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Inspection on 02/07/09 for Elsenham House Nursing Home

Also see our care home review for Elsenham House Nursing Home for more information

This inspection was carried out on 2nd July 2009.

CQC found this care home to be providing an Adequate 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.

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

What the care home does well

Mealtimes are flexible and the menus are varied and the resident`s wishes are taken into consideration when planning the menus. One resident commented "food is lovely". The service provides a homely environment for the residents, one resident said "I have got a lovely room". The service provides and gives opportunities for the residents to be involved in motivational activities.

What has improved since the last inspection?

Improvements have been made in the process of assessing prospective residents. Some changes have been made to the care planning system, this has led to some early improvements. Some improvements made in some aspects of handling, administration and recording of medicines. The majority of staff have had formal supervision.

What the care home could do better:

Ensure compliance with past and current requirements to develop the service and quality of care provided. Make sure that the care plans contain all appropriate details about individual needs and ensure that they are updated as needs change. Further improvements need to be made in aspects of handling, administration and recording of medicines. Although some improvements have been made in the care planning system further improvements need to be made to reflect current needs with prompt revision following identified changes. Review the way the home is managed and co ordinated, so that a greater focus can be placed on developing the service. Ensure staffing levels are adequate to meet the changing diverse needs of the client group who live in the home. Take a more positive view to staff comments by promoting the whistle blowing policy. Make sure all appropriate records are in place for new recruits.

