however it was difficult to have a service on a set day due to the commitments of the minister. A service did take place later that day, which people attended and appeared to enjoy. We saw people tapping their feet in time to the music and singing along with hymms. We observed that people have unrestricted access all areas of the home. The lift between floors is difficult for some people to operate as the button needs to be constantly pressed to ensure that the lift travels, however staff told us that they always provide support to do this. We asked people times of getting up and going to bed; one person said I get up about 7.30am and thats sometimes a bit early, so I ask staff if they will give me five minutes more and they do, they come back a few minutes later. Another person told me I go to bed early but I like that and I have a cup of Horlicks about eight oclock. From observation and in discussion with people who were able to they told us they were able to spend their time how they choose to. According to information sent to the Commission (AQAA), 17 people are diagnosed with dementia and 1 person has a physical disability with specific communication needs. We wanted to establish how peoples needs were met with regard to meaningful activity. Both inspectors and the expert by experience spent time in communal areas observing how staff interacted with the people. We saw examples of good practice and areas which need improvement. During a period of observation in the ground floor lounge, staff engaged with people continuously at the right speed and demonstrated genuine warmth and attention, which people appeared to respond to and enjoy. Similarly, we spent time in the Primrose Unit. The Expert by Experience wrote people were sitting in easy chairs around the room, some were sleeping and two people were sitting at a table. The TV was on, but no one appeared to be watching it, only very few people could have seen it as it was in the corner of the room facing the door. I sat at a table with two ladies, they had a small Christmas picture on the table, and they were able to tell me that they had made it earlier in the morning. There was no evidence in the room of any aids or information to help orientate people as to the date, season, day, time etc. None of the care staff were spending time sitting talking or engaging with people, they seemed to be constantly going in and out of the room. I later asked a member of staff what would be happening in the afternoon and was their any planned activity, I was told we will probably do a ball game; people are ready for some activity. Staff told us that since the last inspection, the activities co-ordinator had left and that they are motivated to Care Homes for Older People Page 20 of 45 Evidence: do activities with people themselves. During the afternoon we observed a group activity of colouring that was taking place in the Primrose Unit. We asked the staff specifically how they knew what a particular person, who we were casetracking, wanted to do in terms of activies and interest. Staff said that they just know (and people) tend to tell you what they like. The person we case tracked has dementia and information in their care file indicated that the person would not be able to make an informed choice about activities. We observed that the person was doing colouring and they appeared frustrated and became agitated when another person kept shouting help, help. We looked at 6 care files and all of which lacked detail with regard to peoples social history and interests. Therefore, staff were acting on instinct rather than on assessed knowledge and information from advocates (for people that lack capacity). We looked at a plan of activities, all of which are group based events. These do not always reflect the level of ability that the person had given the stage of dementia. To illustrate this point, some people might be more responsive to sensory activities such as painting or aromatherapy. Alternatively other people might be more responsive to cognitively based activities, such as a reminiscence quiz. We discussed specific tools that might be useful to gain in depth information about individual capability and interest such as the Pool Activity level instrument. This would also ensure that activities are person centred and pitched at the right level for people. During the morning, the Expert by Experience commented that people were being offered a choice of tea or coffee and allowed to take biscuits from the tin. Drinks were being served in cups and saucers, but for most people the saucers were being taken away. I asked a staff member why this happened and was told we take the saucers away, because people often pour their drink into them and make a mess there was no evidence of any other drinks being available. When people had finished their drinks, they were all cleared away and no drinks were left in the room. When I visited 4 people in their rooms, later on in the morning, only 2 people had a jug of water and a glass in their room, and for one person, the drink was on the window-sill and out of her reach. We spoke to the Responsible individual about this who said that there was no reason why people should have saucers taken away and that she would remind staff about giving people drinks and ensuring drinks are within easy reach of the person. On the second day of inspection, we observed that staff paid more attention to ensuring that people had regular drinks and were given assistance where needed. We were shown a menu that rotates on a weekly basis. Whilst some people were able to tell us that this is discussed every day with them, so that they are given a choice, Care Homes for Older People Page 21 of 45 Evidence: we did not see any prompt boards or pictorial menues that would help people with cognitive impairment to make their food choices and these had not been used. Therefore, people that lack capacity are not enabled