Inspection on 02/02/10 for Drummuir Nursing and Residential Home

This inspection was carried out on 2nd February 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drummuir Nursing and Residential... 29/03/10

Drummuir Nursing and Residential... 03/03/10

Drummuir Nursing and Residential... 02/09/09

Drummuir Nursing and Residential... 03/03/09

Drummuir Nursing and Residential... 11/04/08

Drummuir Nursing and Residential... 11/12/07

Drummuir Nursing and Residential... 05/03/07

Drummuir Nursing and Residential... 26/06/06

Drummuir Nursing and Residential... 10/01/06

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Extracts from inspection reports are licensed from CQC, this page was updated on 10/04/2010.

Key inspection report Care homes for older people Name: Address: Drummuir Nursing and Residential Home 9-11 Northfield Bridgwater Somerset TA6 7EZ     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: Justine Button     Date: 0 2 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 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 40 Information about the care home Name of care home: Address: Drummuir Nursing and Residential Home 9-11 Northfield Bridgwater Somerset TA6 7EZ 01278422144 01278420397 drummuir@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited care home 38 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 old age, not falling within any other category Additional conditions: Elderly persons of either sex, not less than 60 years, who require general nursing care Up to eight places for personal care Up to two persons of either sex, between the ages of 50-60 years who require general nursing care Date of last inspection Brief description of the care home Drummuir Nursing Home is situated in a quiet residential area close to the town centre of Bridgwater. The home is not purpose built. Drummuir is registered with the Care Quality Commission provide general nursing care for up to 38 older people, although the home can only accommodate a maximum of 31 people. This includes up to 8 people who require personal care. The fee range does not include hairdressing, newspapers, toiletries, optician and some activities. 0 4 0 9 2 0 0 9 0 Over 65 38 Care Homes for Older People Page 4 of 40 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 focus of this inspection visit was to inspect relevant key standards under the Commissions Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are:- excellent, good, adequate and poor. This inspection was carried out by two inspectors over a one day period. During this time We, The Commission, were able to speak with people living and working at the home, tour the building, view records and observe care practices. Due to the concern raised relating to medication our pharmacy inspector visit the home on the 04/02/10. The findings of her inspection are incorporated in this report. We were given unrestricted access to all areas of the home and all records requested were made available. Care Homes for Older People Page 5 of 40 There is currently no registered manager but a interim manager has now been based at the home. Many of the people who live at the home are unable to fully express their opinions, therefore much of this inspection was spent observing care practices and interactions. At the time of this inspection there were 25 people living at the home. Fees at the home currently Range from 550 to 850 pounds per week. In October 2009 the home received a key inspection and received a rating of adequate following a previous poor rating. Since this time we have received a number of concerns and complaints about the level of care and support people at the home are receiving. These concerns have been made by visiting healthcare professionals including GPs District nurses, supplying pharmacists and relatives. As a result of these serious concerns we met with Somerset County Council, the Primary Care Trust and the company Ashbourne (Eton) Limited a subsidiary of Southern Cross Health care under Somerset Safeguarding policy. At the meeting it was agreed that Social workers and district nursing staff would be reviewing the care and support afforded to all people at the home. At the time of writing this report these reviews are being undertaken. An additional meeting has been arranged to discuss any actions that will be required as a result of these reviews and the findings of this inspection. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Care Homes for Older People Page 6 of 40 What the care home does well: What has improved since the last inspection? What they could do better: 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. Care Homes for Older People Page 7 of 40 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 8 of 40 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 9 of 40 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. These standards were not viewed in detail on this inspection visit. Due to the concerns expressed to us the company has agreed to suspend new admissions until further notice. Evidence: These standards were not viewed in detail on this occasion. The care plan for one individual who had recently been admitted to the home was viewed. This showed that a preadmission assessment had been completed. The assessment however was conducted only the day prior to the individual being admitted to the home. This short timescale may not enable staff at the home sufficient time to prepare for the admission of the individual. When people are admitted to the home staff should complete a range of assessments and develop initial care plans. In the care plan viewed these assessments were not completed for three days following Care Homes for Older People Page 10 of 40 Evidence: admission. The concerns recieved by us question the number, skills and competencies of staff at the home. The home is not currently meeting the needs of people at the home. Care Homes for Older People Page 11 of 40 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 health care needs of people living at the home are not being met. The current assessments and care plans do not provide up to date information or reflect the