Inspection on 28/04/09 for Down House Residential Care Home

This inspection was carried out on 28th April 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Down House Residential Care Home 21/07/09

Down House Residential Care Home 29/05/08

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Down House Residential Care Home Alum Bay New Road Totland Isle Of Wight PO39 0ES     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Annie Kentfield     Date: 2 8 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Down House Residential Care Home Alum Bay New Road Totland Isle Of Wight PO39 0ES 01983752730 01983753624 clacktmc@aol.com 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) : Mrs Trina Marie Clack care home 17 Number of places (if applicable): Under 65 Over 65 0 17 0 dementia old age, not falling within any other category physical disability Additional conditions: 17 0 17 The maximum number of service users to be accommodated is 17. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP) Physical disability (PD). Date of last inspection Brief description of the care home Down House offers residential care for up to 17 older people. The new owner of Down House took over the home in December 2007. The home is a period property set in spacious grounds and provides bedrooms on the ground and first floors with a passenger lift to access the first floor. The home has two small sitting rooms and a dining room that has recently been extended and refurbished. Residents have access to a sunny garden area with seating and tables. The fees vary according to the care Care Homes for Older People Page 4 of 35 Brief description of the care home provided with additional charges for chiropody and hairdressing. Other additional charges are listed in the service user guide. Care Homes for Older People Page 5 of 35 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: We made an unannounced visit to the home on 28 April 2009. The visit lasted for 6 hours and was with one inspector (Annie Kentfield). During the visit we spoke to the owner (registered provider), the manager, and some of the staff and residents. We looked at some of the communal areas of the home, the laundry and toilets and bathrooms. We also looked at some of the homes records including care plans, medication records, staff training and recruitment records and health and safety records. We received the Annual Quality Assurance Assessment from the home. This is a selfassessment that tells us what the home does well, where improvements will be made and gives us some numerical information about the service. Care Homes for Older People Page 6 of 35 Before the visit we sent surveys to 15 of the residents, 10 staff and 5 health and social care professionals. We received comments from 8 residents, 4 staff and one health and social care professional. We also sought feedback from Social Services on the outcomes of a recent safeguarding investigation about concerns with practice in the home and the safety of residents using the service. All of this information is included in the body of the report. During the visit we made immediate requirements about poor practice in the administration of medication and poor infection control procedures in the home. What the care home does well: What has improved since the last inspection? What they could do better: The registered provider has not taken appropriate action to comply with previous regulatory requirements. Residents are moving into the home without a comprehensive assessment of their care needs being carried out. This means that residents may be at risk of not receiving the care they need and the home may not be able to provide the equipment or staffing to support the resident. Residents are not consulted about their plan of care. Practice in the home for storing, dispensing and recording residents medication is not safe and residents may at risk of not receiving their medication, as prescribed, at all times. This was a previous regulatory requirement and the home has not complied with this legal requirement. The registered person has not complied with legal requirements for the safe storage of controlled drugs. Individual care plans are not person centred and care plans do not record all individual health care or social care needs. The health care needs of the residents are not safely and consistently met at all times. Any risks to residents are not clearly identifed with guidance for care staff on how risks or events must be managed. Residents are offered limited opportunities for social and leisure activities. Residents are not regularly consulted about their choices or preferences for activities. The home does not have an open and positive approach to complaints or comments about the home. The complaints information is out of date. The home does not have robust procedures to ensure that residents are protected from the risk of harm or abuse. Events in the home that affect the safety and well being of the residents must be reported to the commission without delay, this is a legal requirement. Care Homes for Older People Page 8 of 35 The home does not have a staff training and development plan and not all of the staff have received training in all areas of safe working practice. Some areas of training have not been identified and met such as dementia care, mental health care and the Mental Capacity Act. The service has not made an application for the manager to be registered with the commission, in a timely manner. The home does not have a thorough and consistent approach to promoting safe practice and ensuring that the service meets all relevant health and safety legislation. The home has only taken action to meet some health and safety requirements when an inspection has made regulatory requirements. The fire safety risk assessment has not been reviewed and updated and there is no procedure for carrying out regular fire safety drills or practices. The systems for monitoring the quality of care provided are not fully developed or part of practice in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 35 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 35 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not have an organised, consistent or person centred approach to assessing the care needs of prospective residents before they move into the home. Residents who