to have the same level of choice about meals as other people do. We discussed this with the Responsible Individual who said it was a good idea and they would implement it. We observed the experiences of people at lunch. We saw staff assisting people to eat by sitting with each person,attending to them and by supporting them at a pace that suited each person in an unrushed manner. On the Primrose Unit, staff doing this tended to kneel in front of the person they were feeding. Food was served plated to people. A pureed meal had sections separated others meals were nicely presented. No eating aids were seen, which would promote independence for people living in the home that have physical disabilities. One person had a plate but no plate guard and some food did fall off the plate. The same person also finger fed themselves at one point. People we spoke to made the following comments about the meals, There is nothing wrong with the food, The food is very good, but I dont like the fact that I need help with eating, my eye-sight is not very good now and I cant manage very well, I am very happy with the food, I get a good choice and I like the breakfast best. We also heard other people make positive comments during lunch such as The food is excellent and I really enjoyed my lunch. The record of meals provided demonstrated that meals are varied. Care Homes for Older People Page 22 of 45 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that their concerns are acted upon. However, people are not fully safeguarded from potential harm. Evidence: We looked at the complaint procedure for the home, which is in every persons bedroom. This provides clear information for people about the process. The contact details for the Commission are now out of date and need to be amended. Surveys from 13 people living in the home verified that they and or their relatives knew who to speak to if they are unhappy or need to make a complaint. A relative wrote if I have any concerns the staff are very helpful in resolving issues. There has been no major issue since xxx moved in and I am more than happy with the care xxx has received. Surveys from 7 staff verify that 100 percent of carers know what to do if someone wishes to make a complaint. The information given to us in the AQAA tells us that this home has received no complaints since the last inspection 2 years ago. However, relatives told us that they had raised concerns about cleanliness, which had been dealt with to their satisfaction by the Responsible individual. We looked at the complaints file and did not find a record of this. The responsible individual verified that there were no other records other than those of a complaint that had been investigated in 2006. The Commission was made aware of concerns about the home as a result of Care Homes for Older People Page 23 of 45 Evidence: safeguarding procedures. These relate to the quality of care people receive, the staffing levels and management of the home. We have looked at some of these issues during this inspection and are working with the safeguarding team who are undertaking an investigation relating to these allegations. In addition Devon County Council are reviewing the care of the people living at Donnington House. We spoke with staff about what they would do if they saw or suspected abuse. They told us they would tell the responsible individual who is currently managing the home, and this is good practice. A training matrix for the staff demonstrates that nearly all of the staff, except those recruited during the summer have had training about recognising abuse. Staff were described by people living in the home as good and kind. We observed that staff are generally very caring. However, we also observed two instances when a member of staff was somewhat dismissive towards an individual, by referring to her as she and described the person as needing to be pampered all the time. Later the person told us they wanted to do some knitting and the member of staff was dismissive and in front of the individual told us that it was pointless giving her knitting to do as she would lose interest. This demonstrated a lack of understanding about valuing peoples diverse needs. Therefore, some people are not being respected. The Expert by Experience observed a very difficult situation, between two people in the sitting room area, they were friends, but one was constantly shouting for her friend to take her for a walk and the other person did not want to take her. The Expert by Experience wrote in her report There was considerable shouting across the room, which was very disruptive. It was apparent that this happened frequently, but staff seemed unable to cope with the situation and no strategy in place to deal with the situation, so consequently both people were very agitated and the frequent outbursts dominated the atmosphere in the room. Staff did not attempt to offer to walk with the person, or sit with her and try to resolve the situation. Later on in the morning, I was able to sit with the person who had been shouting and she was able to converse and was quite lucid explaining to me why she shouted and what she wanted. Therefore, incidents are not being dealt with appropriately and may be allowed to escalate and this could put people at risk of harm. Some of the people who live at Donnington House are having decisions about forms of restraint made. Occaisionally, this has to happen if the person involved is not able to make these decisions for themselves. For example, we case tracked the care of a person who is being given medication covertly in food. Whilst there was a letter from the GP on file, the circumstances of this decision had not been fully recorded so it was unclear as to whether the decision was being made in the best interests of the person. Care Homes for Older People Page 24 of 45 Evidence: We discussed the requirements of the Mental Capacity Act 2005 with senior staff