current care needs of the individuals living at the home. The management of medication does not safeguard people living at the home. The staff may not have the skills to support people at the end stages of their life. Peoples dignity and self esteem are not respected in all areas Evidence: Concerns have been expressed to us from district nurses, local GPs, the supplying pharmacy, social workers and relatives with regard to the care and support afforded to people living at the home. Although these concerns are extensive, the main concerns relate to the care of people with diabetes, those at the end stages of life, moving and handling and the management of medication. During the inspection visit we identified Care Homes for Older People Page 12 of 40 Evidence: additional concerns with regard people who have or who are at risk of losing weight and those who are or who have developed wounds or pressure ulcers (also known as bed sores). During the inspection we reviewed the care plans and care given to three people living at the home, In addition we reviewed aspects of the documentation (such as weight records) for a number of other people. At the beginning of the inspection we observed one individual who was in bed. The individual was observed to be holding a beaker of fluids but seemed unable to raise the cup to her mouth. The fluids in the cup had been thickened. Fluids are thickened when people are at risk of aspiration (choking). The individual looked very thin with a dry/dirty mouth. The individual did not look well cared for with very dry skin and food remnants on her clothing. We reviewed a number of charts that were in place in the bedroom. These charts are used to record fluid and dietary intake and elimination records. The fluid charts showed that in the days preceding the inspection visit the individual had been supported to have between 230mls and 400mls daily. This is not sufficient and would leave the individual in a state of dehydration. The charts had not been totaled (or added up) so it is difficult to understand how the charts influence the care that staff provide. The individual had a dry dirty mouth. This may be due to being dehydrated but the individual had no toothbrush or paste in her room. There was no evidence of mouth swaps or any other tools that could be use by staff to complete oral hygiene. The lack of equipment leads us to believe that the individual had not been supported to maintain oral hygiene. The individual was on a pressure mattress (used to aid the prevention of pressure ulcers or bed sores.) A chart was in place for staff to record that they had checked that the mattress was in working order and set at the correct level on a daily basis. This had last been completed on the 21/12/2009. In addition to the use of a pressure mattress a regular change of position is required to help in th prevention of pressure ulcers. People who are thin and who are unable to change position independently are at higher risk of developing pressure ulcers. Despite being on a specialist mattress and being thin on observation there were no records to demonstrate that the individual had been supported by staff to change position on a regular basis. We reviewed the care records for this individual. A pre admission assessment had Care Homes for Older People Page 13 of 40 Evidence: been completed while the individual was in hospital. This assessment identified that the individual was thin and at risk of additional weight loss. At this stage, December 2009, the individuals weight was 39kg. The preadmission assessment told us that the individual was at risk of choking and required a diet high in calories and fluids. The assessments completed following admission stated that the individual had two pressure areas that had broken down. On viewing the records we could not determine the progress of these wounds. Despite the pre admission assessment confirming that the individual was of a low body weight and having two small broken pressure areas the pressure ulcer risk assessment that had been completed stated that the individual was of low risk. The pressure ulcer risk assessment had not been reviewed since admission in December 2009. A nutritional assessment had been completed in December 2009. This assessed the individual as being at high risk of losing weight or being at risk of malnutrition. The bowel assessment stated that the individual should be receiving 1020 Mls per day. This was not observed to be given according to the fluid charts held in the room. The nutritional assessment stated that the individual should be on a food chart to record dietary intake. No such charts were observed to be kept. We confirmed this with the manager on duty on the day of the inspection. The nutritional assessment stated that the individual should be supported to have fortisips, forticreme and calogen (all supplements used to support people of low body weight or at risk of poor nutrition). The fortisips were not seen to be recorded as being given regularly on the fluid charts seen. We reviewed the medication records. The medication records showed that the supplements had been signed as given. We are unable to confirm due to contradictory evidence if the individual is receiving adequate supplements as prescribed. Due to poor medication management we cannot complete a drug audit for this individual to ascertain if the supplements had been given. On viewing the care records we could find no evidence of the individuals current weight despite looking thin and the preadmission assessment stating that the individual was at risk of loosing additional weight. We requested any up to date weights from the manager on duty on the day of the inspection. The nutritional assessment stated that the individual should be weighed weekly. This had not been completed. The last recorded weight was dated 11/01/10. Due to this we requested that staff weighed the individual. This was completed and demonstrated that the individual had lost 5 kg since admission. It could not be confirmed due to lack of regular weights and poor documentation if staff had recognized this weight loss and taken appropriate action. Despite observing