move into the home may be at risk of not receiving the care they need. Evidence: When we last visited the home we found that there were no written records of the care needs assessments of people who had moved into the home. On that occasion the registered provider told us that the registered manager had carried out the assessments and the records could not be found. We recommended at the last inspection that the registered person should develop an organised process for carrying out the assessment of care needs before people move into the home. We also said that the assessment should be person centred and comprehensive, to identify prospective residents social, psychological, health care, and religious and spiritual needs. This Care Homes for Older People Page 11 of 35 Evidence: would ensure that care staff have all the information they need to provide personalised care to each resident that is consistent and thorough. In the Annual Quality Assurance Assessment, the registered provider told us that the home makes a full assessment of need before people move into the home so that we can meet their needs. However, we did not find evidence to support this statement. For one resident who moved into the home this year, the assessment consisted of a half page of rough notes made by hand. The registered provider had obtained a copy of the Social Services care manager assessment and a care plan was drawn up from the care manager assessment and the brief notes made by the registered provider. The registered provider told us that she spoke to the residents family to gather more information but there was no written evidence that the home had consulted with the resident or their family about individual needs, preferences, or choices, about how care is to be provided. The notes that the registered provider had written did not contain any information about how many staff would be needed to meet care needs or whether any specialist equipment would be needed by this resident. This means that residents who move into the home may be at risk of not receiving the care they need and staff may not have all the information they need to meet a residents care needs. We were not able to speak to the resident but we looked at what people had told us in the surveys. One person told us that they had been helped to choose the home after their family had visited to look around. All of the surveys told us that people always receive the care and support they need. However, six of the eight surveys were written by one member of staff who helped residents fill them in. Care Homes for Older People Page 12 of 35 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 delivery of health care does not reflect the homes statement of purpose. The ongoing monitoring of health care needs is not organised or consistent. Residents are at risk of not receiving the care they need. Practice in the home for storing, dispensing and recording residents medication is not safe and residents may be at risk of not receiving their medication, as prescribed, at all times. This was a regulatory requirement at the previous inspection and the home have not complied with legal requirements about medication practice and the safe storage of controlled drugs. Evidence: The health and personal care provided is not person centred. The individual plans of care that we looked at contained information about physical and health care needs. The care plans did not have a date so we did not know when the plan had been written. The care plans had not been signed by the resident or their representative. This means that residents or their representives may not have been consulted about their care plan or their preferences or choices as to how they would like care to be provided. Care Homes for Older People Page 13 of 35 Evidence: Concerns about the health of two residents in the home were recently referred to Social Services as a safeguarding concern. The investigation found that the home had not satisfactorily or promptly responded to the health care needs of two residents and there was a lack of awareness in the home of poor practice and the potential effect on the health of the residents. The home told us that since the safeguarding investigation they have reviewed their care plans and introduced new records to monitor the health care needs of residents. We were also told that records of residents contact with GPs or Community Nurses are now separately recorded in the care plans. We looked at three care plans. One care plan was for a resident who needs continence care but there was no continence assessment or care plan. The registered provider told us that continence assessments are carried out by the community nurses and the home does not have a copy. However, there was no plan of care for how continence needs would be met or information on what size pad should be used and when, or whether the resident needed to be assisted to go to the toilet. This could lead to people receiving care differently from different staff because there is no written guidance or information. One care plan stated the person may not eat if they are low in mood. The care plan did not contain guidance for care staff on the indicators for low mood and what action they should take if this happens. This resident did not have a nutritional assessment around their potential eating problems and the risk of weight loss. The care plan says that the resident should be weighed monthly but the daily records only record one weight check on 16 April 2009. The daily care records state that weight for this resident has fluctuated and food intake should be monitored, however, we did not find a record of food intake being monitored. The registered provider told us that the residents GP was consulted about the weight loss but we could not find a record of this. The care plan for this resident was reviewed on the same date (16 April) but the review did not contain any information about changes in care needs or the need to monitor food intake. This means that the resident may not have their health care needs met and staff may not be aware that there are changes in their care needs. One care plan records that a resident manages their own inhaler. The home supports the resident to do this. They did not however do a risk assessment to cover the risks that this activity might pose to the resident, or