and the responsible individual and they verified that a referral had not been made to request a Best interests assessment to be done. Such measures might be considered to be forms of restraint without careful assessment and agreement from all stakeholders, including the individuals advocate. We discussed this with the responsible individual who is aware of requirements in the Mental Capacity Act 2005 for there to be ongoing assessment of an individuals capacity at an exact moment about a particular decision or issue. Care Homes for Older People Page 25 of 45 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. People living at Donnington House enjoy a homely environment. However, improvements are needed to ensure that people are fully protected from the risk of infection. Evidence: Donnington provides a homely environment for people to enjoy. A maintenance book demonstrated that routine maintenance and renewal of the fabric and decoration of the home is done. Whilst touring the building we saw that the window in one persons bedroom was taped up and a draught was coming through it. We spoke to the responsible individual who told us that new window locks had been ordered and would be fitted as soon as possible. Since we last inspected Donnington the refurbishment of the Primrose Unit has been completed. Information sent to us by the provider (AQAA) tells us that new carpets and furniture have been purchased for people that live on this unit. All of the bedrooms were personalised with photographs and ornaments of the occupant. There is a light and airy conservatory attached to the lounge in this unit, with access to a paved area outside. The Expert by Experience wrote the dining area lacked colour and any feeling of a pleasant social activity, there were no plants or flowers in the room and no curtains to Care Homes for Older People Page 26 of 45 Evidence: the windows. The view from the dining area window was to the patio outside and this looked equally bare and unattractive. Information sent to us by the provider tells us that the Garden planting needs to be completed. Development of the small courtyard into a fragrant small garden with potted plants and trellis is still in the planning stages. Once completed this sensory garden will provide people with a nice outlook and in warmer weather a place to stimulate the senses of touch, sight, sound and smell, as well as taste. The communal room in the Primrose Unit could be made more homely and include daily notice boards, pictorial menus, better signs in line with research available on best practice in the care of people with dementia. We found that call bells are accessible in every room and that there is a lift to assist people when needed, in addition we saw grab rails and other equipment to assist people. We observed that a hoist is used by staff when moving the position of a person. Radiator guards are fitted throughout the home. Therefore, people we spoke to felt that their surroundings were much improved and provide a comfortable place for them to live in. Information sent to the Commission verified that 5 staff has done infection control training and further in house sessions are planned. We looked at the laundry, which is situated in the home. We met the member of staff who was doing the laundry and saw that there is a good system in place that ensures clothes and linen and washed separately for infection control purposes. Similarly, we observed that linen and clothes are taken to the laundry in receptacles and clean clothing is returned to people the same day after being washed, dried and ironed. People looked well turned out in their own clean clothes. 100 percent of people in a survey commented that the home is always clean. At the inspection, we found all areas of the home to be odour free. However, whilst most parts of the home were clean we found some areas on the Primrose Unit which require deeper cleaning. For example, the underside of a fixed hoist was coated in thick yellow/brown residue and commodes in 3 bedrooms had dirty and soiled pots. We discussed the current cleaning arrangements with all of the staff we met. They told us that staff on the Primrose Unit are responsible for cleaning in addition to caring for the most vulnerable people in the home. We discussed this with the Responsible Individual who told us that they were unaware of this and would immediately take action to reallocate cleaning to domestic staff that work in the home. The home has guidance on infection control that is accessible to staff. Information Care Homes for Older People Page 27 of 45 Evidence: sent to the Commission verified that the Department of Health Guidance Essential Steps had been used to audit practices to establish the effectiveness of infection control measures in place. We observed that protective clothing is accessible for staff and they used this and washed their hands after caring for people. However, the same level of attention to detail is not put into effect for people that are being cared for. For example, we observed 3 people living on the Primrose Unit had long dirty nails with grey deposits under their nails. When drinks were being served, we observed the same 3 people being offered biscuits which they helped themselves to from a tin. A professional told us that on one occaision a person had faeces between their toes even though the individual had been recently showered. Therefore, people living in the home are not fully protected from the risk of infection. Care Homes for Older People Page 28 of 45 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always enough staff on duty with the appropriate qualifications, training and skills to care for people living here. Recruitment practices are placing people at risk of harm. Evidence: 13 people living in the home returned surveys. Staff were described as being caring and attentive. The expert by experience met a relative who said my relative is