the individual having thickened fluids and pureed diet no risk assessment had been completed for the risk of choking. Care Homes for Older People Page 14 of 40 Evidence: When we reviewed the Medication record for the individual we were told that medication had not been given that day as it had ran out. Staff confirmed that this was due to the fact that they had neglected to order the medication in time. The medication had since been ordered but would not arrive in time for that day. Due to potential dehydration, weight loss and poor physical condition we requested that a GP visit to review the individual. We reviewed the weight records for people living at the home. We were told that on the day of the inspection visit 25 people were living at the home. Weights were available for only nineteen people. Staff told us that they only had one set of sit on scales and that these were not suitable for all people at the home. Staff told us that scales for use with the hoist were not available. Of the nineteen people who had weight recorded we looked at ten peoples weights in detail. Nine of these ten people had lost weight. Weight loss ranged from between 0.7kg and 3.4kg. Given these finding at least ten people at the home have lost weight since December 2009. We reviewed the care records for another individual living at the home. This person has diabetes who is controlled by the use of insulin. The nutritional assessment stated that the individual was under weight however only one weight was recorded. This individual was not on the list supplied by the manager on duty on the day of the inspection. The assessment states that the individual should be weighed but does not state how often this should e completed. Despite being on insulin there was no clear care plan with regard to the how often staff should complete blood sugar levels. There was no plan in place giving clear details to staff on the individuals normal blood sugar. There was no details of the signs or symptoms of high or low blood sugars. A chart was in place recording challenging behavior however there was no plan in place detailing what behaviours were exhibited or what staff should do when these behaviours are shown. The care plan for another individual was viewed. Again concerns were found with regard to weight loss and lack of clear care planning in this area. No regular monitoring of the individuals weight had been completed. The individual again was at risk and had developed pressure ulcers. The charts in place did not demonstrate a regular change of position despite the care plan stating that the individual should be supported to change position on a four hourly basis. Care Homes for Older People Page 15 of 40 Evidence: We reviewed the charts in a number of the bedrooms and those held in the lounge area. These confirmed that fluid charts turn charts and dietary intake were not completed accurately by staff. It could not be confirmed due to the lack of information held on the charts, care plans and daily records that the healthcare needs of people are being met in relation to dietary intake, fluid intake and pressure area care. In the rooms viewed a number of people had not been supported to complete oral hygiene. Some people had no toothpaste or toothbrushes. For some who did have this equipment a number of these were seen to be hard and dry. As a result of the concerns raised with us a CQC pharmacist visited the home and wrote the following report The pharmacist inspector visited the home on 4th February. During this visit we spoke to two qualified nurses currently working in the home. One of the nurses told us that she had been brought in to the home to help them with managing medicines safely. We also met a relief manager, a training manager and the service quality adviser for the registered provider, Southern Cross, who are all providing support to the home. Medicines are supplied by a local pharmacy using a monthly blister pack system. The pharmacist has visited the home several times over the last few months to provide additional support to the home. No-one living at the home is able to look after their own medicines and all are looked after and given by staff. Paracetamol is kept for use as a homely remedy and we saw suitable records for its use. We saw some medicines being given after lunch. Medicines were transported safely around the home and the medicines administration record sheets were checked and signed as medicines were given. A company policy for medicines administration is available for staff. Nursing staff told us that giving medicines had improved since they had two trained nurses on duty in the morning. They can now each give medicines so people receive their medicines at a more reasonable time. We looked at some of the supplies of medicines in the home. One of the nurses told us that she has been checking all the medicines and recording the quantity of medicine carried on to the new administration record from the previous month. This makes it easier to audit the medicines supplied in standard packs and to check that they have been given correctly. We checked a number of packs and saw some discrepancies which indicated that medicines had not been given as recorded. For example one bottle of liquid medicine had very little missing from the bottle although the signatures Care Homes for Older People Page 16 of 40 Evidence: showed that 20mls had been given from a bottle containing 60mls. One box of tablets had 28 tablets missing but the record showed that 37 tablets had been given. A monthly blister pack of medicine had a tablet left in the pack on two days that staff had signed that the tablet had been given. A record for Paracetamol tablets showed that 18 tablets had been given but only 12 tablets were missing. Action must be taken to ensure that medicines are given as prescribed and that administration records are accurate. The pharmacy provides printed medicines administration record sheets for staff to complete each month.We saw that where staff had made handwritten additions to the record they signed and dated these and had them checked by a second member of staff. This is good practice to reduce the