other residents, nor how any risks could be minimised. The daily records of care recorded on 27 April 2009 state that one resident should have their fluid and food intake monitored. We asked the registered provider why this had been recorded and we were told that the resident had not been eating very much. Care Homes for Older People Page 14 of 35 Evidence: However, the fluid and food intake had not been monitored and we were told that staff would know if the resident was not eating or drinking. However, as there was no written record there was no evidence that this was being monitored for any risks to the health of the resident. The registered provider told us that the home had only recently started to weigh residents and residents had not been weighed when they first moved into the home. A separate record is kept of bathing and weight checks but when we looked at these the records had not been completed since 24 April 2009. The gaps in recording puts the resident at risk of not having their nutritional and health care needs identified and met. The Annual Quality Assurance Assessment completed by the registered provider states that a nutritional assessment has been completed for every resident but we did not find evidence of this in the care plans. This means that residents who are at risk of not eating or drinking do not have a nutiritional care plan to guide staff on meeting their health care needs. One care plan had identified that a resident has a high risk of falling. However, the care plan did not contain any information on how this would be managed or minimised to protect the resident from harm. This means that the resident may receive care and support differently from different staff. The care plans are now reviewed monthly but records show that the review is recorded with a signature of a member of staff and the review does not contain any details of events or changes in care needs. When we visited the home in May 2008 we had concerns about gaps in the information and records of care and we made a regulatory requirement for the home to ensure that any risks to residents must be identified in the care plans and for a risk management plan to include clear written guidance for care staff on the action they must take to manage or eliminate any risk to residents. The home has not taken action to comply with this requirement. Failure to comply means that residents may be at risk of their care needs not being met, and staff may not have the information they need to manage events or minimise risks to residents health and well being. We also made regulatory requirements in 2008 about medication practice in the home and the storage of controlled drugs. The home has not taken action to comply with these requirements within the timescales given. The home does not have a clear audit trail for medication received, dispensed or returned. Some of the records of medication on the medication administration sheets did not match up with medicines in the medication cupboard for example; one resident Care Homes for Older People Page 15 of 35 Evidence: is prescribed furosemide but the amounts recorded on the medication administration records did not match up with the amounts in the cupboard. The manager and registered provider were not clear about areas of responsibility for safely managing residents medication. Some of the medication is in monitored dosage packs and some in original containers, however, the registered provider has not asked for specialist pharmacy advice on how the home can safely resolve some of the problems they are experiencing with receiving, storing and dispensing residents medication. The manager and registered provider did not know why some of the medication prescribed for residents is not printed on the medication administration record that is supplied by the pharmacy but they had not sought clarification on this. Some medication has been hand written by staff onto the administration record. These hand written records have not been checked and counter signed. This means that the medicine and the amounts to be taken may not be correct and match the prescribing instructions on the original container. Some of the residents are prescribed medicine that is to be taken as and when required (PRN). The individual plans of care contain a PRN medication record. However, the records do not contain specific information for each resident and each medicine. There was no information informing staff as to when and why these medicines should be given. This could lead to people receiving their medicines differently from different staff. Medication is supplied to the home in a monitored dosage system, and in individual containers. We observed staff transferring medicines from the original pharmacy supplied and labelled container and place them into another container for administration. This is called secondary dispensing and is an outdated and unsafe practice and is not in line with best practice as described in The Handling of Medicines in Social Care, produced by the Royal Pharmaceutical Society of Great Britain. This practice was also described as frequently associated with medication errors in a report by the Department of Health, Building a Safer NHS for Patients. We also observed staff handling medication without gloves and dusting the medication pots with their overalls. When we spoke to the registered provider we were told that staff have always dispensed medication this way and the registered provider was not aware that the practice is unsafe. Some of the staff in the home have received training in the safe administration of medication, however, some staff are dispensing medication without being trained or assessed as competent to do this. When we looked at the training records, one person had not done any medication training since 2003, and two other members of staff who dispense medication had not done any training or been assessed by the registered Care Homes for Older People Page 16 of 35 Evidence: provider as competent to safely dispense medication. This means that residents may be at risk from poor practice in the administration of residents medication. We made a regulatory requirement in 2008 for the home to meet current legal requirements for the storage of controlled drugs. The timescale for the home to comply with this requirement was 30/09/08 and the