always well fed, clean and comfortable, the staff are marvellous, I couldnt ask for more. In the AQAA, the provider tells us the ratio of staff in the Primrose Unit is 1 to 4 in the morning, 1 to 5 in the afternoon till 6pm then 1 to 8 in the evening whereas upstairs it is 1 to 8 all day. We have 2 waking night staff. An area that is said to have been improved is staff levels/ ratio to clients [have increased] at peak times during the day, continued monitoring of troublesome periods and solutions sought. However, as part of the safeguarding process concern was raised about the level of experience and numbers of staff on duty and an increased risk that peoples needs were not being met. Over the course of 2 days we looked closely at staffing levels in relation to the needs of people. We looked at duty rosters for the weeks commencing 24/10/09, 31/10/09 and 14/11/09. Every morning there are 6-7 carers rostered on duty until 2pm. Most Care Homes for Older People Page 29 of 45 Evidence: afternoons there had been between 3 and 6 carers on duty and and during the evening between 4 and 6 carers. On one occaision 11/11/09 staffing levels dropped to 3 carers on duty between 2-5pm, during this period a person had sustained an injury the cause of which was recorded as unknown. We interviewed 5 staff, who all said that there is usually 2 staff allocated to the first floor and 3 on the lower ground floor, known as the Primrose Unit, every morning. They also verified that an additional person works from 7am - 11am doing an hour of care then moving on to domestic duties. Staff said staffing levels have increased. However, whilst they told us they were very motivated to do activities, time is a factor. In surveys staff wrote more staff are needed on a morning shift. Information sent to us by the home gave us a picture of peoples needs. The provider told us that all of the people living at the home need help with undressing and dressing, and need help to go to the toilet. 15 people are incontinent of both faeces and urine and 17 people have dementia. 2 people are listed as needing two members of staff to help them with their care. We looked at the records relating to falls and injuries between 26/8/09 - 14/11/09. According to these records people have been found to have fallen when there have been no staff present on 10 separate occasions. This means that people are not being sufficiently supervised by staff to keep them safe. Additionally, our observation of medicines being administered during the evening on the Primrose Unit on the first day of inspection highlighted that there are insufficient staff. People were quite vocal and some appeared distressed needing attention. The member of staff was alone in the lounge whilst 2 other staff were in other parts of the unit providing care to people, in what was becoming a chaotic atmosphere. This meant that the carer giving out medications was constantly distracted, attending to other peoples needs and at the same time having difficulty coaxing an individual to take the medication. It was impossible for the carer to give every person the reassurance and attention they needed. We have commented in other sections about lack of attention to detail such as 3 people having long dirty nails and a professional reporting that a person they had visited had faeces between their toes even though the person had been showered. Additionally, staff told us that they had cleaning duties to do on the Primrose Unit. We asked people whether staff were available when they needed help, and they made comments like theyre busy, they have enough to do. Relatives told us theres not enough staff particularly on Saturday mornings there only seems to be 3 on, 2 doing rooms. Therefore, peoples health and welfare needs are not being met. We spoke to the responsible individual about the needs of people and our observations. They told us that they would immediately review staffing levels. They Care Homes for Older People Page 30 of 45 Evidence: told us that they were not aware that staff were doing cleaning on the Primrose Unit and that they shouldnt be because there are cleaning staff to do these tasks. We met a cleaner on the first day of the inspection who told us that they were responsible for cleaning the ground and first floors. An off duty senior carer told us they had come in to clean carpets. In the dataset the provider told us that there has been a very high turnover of staff in the last 12 months - 61 percent (16 out of 26 staff). We spoke to the responsible individual about recruitment and we discussed the appointment of 4 new staff. We examined the files for these individuals to establish whether the recruitment procedure was robust and had been followed. We asked the responsible individual whether there was any other information about these appointments and after searching found no other information other than the following: One file did not have a start date recorded. Independent safeguarding authority (ISA) checks had been obtained for 1 out of 4 of the new staff before employment. A member of staff had started employment on 29/8/09 before an ISA check had been completed. The person told us they spent one and half weeks on induction getting to know the residents before my CRB came back. Other pre-employment checks such as references had been obtained after the individual had been employed. In second file we read an undated hand written testimonial from a friend. The person had previously worked in a care service and the professional reference from the service is dated the same day that the person started employment on 1/6/09. The member of staff verified the date of employment as being 1/6/09. In the third file, 2 written references were dated more than a month (27/10/09 and 21/10/09) after the person started employment on 19/9/09. Finally, a fourth file contained 2 written references that had been obtained before the individual started employment. We concluded that recruitment procedures are not robust and people living in the home are not protected because of this. We discussed our findings with the responsible individual and made her aware of best recruitment practice. Information sent to us by the manager tells us that 53 percent (14) of staff hold NVQ level 2 in care and another 46 percent (12) staff are in the process of doing this award. 