risk of mistakes being made. However we also noted that many people had medicines spread around a large number of record sheets. There were a variety of reasons for this but it could make it more difficult for staff to find the appropriate record sheet and increase the risk of mistakes being made. Action should be taken to make the record sheets as easy to follow as possible. Some protocols are in place for medicines prescribed to be given when required. These help staff to give the medicines appropriately and consistently. However these had not always been completed for example one person was prescribed three different medicines to be given when required but only one had a protocol for its use. Action should be taken to complete these for all when required medicines. Some medicines have been prescribed with a variable dose but a record has not always been made of the amount that has been given. For example one person is prescribed an inhaler with a dose of one to two puffs. There is no record of how much has been given and also no guidance for staff about how they decide how much to give. We saw a number of gaps in the records of medicines given. It was not clear whether the medicine had been given. For example a 3 day course of tablets only had two signatures. The record for another person had five gaps for one of their medicines but no record of whether the tablet had been taken or missed for some reason. Records for the use of some creams are kept in files in peoples rooms and are signed by the carer who has provided personal care to that person. However we saw that a medicated cream prescribed twice daily for one person had no record of its use and the tube was unopened in the cupboard. Another person had three different creams in their room, only one was labelled with their name and instructions for use. None of these creams appeared on their medicines administration record and there was no Care Homes for Older People Page 17 of 40 Evidence: record that they had been used.We could see no information in their care plan about the use of these creams. This means that the person may not get appropriate treatment. Records for the use of some sip feeds were difficult to follow to see if they were given as prescribed. One person prescribed a feed daily had signatures on 15 out of 21 days but no record of the reason it had not been given on the other six days. One person prescribed a medicine which needs special monitoring had the appropriate records in place to enable staff to give the medicine safely. Records are kept of the receipt of medicines into the home and the disposal of unwanted medicines. We saw staff recording the disposal of medicines which people had refused to take. We looked at three peoples care plans to see if suitable information was recorded concerning their medicines. Staff showed us information about disguising medicines, if necessary, for one person who did not like to take them, although they told us that they did not do this. The care plan did not demonstrate that an assessment had been made of the persons capacity to make a decision about their medicines and staff did not know whether this had been done. One person has had a recent review of their medicines this had been documented in the care notes but there no details of how the medicines had been changed was recorded. This means that staff would not be able to easily check that the correct medicines were supplied and given. One person had some new medicines prescribed which were not yet needed. We could not find a care plan in place to help staff to use these medicines appropriately and asked that one be written. Staff confirmed the next day that this had been done. Suitable secure storage is available for medicines. Two medicine trolleys are used to transport medicines securely around the home. One of the nurses told us that she had requested a third trolley so that there was one for each floor of the home. A medicines fridge is available and records show this is kept at a suitable temperature for storing medicines. Recent records show that action has been taken to ensure that the room is a suitable temperature for storing medicines. A suitable cupboard is available for storing medicines that require additional security and suitable records are kept of the use of these medicines. Care Homes for Older People Page 18 of 40 Evidence: The concerns expressed to us lead us to believe that staff do not have the skills to meet the needs of people at the home. Community nurse have been asked to visit the home to complete tasks such as catherisation, bloods montioring and syringe drivers (used to provide pain relief at the end of life) and subcutanous fluids. These are tasks that staff within a care home providing nursing care should be able to complete on the majoirty of occassions. In addition we have reiceved notifactions an occassion when the care of people with diabetes has been compromised. As a result of these concerns we have requested that the company conduct an audit of the skills of the regsitered Nurses working at the home. As result of the concerns raised both at the inspection and from other professionals visiting the home a meeting was held under the Somerset Safeguarding policy. Somerset County Council are responsible for this procedure. During the meeting we discussed our concerns with senior managers from Southern Cross Health care. It was agreed that the PCT along with social workers would review the care and support needs of all people living at the home in order to assess if the home could continue to meet individuals needs. The reviews are being conducted at the time of writing this report. Due to the current concerns expressed the community nurses are visiting the home on daily basis to support people at the end of thier life and those with diabetes. In addition as previously stated admissions to the home have been stoped until further notice. Care Homes for Older People Page 19 of 40 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social and recreational opportunities are available. visitors are made welcome at the home. People are not able to exercise autonomy and choice. people living at