registered provider has failed to comply with this legal requirement. We found that controlled drugs are stored in a cash box in the medication cupboard and this does not meet legal requirements. We were told that a cupboard had been purchased to store controlled drugs and was awaiting installation. However, the cupboard is a first aid cupboard and does not meet the legal requirements for the safe storage of controlled drugs. We spoke to the registered provider and made immediate regulatory requirements about medication practice and the storage of controlled drugs. Care Homes for Older People Page 17 of 35 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. Residents are offered limited opportunities for social and leisure activities, collectively rather than individually. Wholesome meals are offered in pleasant surroundings. Visitors are welcome at any time. Evidence: We were told in the Annual Quality Assurance Assessment that there is an extra member of staff on duty on Thursday and Friday mornings to co-ordinate games, quizzes and activities with the residents. A local community arts group visit each month to do music and reminiscence sessions with the residents. The record of activities was not up to date and nothing had been recorded since 10 April and the last recorded visit for the arts group was 10 February. At the last inspection we wrote that the home should consider, as good practice, how activities can be arranged that are suitable for the different needs and abilities of residents who have dementia, but there is no evidence that this has been addressed. The care plans do not contain details of residents choices or preferences about activities they like to do, or details of their spiritual or cultural interests or choices. There is no evidence that residents are Care Homes for Older People Page 18 of 35 Evidence: consulted about their choice of social activity. In the AQAA the registered provider stated that the service could do better by having a list of all service users choices to place in the activities book. The AQAA did not provide evidence of when this would be completed. Comments from staff in the surveys told us that they would like to have more time to take residents out for trips, shopping etc. The AQAA stated that outings will be arranged during the summer. Residents who completed surveys told us that they enjoyed the games and community arts group. However, surveys were completed with assistance from staff in the home and all comments were identical. Wholesome meals are provided in pleasant and attractive surroundings. The home employs a cook for 5 days each week who prepares and cooks the lunchtime meal. The registered provider cooks at weekends. Feedback from residents in the surveys confirms that the meals provided are good. The dining room is furnished with matching round tables and chairs, with tablecloths, flowers etc, to make mealtimes an attractive and pleasant experience. Visitors to the home are welcome and there is information for visitors and a visitors book in the entrance to the home. Care Homes for Older People Page 19 of 35 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. Residents are not protected because of poor and inconsistent practice in the home. The registered person has not ensured that the home has robust procedures for recognising or responding to concerns about the safety of residents in the home. Residents and their representatives are not provided with clear and accessible information about the homes complaints procedure. Evidence: The registered provider told us in the AQAA that all staff in the home have received training in safeguarding or protecting vulnerable adults. However, the training records were not up to date and did not provide evidence to support this statement. We were told that 5 of the care staff did some training the week prior to our visit in safeguarding awareness and were awaiting training certificates, but the manager was not able to demonstrate that all staff in the home were up to date in their safeguarding training because of the absence of up to date training records. There have been recent concerns about practice in the home and vulnerable residents have been identified as being at risk of neglect because the registered person has not taken prompt and appropriate action to meet their health care needs. The concerns were reported by health and social care professionals who visit the home. The registered person has not taken action to meet previous regulatory requirements Care Homes for Older People Page 20 of 35 Evidence: to ensure that any risks to residents are clearly identified and recorded and staff do not have clear guidance on how events are to be managed or how any risks to residents must be minimised or eliminated. This means that residents in the home may be at risk of their health care needs being overlooked or not met. The registered person has not notified us of events in the home that affect the safety or well being of the residents. This is a legal requirement. The incident records in the home show that there have been events affecting residents that have not been reported to us. The registered provider told us that she did not realise that this was a regulatory requirement. This means that residents may be at risk because the home do not have a clear policy and procedures for reporting events to the commission. Events affecting the safety and protection of residents have not been reported to Social Services as safeguarding concerns. This means that staff are unaware of their responsibilities to protect residents in the home and are not clear about the agreed policies and procedures they must follow. The complaints procedure for the home is not easily accessible and the procedure has not been updated with information about how people can contact the commission if they need to. The statement of purpose for the home says that despite eveything that we do to provide a secure environment, we know that residents may become dissatisfied from time to time and we will provide when necessary a simple, clear and accessible complaints procedure. However, the service user guide says that the complaints procedure has to be requested. In addition, the information about contacting the commission refers to both the National Care Standards Commission (not in action since 2004) and the