100 percent of staff have completed the induction training. Staff in a survey verified there are regular training sessions about dementia, manual handling, first aid. One person who had done a course in dementia care gave a good description about how to care for someone with dementia, which was good practice. New staff said that their induction was thorough. We were sent the training matrix for the team, which demonstrates that there is a good programme in place. However, there are some gaps in knowledge which we have identified as a result of this inspection. We asked staff whether they had had any training in dealing with challenging Care Homes for Older People Page 31 of 45 Evidence: behaviour. Staff said lots of new staff havent done this, which we were able to verify on the training matrix. This shows that staff employed since June 2009 havent yet had this training. Similarly, not enough staff have had specific training about the prevention and care of pressure sores and nutritional care. The latter is listed on the training programme. We spoke to senior staff that have been responsible for assessing risks in the absence of the manager and deputy manager. None of these staff had completed training about risk management and we found that important information about people had not been acted upon. For example, a person that had been assessed as being at risk of developing pressure sores but a decision was made not to use a pressure relieving cushion or matress for that individual. This contravenes best practice guidance on the NICE website. The persons condition deteriorated. Some good practice was seen with regard to seeking medical assessment from the GP and subsequant management of fluid intake, however the risk of development of pressure sores increased for the individual and was not acted upon quickly enough to prevent sores developing. The persons plan of care was not updated until the person had developed pressure sores and at this point District Nurses were asked for advice. Therefore, staff do not have sufficient skills and experience to make decisions about managing known risks safely for people living in the home. Care Homes for Older People Page 32 of 45 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. A lack of leadership in this home means that systems are not in place to ensure that people receive the care they need to an acceptable standard in a way that ensures their safety. Evidence: This home does not have a Registered Manager. The previous manager has been on sick leave since August 2009. The responsible individual told us that the company had just received a letter of resignation from the manager. The deputy manager had been suspended and disciplinary procedures were being followed. Since August 2009, the home has been managed on a temporary basis. The temporary manager is the responsible individual for Stonehaven Ltd. and does not have care experience. She notified the Commission that she works 4 days per week, usually working 9am up to 7pm. In the last 2 months the Commission has received comments from professionals who say the overall management of the home has declined. One person described the Care Homes for Older People Page 33 of 45 Evidence: management as chaotic, saying that this has resulted in people not getting the care they need. We looked to see if there are systems in place to ensure the home runs efficiently and safely, and that people get the care they need. We found that systems are not robust enough to achieve this. For example we looked at the system for communicating peoples needs and changing needs, and for ensuring that peoples needs are met. Information sent to the Commission told us that this is achieved through the care planning system. However, we found that these documents are complex and contradictory in places. They do not always provide the level of detail needed by staff to ensure that they have the information they need, and to ensure that peoples needs are met in a way that is consistent and of a satisfactory quality. We found that reviews of peoples care do not include all the information available, in particular professional assessments and do not always provide evidence for some of the care decisions made (see Health and Personal Care). Care staff told us they do not always have time to read care plans. We asked if they had a handover at the beginning of each shift and were told that some information is handed over. We asked the responsible individual how information is relayed to staff. She told us that she expects the senior care staff to do this. The evidence in the Health and Personal Care section of this report, shows that this is not always happening. We looked closely at how some decisions about peoples care are made. For example,records are written in the first person giving the impression that people have mental capacity to do this, when clearly some people do not. The requirements of the Mental Capacity Act 2005 must be considered to ensure that a decision to give covert medication was in the best interests of that individual. The evidence in the Health and Personal care section of this report shows that this has not been properly followed. We looked at how risks in the home are managed. 