the home may not be receiving an adequately nutritious diet Evidence: On the day of the inspection the activities organiser was on duty. A range of activities were on offer including some arts and crafts, connect 4 and reminiscence. People who were involved in the activities appeared to have be having a positive experience. A number of other people either those who remained in their rooms or those in the main lounge area appeared to have little or no interaction. Staff presence in the room was spasmodic and staff to did engage with people frequently. No visitors were seen on the day of the inspection however people living at the home told us that friends and family are able to visit. These were the findings of previous inspections. Care Homes for Older People Page 20 of 40 Evidence: People living at the home may not have choice and autonomy. Choice with regard to meals may be limited for those people who require a specialists diet (see below). In addition choice is limited for some people with regard to the choices they make about how to spend their time and lifestyle choices for example what time they get up or go to bed, (see outcome area 6 re staffing) At the last inspection it was reported lunch was a choice of Cornish pastie or cheese and onion quiche. Both of these products were shop bought and not made on the premise. This may have been due to the breakdown of the freezer but the management need to keep this under review to ensure that nutritional value of the meals served is adequate. Chips or mashed potato were available as well as swede and carrots. Omelettes and salad were also available although this was not chosen by anyone living at the home. On this inspection again the food seen to be served at lunch time were shop bought and from a supermarket value range. The meal consisted of faggots or mince and onion pie. mash potato or chips. Frozen vegetables were served. Although the nutritional value of frozen vegetables is not under debate people living at the home told us that the majority of vegetables were frozen. People told us that they would like fresh vegetables more frequently as they maintained their texture. During the inspection we reviewed the foods available in the kitchen. The freezers which was broken at the last inspection had been replaced. Limited stock was available in the freezer. Food seen included value fish cakes, frozen breaded fish and some frozen vegetables. The fridges also held limited stock. A small number of yoghurts, cream, eggs and cheese was seen. A small amount of lettuce and tomatoes were available. No fresh vegetables were seen only some pre chopped cabbage in vacuum pack packaging. This had come from a wholesaler supplier. Desert on the day of the inspection was creme caramel. This was seen to come from a ready mix that was stored in the store cupboard. In addition mousse and lemon meringue mix were seen. The nutritional value of these puddings is questionable. On the day of the inspection three kitchen staff were available over the lunch time period so it cannot be confirmed why some of the meal provided was not homemade. This is particularly relevant considering the number of people at the home who have lost or who are at risk of loosing weight. If foods were homemade the meals could be fortified to reflect peoples individual needs. the lunch time kitchen staff prepare the evening meal for the evening kitchen staff to warm up and serve. On the day of the inspection visit fish pie, soup (from a packet) and sandwiches were prepared. The sandwiches were observed to be covered in the fridge. the fish pie and soup however were observed to Care Homes for Older People Page 21 of 40 Evidence: left uncovered in the kitchen. These were left for several hours between lunch and the serving of the evening meal. This practice needs to be reviewed to ensure robust food safety. Choices of main meals are prepared on a daily basis. The cook prepares a list of the food to be cooked and prepared the following day. During the evening staff go around and ask people what they would like the following day. The list was seen in the kitchen on the day of the inspection visit. Eight people living at the home had asterisks beside their name. At the bottom of the page the key to the asterisk noted do not ask feeds. The term feeds relates to people who require support with meals or those who require a softer diet. This term does not maintain the dignity of people living at the home and demonstrates a lack of respect from staff. In addition people who require a specialist diet should have choices and options made available to them. We viewed the support given to people at the home over the lunch time period. Some people require a soft or pureed diet due to difficulties in swallowing or chewing. At this inspection the pureed diets were seen to mixed together. This does not allow people to taste the the constituent parts of the meal and the presentation of the meal is not appetising. Staff were observed to support people sitting down. Despite the availability of dining room space only two people were supported by staff to access a dining room table. The majority of people remained in the lounge area with a table in front of their chair. One staff member was observed to having her lunch with a person living at the home. This is acceptable if this is for social reasons and to develop relationships between staff and people. However on this occasion the staff member was eating her meal sat in the lounge area whilst supporting an individual living at the home. The impression given was that the staff member was eating her meal as she did not have time for a dedicated lunch break. It was noted during the meal that all people living at the home were wearing food protectors. Whilst it is appreciated that this may be required for some people the use of this equipment for all did have add a rather institutional feel to the meal. Staff need to consider how this impacts on peoples dignity and self esteem. Any soiled clothing could be changed following the meal. In addition it was noted that squash was the only drink available. Staff need to ensure that at least water is also on offer. All