Commission for Social Care Inspection, and also gives the wrong address for the commission). The AQAA states that no complaints have been received. We did not find evidence that the service openly welcomes or values complaints or comments and the complaints information is unclear and incomplete for residents and visitors. At the last inspection we were told that the home plans to produce a complaints leaflet that is accessible and easy to read, however, the registered person has not done this. Care Homes for Older People Page 21 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Current staffing issues have meant that some areas of the home are not being maintained in a clean and hygienic state, at all times. Staff are not clear about the policy and procedures for infection control and reducing the risk of cross infection and this may put vulnerable residents at risk of infection. Evidence: Comments from residents confirmed that the home is usually clean, tidy and pleasant. However, the cleaner employed by the home has left and will not be replaced until 18 May 2009. We were told that in the interim period, care staff would be doing the cleaning. However, care staff have not been given specific tasks or cleaning duties to ensure that all areas of the home are regularly cleaned. The shared toilets were in a very soiled and dirty state and there was no record of when they were last cleaned. Washbasins and commodes in some bedrooms were in urgent need of cleaning. Commode frames were very dirty. The frame, legs and lids of the commodes in residents bedrooms were stained and dusty. When we asked what the cleaning rota is for equipment in the home, the manager did not know. We also found that one commode contained urine that had not been emptied. Mobility equipment such as zimmer frames and wheeled rollators were very dirty and in urgent need of cleaning. The seat and frame of one wheeled rollator did not appear Care Homes for Older People Page 22 of 35 Evidence: to have been cleaned for some time. This means that residents may be at risk of the spread of infection if essential equipment is not regularly cleaned and disinfected. We made an immediate requirement for action to be taken to ensure the home is clean and hygienic to protect residents from the risk of infection. The home does not have a sluice and we were told that commode pans are cleaned in the sink in the laundry. To access the laundry room, staff have to carry commode pans and soiled laundry through the dining room and kitchen. We asked two members of staff about the infection control procedures for the home. We also asked if staff have a written policy and procedure to follow. Two people did not know if there was a policy and procedure for safe practice. We were told by a member of staff that staff do not wear plastic aprons when cleaning commodes. We were told that the home has temporarily run out of gloves. One person told us that commode pans are cleaned every week in the laundry sink with disinfectant and another person told us that pans are bleached every week. This means that different staff may be working in different ways without clear guidance on what they should be doing to ensure that procedures are safe and hygienic. The manager told us that they have not sought advice on best practice guidance from an infection control specialist. Some areas of the home have been decorated and refurbished and some residents commented on how nice the decoration is. Work is currently ongoing on the exterior of the building. Since the registered provider purchased the home in 2007, the building has been extensively repaired and refurbished. The registered provider told us that the building had not been maintained well by the previous owners and the repairs needed to the building were still ongoing. Care Homes for Older People Page 23 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not have a comprehensive staff training plan and some of the staff training is out of date and some areas of staff training are not being identified and met. The home does not provide person centred care and staffing levels mean that activities for the residents are limited. Staff recruitment procedures are not robust and staff supervision is infrequent and residents may not be protected from poor or inconsistent practice in the home. Evidence: The staff rota for the home shows that there are 2 care staff on duty between 7.30 am and 10 pm. Usually there is an extra member of staff on duty on Wednesdays and Thursdays between 8am and 1pm to provide social activities. However, for the week beginning 27th April there was a gap in the rota on Wednesday 29th April that had not been filled. The cook works from 9am - 1.30pm on Mondays to Fridays and we were told that the registered provider cooks at weekends. (The provider did not confirm that she has the required food safety and food handling qualification) When a cleaner is employed, this person works 20 hours per week. The manager and provider were not on the rota and we were told that the manager is employed for 30 hours per week, working 9am - 2pm on Monday to Friday, with occasional shifts to cover gaps in the rota. The home employs one person to work from 10pm to 7.30am and we were told that the provider is available to be on call at night if a second carer is needed. The Care Homes for Older People Page 24 of 35 Evidence: home does not employ agency staff and gaps in the staff rota are covered by existing staff. There are currently 12 residents in the home and the numbers of staff employed mean that there may not be enough staff to provide social or leisure activities every day, or provide person centred care. Two of the residents require the assistance of two carers with all activities and personal care. This may mean that residents may have to wait for help when they need it if staff are preparing the evening meal or are assisting another resident at times when there are only two staff on duty in the evenings. If there is only one person on duty at night, there is a risk that residents may not receive the help they need, when they need it. The home does not have a thorough and comprehensive training plan to ensure that staff have the skills, knowledge and competencies to meet the needs of the residents. Some improvements to staff training have been made recently in response to