3 of the people we casetracked had bedrails. Whilst there were risk assessments, these were limited and did not consider safety issues such as the risk to the individual of entrapment and what measures should be taken to minimise this. We found that people are identified as being at risk of falling. Care records instruct staff to observe them. Records show that a lot of falls have happened to people when staff are not present. Although there is a system for recording this information, there is not a system for monitoring and analysing this information, and therefore actions have not been taken to help prevent and reduce the number of falls. Recruitment systems that the organisation have in place are not being followed and may have put people at risk of being cared for by inappropriate staff. The Commission is not being notified of all incidents that affect the welfare of people living here as they should be. For example, records highlighted that a person that Care Homes for Older People Page 34 of 45 Evidence: sustained a serious injury after falling was admitted to hospital and the Commission had not been notified of this. The records demonstrated that there is a system for recording accidents and incidents. As part of the safeguarding process professionals reported that staff dealing with this incident failed to call emergency services, had to be instructed to do so but then refused on the grounds that they did not have the authority. The professional called the emergency services themselves. The responsible individual has been asked by the Safeguarding Team to investigate this under the homes disciplinary procedures. We spoke to 3 staff, all of whom had done First Aid training. They described good practice when asked what they would do if a person had an injury, which was bleeding and could not be stemmed for example. Additionally, the home had a robust procedure for staff to follow in the event of an emergency. Another member of staff said they did health and safety course and learnt a lot. It was a real eye opener. I learnt how to save someones life. All of the staff we spoke to were clear about the homes procedures around emergencies and two first aid boxes on the ground floor had appropriate well stocked contents. Given the incident described, we concluded that medical assistance is not always appropriately sought because some of the staff do not have sufficient skills and knowledge of the homes procedures to deal with emergency situations. The responsible individual has been asked to investigate this under the homes disciplinary procedures as part of the Safeguarding process. We looked at how equipment being used for the people we case tracked is maintained. We found a label on an electric nimbus pressure relieving mattress stated that the PAT test was next due on 7/1/09 and there was no evidence that this had been done. However, other equipment such as the stair lift had a LOLER sticker demonstrated that it had been serviced on 24/09/09. Similarly, a fixed bath hoist on the Primrose unit had a sticker demonstrating that it had been serviced on 24/09/09 and another hoist in a bedroom had been serviced on the same day. Confidential information about people living in the home, in a kardex, was seen on the table next to the signing in book. Care files were on shelving in the hallway on the ground floor and over the carers desk in the Primrose unit. Relatives told us that the records of another person had been left in their relations room earlier in the week. Additionally, care plans were not always up to date or acurately reflected professional information. Therefore, peoples records are not being maintained in accordance with Data Protection Legislation. We checked the financial systems for management of money for 3 people who we case tracked. All monies checked tallied with totals recorded. The responsible indidvidual told us that she is the only person with the key to the cabinet where monies are kept. Care Homes for Older People Page 35 of 45 Evidence: Small amounts of money are kept, usually not exceeding £100. Most spending had been for chiropody appointments or hair dressing. In April, records showed that people paid towards a quiz and cream tea for the home. From the care records seen about the people we case tracked, it is not clear how a person with dementia could consent to this. Relatives of a person with dementia told us that their relation lacked capacity and that they had power of attorney. They said weve only had 1 statement telling us where her moneys going. Therefore, some good practice is being followed with regard to management of peoples money but this could be further improved by ensuring better consultation with advocates for those that lack capacity. We looked at the homes environmental risk assessment file. There is no environmental risk assessment for wardrobes falling onto people. We checked wardrobes in rooms on the Primrose Unit as this is occupied by the most vulnerable people in the home. Wardrobes were not fixed in rooms 22,24,25,26,27,29,30 and both wardrobes in the shared room 21. The environmental risk assessment did not consider that people who are confused could be at risk of injesting hazardous materials. We saw toiletries in the shower room, which is assessible to anyone who could walk into the room. Therefore, environmental risks for people with dementia for example are not always being picked up and measures taken to prevent injury occurring. All of the staff that we met verified that they had done fire training in the last six months. Care Homes for Older People Page 36 of 45 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 37 of 45 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 3 14 Assessments must consider 08/01/2010 whether or not a person has the mental capacity to make specific decisions. This will ensure that that decisions for people who do not have the capacity are always in their best interest. 