drink were served in plastic beakers. Again this added a rather institutional feel to the home. As previously stated a number of people at the home had lost weight or required a soft diet. We viewed the drinks trolley which was used to serve the morning and afternoon drinks. Biscuits were available on the trolley. These would not be suitable for those people requiring a specialist diet. The management need to ensure that a range of snacks are available. Care Homes for Older People Page 22 of 40 Evidence: Care Homes for Older People Page 23 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints procedure It could not be confirmed that all staff have recieved training in protection. Evidence: As previously stated we have received a number of concerns and complaints about the care and support provided at the home. This has resulted in a meeting being held under Somerset Safeguarding procedure. Subsequent reviews of the care provided is on going and has not yet been concluded. These standards were not viewed in detail. At the last inspection it was reported The home has updated the complaints policy to include the correct contact details and is displayed in the home to enable access to all. It is also available in the homes Statement of Purpose/ Service user Guide provided in each persons bedroom. Both people using the service and staff told us that if they had any concerns they would raise them with the manager designate and would be confident that appropriate action would be taken. The homes AQAA states, All complaints whether verbal or written are recorded in the complaints log. A holding letter is sent within 24 hours of the complaint being received and is dealt with within 28 days and signed off by the Manager when resolved. Care Homes for Older People Page 24 of 40 Evidence: During this inspection we reviewed the staff training matrix. This did not confirm that all staff had received training in the recognition and prevention of abuse. Care Homes for Older People Page 25 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not provide a pleasant environment in all areas. The home may not provide adequate specialist equipment to meet the needs of people living at the home. Evidence: At the last inspection it was reported that a programme of refurbishment and decoration was being undertaken. At this inspection it was noted that this programme appears not to have progressed. The decor in some of the bedrooms is poor with wood chip wallpaper and mismatched furniture. Malodours were apparent in some areas and the overall cleanliness of the building was not high. This gave the home a neglected impression and does not provide a pleasant place in which to live. People visiting the home both professional and relatives have also expressed this opinion. Issues with malodour have been raised at previous inspections and appear to be a reoccurring issue at the home. The management now need to address this as a matter of urgency. During the inspection we were informed that staff could not monitor peoples weights as the home did not have scales which could be used by all people at the home. The management now need to ensure that this equipment is provided. In care homes especially those with nursing hoists are used by staff to undertake Care Homes for Older People Page 26 of 40 Evidence: moving and handling. These are used to protect both people living at the home and staff from injury. During the inspection we were told that the home had some hoists however that these had been borrowed from another Southern Cross home in the local area This home was now requesting the return of the equipment. The management need to review the equipment within the home and ensure that all necessary equipment is available During the tour of the building we noticed that the majority of bedrooms had portable heaters in place. We were informed that these were being used due to issues with the boiler. We have not received any notifications from the company since March 2009 stating that there have been any issues with the heating. On the day of this inspection the boiler was undergoing repair. During the tour of the building it was notices that a number of the bathrooms were used as storage. This may impact on the number of baths/showers available for the use of people living at the home. This needs to be reviewed to ensure that care is not compromised and that there ia an accessible bathroom on each floor. Care Homes for Older People Page 27 of 40 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. Staffing levels may not be adequate to meet the needs of people living at the home. Staff at the home may not have the skills to meet the needs of people at the home. The induction of new staff is not always adequate Staff requirement procedures are robust. Evidence: A number of the concerns raised with us relate to the skills and competencies of the Registered Nurses working at the home. Concerns related to staffs ability to care for people with diabetes, those at the end stages of life including the use of syringe drivers and subcutaneous fluids, those who require blood monitoring and catheterisation. We currently do not have details of the training that the Registered Nurses have undertaken to maintain and update their clinical skills. At the safeguarding meeting we requested that Southern Cross Health care complete and forward to us a skills audit for the nurses at the home. The management then need to organise any training required to ensure that staff can meet the needs of people at the home. During the inspection we requested a copy of the most recent staff training matrix. A Care Homes for Older People Page 28 of 40 Evidence: copy of this was reviewed following the inspection visit. The training matrix did not reflect the staff working at the home when compared to the duty rotas. We are unable to ascertain therefore if all staff have received the necessary mandatory training. Of the staff (41 in total) who are listed both in the training matrix and duty rotas 24 have not received recent fire training, nine have not received food hygiene including two kitchen assistants. 