recommendations from Social Services following the investigation into concerns about poor practice in the home. However, the training records are not complete and up to date and there is evidence that not all of the care staff have received up to date training in all areas of safe working practice. For example, some of the staff who dispense medication have not received appropriate training in the safe administration of medication and not all of the care staff have received appropriate training in food safety, infection control or first aid. The training provided is limited and staff have not received up to date training in dementia care, mental health care or the Mental Capacity Act and the code of practice for this. The registered provider told us that the home has purchased a staff training programme that will cover all of the areas of skills and knowledge that staff need to meet the needs of the residents. At the time of the visit, the manager did not have a date for when staff are likely to complete this training. However, the manager has identified that some of the training programmes that have been purchased do not provide practical experience for staff in safe moving and handling or first aid and will address this issue. The AQAA states that all of the care staff have achieved a National Vocational Qualification in Care (NVQ), however, the records do not confirm this. Four care staff have an NVQ in care or equivalent at levels 2,3 or 4 and one person is currently enrolled to achieve an NVQ level 3 in care, this equates to about 50 of staff who have a qualification in care. We looked at the recruitment records for two new members of staff. The records show that some checks were in place before staff started to work in the home, however, the recruitment procedures are not robust and thorough and one reference was requested from the registered provider for one member of staff and the other member of staff Care Homes for Older People Page 25 of 35 Evidence: had references that were not dated or verified. The home had not carried out and recorded a risk assessment or other action to protect residents when a criminal record check revealed a previous conviction. The staff application form is not thorough and does not ask for a full employment history with dates of starting and leaving previous employment. One application form has not been dated or signed. This means that the recruitment procedures for the home are not robust enough to demonstrate there are sufficient checks to ensure that all staff are suitable to work in the home with the residents. At the last inspection the registered provider told us that arrangements were being put into place to ensure that staff receive regular support and supervision. Records show that staff supervision has been infrequent with long intervals between supervision sessions. Following recommendations made by Social Services, the home told us that staff supervision will be arranged every two months. There are no records to demonstrate that practice in the home is regularly monitored or that staff who work nights or weekends receive support and supervision or that practice is monitored to ensure that the homes policies and procedures are being followed at all times. This means that residents may be at risk from poor or inconsistent practice in the home. Care Homes for Older People Page 26 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a new manager who is not yet registered with the commission. Practice in the home does not consistently protect and safeguard the health and well being of the residents. Practice in the home is not consistently monitored to ensure that policies and procedures for safe working practice are always followed. Evidence: A new manager started working in the home in September 2008. We wrote to the manager and registered provider on 15 April 2009 because we had not received an application to register the manager. The manager has now confirmed that a registration application was sent to the commission on 23 April. The manager is currently enrolled to achieve the National Vocational Qualification (NVQ) level 4, in care, and plans to finish this by the end of 2009. We were told that the manager will then enrol to achieve a management qualification. We were told that the manager works in the home for 30 hours per week plus occasional cover for shifts when rotad staff are unavailable. The hours that the manager works should be included on the Care Homes for Older People Page 27 of 35 Evidence: staff rota so that staff are clear when the manager will be in the home. The manager does not have previous management experience. At the last inspection we made a regulatory requirement for the registered person to ensure that there are effective quality assurance and quality monitoring systems in place. The home must measure how well the home is providing good outcomes for residents and demonstrate compliance with requirements of the Care Homes Regulations 2001. We did not find evidence of effective quality monitoring systems in place. Some practice in the home such as medication practice, review of the health care needs of the residents, infection control and health and safety practice is not being regularly monitored. This means that the home are not consistently promoting safe practice and the health, safety and well being of residents is not consistently protected. The registered provider has been writing a monthly report of her inspections of the home but these reports have not identified those areas of concern such as cleanliness and hygiene, poor care planning, poor medication handling and poor organisation and management of the service. The registered provider has started to address staff training issues because there are concerns about the safety of residents in the home. There is not a clear health and safety policy in the home and action has been taken to review policies and procedures only when problems or incidents have been highlighted. The home had a health and safety inpection in October 2008 and this highlighted that the home did not have an up to date safety management system, full policies and procedures and risk assessments and did not have manual handling risk assessments. The registered provider confirmed that these were now in place. A food safety inspection of November 2008 highlighted that the home had