2 3 14 People must not be admitted 08/01/2010 to this home unless their needs have been assessed by a suitable person. This assessment must include health and social care assessments and take account of information provided by professionals, if the placement takes place through health or social care services. This will help to ensure that each persons needs are identified and can be met. Care Homes for Older People Page 38 of 45 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 3 7 15 The registered person must ensure that care plans provide clear and up to date instructions on how each persons care needs are to be met, recorded and monitored. Information recorded in care plans must be relevant and appropriate and updated as needs change. This will ensure that staff will have the information they need to ensure that peoples needs are better understood and met. 08/01/2010 4 8 12 The registered person must 08/01/2010 ensure that there is a system in place to ensure staff are aware of and are up to date with peoples health and welfare needs. A system must also be in place that monitors the health and welfare needs of people and that actions are taken and recorded when appropriate. This will help to ensure that peoples needs are met in the most effective way. 5 10 12 The registered person must ensure that the home is conducted in a way that ensures people are treated 08/01/2010 Care Homes for Older People Page 39 of 45 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 with respect and in a dignified way. This will help to ensure that people are treated appropriately with dignity and respect. 6 15 16 People must be offered drinks, meals and supplements regularly. The registered person must ensure that people who lack capacity are encouraged to eat by offering them a variety of foods and supplements that suit their needs and preferences. This will help to ensure that people are supported to remain healthy. The registered person must ensure that unnecessary risks to the health or safety of people living in the home are identified and so far as possible eliminated. In paricular, staff should have the knowledge and skills to diffuse potentially abusive situations that may put vulnerable people at risk of harm. This will ensure that people are safeguarded from potential harm. 31/12/2009 7 18 13 31/01/2010 Care Homes for Older People Page 40 of 45 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 18 13 The registered person must 08/01/2010 ensure that people are not the subject to physical restraint, for example certain medication, unless it is is the only practicable means of securing the welfare of the individual. And must ensure that where a person lacks capacity a referral for a best interest assessment is made. This will ensure that decisions are always made in the best interests of the person and therefore safeguards them from potential harm. 9 26 13 The registered person must ensure that adequate infection control procedures are in place. This will help to ensure that people are protected from the spread of any infections as far as possible. 08/01/2010 10 27 18 The registered person must 31/12/2009 ensure that there are always enough suitably qualified and skilled staff on duty. This will help to ensure that peoples needs can be met. Care Homes for Older People Page 41 of 45 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 11 29 19 The registered person must ensure that recruitment procedures are robust. This will help to ensure that people are cared for by appropriate staff. 31/12/2009 12 31 8 The registered person must ensure that an application is submitted to register a manager for this home. This will help to ensure that people benefit from living in a home that is managed by a suitable person that oversees management systems that help to ensure peoples safety and well being. 31/01/2010 13 32 37 The registered person must ensure that the Commission is notified about any event that affects the health or welfare of people. This will ensure that procedures are properly followed and people are protected as a result of this. 31/12/2009 14 37 17 The registered person must ensure that all records relating to people living in the home are up to date, meet and kept securely. This is to ensure that 31/12/2009 Care Homes for Older People Page 42 of 45 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 information kept about people is accurate and their rights of confidentiality are maintained. 15 38 13 The registered person must ensure that equipment provided at the home for use by people living here is maintained in good working order. This will help to ensure that people are kept safe 16 38 13 The registered person must ensure that risks to people living at Donnington House, in respect of the risk of falling, use of equipment and other environmental hazards be identified and as far as possible should be eliminated. This will help to ensure that people are kept safe Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 08/01/2010 31/12/2009 1 12 The diverse needs of people are taken into account when organising individual and group activities so that everyone leads a full and stimulating life. For example, use an assessment tool like the Pool Activity level instrument to establish exactly what individuals are able to do and indentify suitable activities accordingly. Care Homes for Older People Page 43 of 45 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 2 22 People should live in an environment that is appropriate for their needs, is stimulating and promotes independence by implementation of best practice guidance. This should include the use of prompt boards, pictorial menus, signage and bright lighting in dark areas. People should be confident that all staff have had the training they need to care for individuals appropriately. A system should be set up so that the advocates of people that lack capacity are consulted about how money is spent on the individuals behalf. This will ensure that peoples interests are safeguarded. 3 4 30 35 Care Homes for Older People Page 44 of 45 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 45 of 45 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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