14 staff have not received moving and handling training. The training matrix stated that moving and handling training is not applicable to two members of staff described as house assistants. The management need to ensure that all staff have received all mandatory training. In addition we have received concerns from both GPs and social workers with regard to poor staffing levels. Both have stated that staffing levels have impacted on the standard of care and support afforded to people at the home. One person told us the when they had visited the home in the late evening to find people distressed in the lounge area as there were not staff to support them. We reviewed the duty rotas as a result of these concerns. The home is currently using a high number of agency staff due to staff shortages. These agency staff are not recorded on the duty rotas. As a result we do not know if the home has sufficient staff on duty at all times. On the day of the inspection visit the staff on duty did not not reflect those who were due to work according to the duty rota. It is concluded therefore that the duty rotas are not an adequate reflection of the staff who work at the home. We reviewed the files of three staff who had recently been employed at the home. These showed that robust recruitment procedures were in place. All checks including two written references and Criminal Record Bureau checks. We spoke to one person recently employed. The individual told us about the induction that they had undertaken. The induction had been completed over one day. We confirmed this by reviewing the induction documentation for this individual. The current induction is not satisfactory and would not equip staff to meet the needs of people at the home. The management need to ensure that all staff have the opportunity to complete a robust induction that meets current best practice guidelines. Care Homes for Older People Page 29 of 40 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. There is no clear management structure resulting in a lack of leadership and direction for the home. Quality Assurance monitoring is not robust and does not effectively address areas that require improvement. Health and safety at the home may be compromised Evidence: At the last inspection, in 2009, a new manager had been employed. At this inspection we ascertained that the manager had left employment. Southern Cross health care had not informed us of this and as such we are unclear what the recent managerial arrangements at the home have been. At the safeguarding meeting held Southern Cross explained that an interim man anger has been transferred into the home. There has been no registered manager at the home for a significant time and management arrangements over the past few years have been inconsistent. This has led to a lack of Care Homes for Older People Page 30 of 40 Evidence: leadership and direction for the home. Southern Cross now needs to consider why the retention of a manager at this home is difficult. Over the last few years the home has not provided a consistent level of service. Issues are identified which leads to input from both the regulator, PCT and social services. Improvements are made however these are never sustained or maintained. Prior to the most recent concerns the last safeguarding issues were raised in Autumn of 2009. Due to this th local Authority are currently considering if they will continue to commission or buy beds at the home. The company has its own quality assurance systems to monitor the quality of care. Monthly visits to the home in line with regulation 26 and numerous monthly audits, based on the National Minimum Standards, are undertaken. It is however concerning that audits and visits have not highlighted the shortfalls in the service identified at this inspection. Or if issues have been highlighted that action has not been taken by the company to address the shortfalls. Under Regulation 37 of the care home Regulations care homes should inform us of any event which may adversely effect people living at the home and the absence of the manager. These have not always been received for example we were not informed that the manager had left employment, that there were issues with the heating and boiler system nor any time that the home has been understaffed. Given the concerns highlighted in this report with regard to lack of staff training and competencies, poor staffing and lack of equipment it cannot be confirmed that the health and safety of people at the home is maintained Care Homes for Older People Page 31 of 40 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 12 The responsible individual is 08/05/2009 required to ensure that each person has been risk assessed and has a suitably detailed supporting care plan in place to ensure all identified needs are met. This is required to ensure that staff can provide the care needed and the person using the service is not placed at risk. 2 26 16(2)(j)(k) The registered provider is required to ensure that all areas of the home have a satisfactory standard of hygiene and ensuring that there is no malodour. The responsible individual is required to ensure that a manager is registered with the Commission. This is required to promote the stable management of the service. 01/10/2008 3 31 8 08/04/2009 Care Homes for Older People Page 32 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 7 12 An urgent audit is completed 04/02/2010 for two identified individuals which assess their current health needs. Associated care plans and assessments are formulated to ensure that staff have clear guidance on the care needs of the individuals This will ensure that both individuals receive the care and support that they require. 