not done the required food safety hazard analysis. The provider confirmed that this was now in place and the home has a 4 star (out of 5) food safety rating. The records for fire safety checks were up to date for the fire alarm, emergency lighting and fire exits. However, the fire safety risk assessment was not dated and did not contain a risk assessment for a resident who smokes in the home. The record for fire drills recorded that two drills were held in January 2009, but none since then. This means that residents may be at risk because practice in the home is not regularly monitored to ensure that residents are protected and staff are following policies and procedures for safe working practice. The Annual Quality Assurance Assessment was returned by the registered provider but provided very little information about the service, with minimal evidence to support any of the statements made within it. The questions relating to the views of the Care Homes for Older People Page 28 of 35 Evidence: residents and to equality and diversity were poorly completed. In answer to the question about what the home does to incorporate equality and diversity into what they do, we were told freedom of choice, and communication, but the AQAA did not contain any evidence of how the home promotes freedom of choice and communication. The AQAA does not give us a reliable picture of the service. The home does not promote person centred care planning and there is no evidence that care is provided in a person centred way. There is no evidence that staff in the home have received information or training in the Mental Capacity Act or that the home has acquired a copy of the Mental Capacity Act Code of Practice. This means that staff may not be aware of their responsibilities with regard to the rights of residents in the home. The AQAA did not provide any information about how the service is planning to make further improvements as a result of listening to people who use the service, the only evidence in this section was update further training. This did not tell us how the service ensures that the views of people are noted and incorporated into what they do. The policy of the home is that staff do not take responsibility for residents financial or legal affairs. However, the home does not have a policy or procedure in place on what action would need to be taken to protect a resident who does not have a representative and who does not have the capacity to manage their own affairs. Care Homes for Older People Page 29 of 35 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 13(4) The registered manager 30/07/2008 must ensure that any risks to residents are identified in the care plan. The risk management plan must include clear written guidance for care staff on the action they must take to manage or eliminate any risk and what they must do to manage any event that may put a resident at risk of harm. 2 9 13(2) The registered manager 30/07/2008 must make suitable arrangements to make sure that residents medication is safely stored and dispensed. This will ensure that residents receive their medication, as prescribed, at all times. The registered manager 30/09/2008 must ensure that the storage of controlled drugs meets the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 as amended. The registered manager must ensure that there are 30/09/2008 3 9 13(2) 4 33 24 Care Homes for Older People Page 30 of 35 effective quality assurance and quality monitoring systems in place to measure how well the home is providing good outcomes for residents, and demonstrate compliance with the requirements of the Care Homes Regulations 2001 and meeting the National Minimum Standards. Care Homes for Older People Page 31 of 35 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 The needs of the residents must be assessed by a suitably qualified or trained person in consultation with the resident or their representative. Residents should only move into the home if the service is confident that they can meet all health and welfare needs and that staff in the home have the skills and expertise needed to meet the needs of residents. 30/06/2009 2 9 13 Controlled drugs must be stored in a controlled drugs cupboard that complies with the Misuse of Drugs (safe custody) Regulations 1973 (as amended) In order to comply with the law. 30/06/2009 Care Homes for Older People Page 32 of 35 3 9 13 The registered person must 30/06/2009 make suitable arrangements to ensure that residents medication is safely stored, dispensed and returned. Staff must be competent and trained and follow clear policies and prodedures for the safe administration of medication received into the home. 4 9 13 In the interests of safe 30/06/2009 medication handling all medication must be administered directly from the original labelled container to the service user and not be placed into any secondary container for later administration. Residents must receive their medication, as prescribed, at all times. 5 18 13 Suitable arrangements must be made to prevent residents being harmed or suffering abuse, or being placed at risk of harm or abuse. The registered person must ensure that all staff receive suitable training to ensure they are aware of their responsibilities to protect residents from the risk of harm or abuse. 30/06/2009 Care Homes for Older People Page 33 of 35 6 26 13 Suitable arrangements must be made to prevent infection, toxic conditions and the spread of infection at the care home. Residents must be protected from the risk of infection. Staff must have clear guidelines and suitable equipment to ensure practice in the home follows best practice guidance for the control of infection and maintaining a hygienic environment. 30/06/2009 7 30 18 Staff working in the home 30/06/2009 must receive training appropriate to the work they do. Staff must be trained and competent to meet the needs of the residents in the home. 8 38 37 The registered person must notify the commission without delay of any event in the home that affects the safety or well being of residents. To protect the safety, health and well being of the residents. 30/06/2009 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 Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 35 of 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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