2 8 12 All people living at the home 04/02/2010 should receive an adequate fliud and dietary intake. everyone living at the home should have an up to date weight and nutritional assessment completed. associated care plans should be developed giving clear and specific guidance to staff on the nutritional needs of people living at the home. care plans should give clear guidance on actions to be taken where concerns are highlighted fluid and diet charts should be accurately completed where applicable To ensure that people at the home receive adequate diet and fluids Care Homes for Older People Page 33 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 18 All staff should receive all mandatory training according to their job role. This may include moving and handling, fire training, Abuse prevention, health and safety and Control of Substance Hazardous to Health (COSHH). This will ensure that staff can meet the needs of people living at the home 26/02/2010 2 18 All new staff employed should complete a robust induction in line with best practice This will ensure that all new staff are adequately supported and develop the skills to meet the needs of people at the home. 18/02/2010 3 8 12 People living at the home who are at risk of developing pressure ulcers should have a regular change of position in line with the care plan and their assessed need. This will ensure that people do not develop pressure ulcers and help to maintain peoples comfort. 18/02/2010 Care Homes for Older People Page 34 of 40 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 4 8 12 People who are risk of choking are supported with diet and fluids in line with a completed risk assessment and up to date care plan This will ensure the safety of people living at the home 18/02/2010 5 8 12 People at the home should be supported to complete oral hygiene in line with the assessed need and plan of care This will ensure that peoples preferred level of personal hygiene and maintains peoples comfort 18/02/2010 6 8 12 Charts and records used to monitor care such as fluid charts, positional change charts and nutritional charts are completed accurately where applicable This is required so that the health care needs can be monitored and appropriate care and support provided 18/02/2010 7 9 13 If medicines are prescribed with a variable dose the amount given must be recorded. This is so that it is clear how much medicine is needed and has been given. 18/02/2010 Care Homes for Older People Page 35 of 40 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 9 13 Action must be taken to 18/02/2010 ensure that medicines are given as prescribed and that accurate records are kept of all medicines given by staff, including creams and ointments. If regular medicines are not given a reason must be recorded. This is to safeguard peoples health. 9 15 16 A range of snacks should be available to people on specialist diet according to their needs. This will provide support to those people who have lost or are at risk of loosing weight and those who have swallowing difficulties. 18/02/2010 10 15 16 The management need to review the menus and ensure that they are nutritional balanced with a mix of frozen, fresh, tinned and powdered foods. This will ensure that the food served meets the nutritional needs of people at the home. 18/02/2010 11 15 16 People on specialist diets should be able to make choices with regard to the meals they receive. 18/02/2010 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure all people ahve a choice 12 18 13 All staff must receive training with regard to the prevention and recognition of abuse This will ensure that people at the home are safegaurded 13 22 13 The management must ensure that the home is adequately equipped to meet the needs of people living at the home. This should include weighing scales and hoists used in moving and handling This will ensure that staff can meet the needs of people at the home. This will ensure that safety at the home is not compromised. 14 27 18 The management need to ensure that there are adequate numbers of suitably qualified staff on duty at all times. This will ensure that there are enough staff on duty to meet the needs of people at the home. 18/02/2010 18/02/2010 25/02/2010 Care Homes for Older People Page 37 of 40 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 15 27 17 The management need to ensure that the duty rotas reflect the staff working at the home at all times This will help to ensure that adequate staff are on duty to meet the needs of people at the home. 18/02/2010 16 30 18 The management of 19/02/2010 Southern Cross Healthcare should complete an audit of the skills of the regsitered nurses. Where training needs are identifed Southern Cross healthcare need to develop a plan as to how these training needs will be adressed This will ensure that staff at the home can meet the needs of people living at the home. 17 31 37 The home must notify us of any event as described in regaultion 37 of the care home regulations This will ensure that people liivng at the home are protcted and action taken for any shortfalls 19/02/2010 18 31 10 The registered person must ensure that there is a clear management structure 19/02/2010 Care Homes for Older People Page 38 of 40 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 To give clear leadership and direction to the home and ensure that care and support is of a high standard and appropriate to the needs of people living there. 19 33 24 Quality Assurance systems must be more robust. To ensure that shortfalls in the service are identified and action is taken to address them. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 19/02/2010 1 9 Action should be taken to ensure that more detailed information concerning peoples medicines is kept in their care plans to help staff give medicines safely and appropriately. It is recommended that staff discuss with their supplying pharmacist how they can ensure that medicines administration records can be made as clear and easy to follow as possible. soft meals should be served separately in their constituent parts to ensure that they remain appetising people who require specialist diets have a choice of meals made available to them. Consideration should be given to reducing the insitutional feel of meal times such as serving drinks in glasses, increasing the use of dining room tables and reducing the use of clothes protectors. These changes should be made in line with peoples assessed needs. 2 9 3 4 5 15 15 15 Care Homes for Older People Page 39 of 40 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). 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