Key inspection report Care homes for adults (18-65 years) Name: Address: Elsenham House Nursing Home 49-53, 57 Station Road Cromer Norfolk NR27 0DX     The quality rating for this care home is:   one star adequate 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: Marilyn Fellingham     Date: 0 2 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 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 Adults (18-65 years) 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 Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Elsenham House Nursing Home 49-53, 57 Station Road Cromer Norfolk NR27 0DX 01263513564 01263511511 elsenhamhouse@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Elsenham House Ltd care home 31 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: One named service user over the age of 65 may be accommodated. Date of last inspection Brief description of the care home Elsenham House is situated in an urban location, on the outskirts of Cromer and comprises of four properties, divided by one house in between. The first three properties were built in approximately 1890, they have small rear gardens where there are lawned areas and patios for Service Users use. Public transport services include a bus service every 15 minutes and a train service from Cromer every 20 minutes. Fiftyseven Station Road, Cromer, the fourth property, is intended as a unit where Service Users are encouraged to develop their skills and become more independent, prior to moving back into the community. Many of the Service Users are encouraged to promote as much independence as is possible and are facilitated to continue to engage in outside the Home activities and work experience. Fees range from £470.35 to £1500 per week. 0 6 0 1 2 0 0 9 31 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 30 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: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support peterchart Concerns, complaints and protection Environment Staffing Conduct and management of the home Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection that took place over six and a half hours. The lead Inspector was accompanied by another Inspector and the Commissions Pharmacy Inspector. The key inspection for this service has been carried out using information from previous inspections, information from some residents and people who work in the home. The main method of inspection used was case tracking. This involved selecting individual care plans and information available as a result of the support provided. During our visit a tour of the premises was undertaken and residents records and staff files were looked at. Care Homes for Adults (18-65 years) Page 5 of 30 Care Homes for Adults (18-65 years) Page 6 of 30 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 Care Homes for Adults (18-65 years) Page 7 of 30 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be assured that pre admission assessments and information is very thorough and informative, we should hope its all good now and see how it goes in the future. Evidence: We looked at two records of assessment for newly admitted residents, we noted that a new format had been used to assess one of these residents; the assessment was informative and from this information the service was able to decide if the prospective residents needs could be met. The clinical lead nurse does most of the initial assessments of the prospective residents, he spends time with the nurses involved in their care and also the social workers and whoever else is involved in the care. We spoke with one resident who told us that they had been given plenty of information about the home and had also visited the home before deciding if they wanted to move into the home. The service has been undergoing a change in the way that they now assess residents having employed a consultant to advise them about this process and how to improve the system for admission purposes. Care Homes for Adults (18-65 years) Page 10 of 30 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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 residents can be assured that they will have a plan of care that staff know and understand. However this is not always sufficiently detailed to enable staff to deliver fully determined care goals in a consistent way to ensure peoples safety regarding more challenging care needs. Evidence: We looked at four care plans for residents living in the home; one of these was for a person who was considered to be a high risk to the residents and staff. The home, because they are in the middle of changing the system for care planning are using the risk assessment for this person that came with them from another environment and therefore not applicable to the environment that they were now in. The care plan does however refer to other strategies needed to deal with the risk that this person presents. A care worker that we spoke with was aware of the risks and was familiar with the care plan and what was needed in relation to maintaining a safe environment. In the nursing notes for this person we noted that they had refused some medication but no record was found in their care plan for non compliance with medication as to Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: how this was being managed. There was confusion in the records as to when this resident had been admitted as the medicine record chart identifies them as having medicines on the 10/06/09 although he was actually admitted on the 11/06/09. A second care plan we looked at had no dates of commencement or dates for evaluation of care, this person had been admitted on the 12/02/09. We found no reference in the care plans to suggest that this person had been involved in the care planning process. We were unable to see from this persons records how their mental health was being managed; this residents daily notes recorded that they had difficulty in sleeping at night but there was no evaluation in place to inform us if this was being managed. We noted that this resident had a risk assessment tick box however none of the identified risks had separate risk assessments in place to guide staff. The progress notes for this resident recorded that they had had a problem with urine incontinence, we found no care plan for dealing with this. This resident had a care plan in place that identified a specific mental health problem, the care plan stated give prescribed as required medicines; there was no plan in place to justify continued use of this medication. The next residents notes we looked at stated that they had a history of alcohol abuse, however there was no care plan in place as to how this was being managed. We also noted that it was recorded that this resident had been hitting out at another resident, risk assessment tick boxes were in place but no risk assessment specific to certain risks with strategies in place to deal with the identified risk. The fourth residents care plans we looked at showed some improvement in the prescribed care for this person; they now had care plans in place for the use of oxygen and other aspects of their physical care. However there were still aspects of this persons care related to specific needs that were not identified on a care plan. On our visit we observed this resident being taken through the smoking room with their portable oxygen (where residents are smoking and using cigarette lighters) to the garden. The explanation for this was that it was unsuitable for this resident to enter the garden from the front of the house as a long way and there were steps that they would have difficulty in using and they cant go through the kitchen as wish to maintain infection control. There was no care plan in place to justify this action and any risk associated with the use of oxygen, however the care worker we spoke with was familiar with other important aspects of this persons care and had read the care plans that were in place. We noted that this resident had a care plan in place for for the use of as required medication, but the evaluation just states no change so staff would not be able to monitor or justify the continued use of this medicine. This resident had been prescribed a nasal ointment but there was no care plan to for this or if it had been discontinued. This persons notes also indicated that they had a wound, one nurse we asked did not know this, however she was fairly new to the home, we asked the clinical lead nurse who thought that it had been a wound on the Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: ear but was not too sure. The care plan for MRSA states that it is to be reviewed weekly and we noted that this had not been carried out as last reviewed on 10/05/09 We talked with four residents who told us that the care could not be better, one commented that the staff cannot do enough for us when we are poorly; another resident told us its good here and I have got a lot better. One resident commented that they felt nurses not so good as as always busy and a little bit strict and went on to say that they chose what they wanted to do, when they went to bed and what they did every day. We were able to speak with a key social worker who has a client in Elsenham House, they explained that they thought the care their client received was good and appropriate to their needs as they were a very difficult person to handle. Matters regarding this persons care plans are referred to in the above text. We spoke with a Community Mental Health nurse who was reviewing one of their clients. They told us that they review this resident every six months and so far has not required admission to an acute care setting. They told us that this person could be a risk to others but we noted there were no written risk assessments in place or strategies to deal with any difficult behaviour. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to take part in meaningful and motivational activities. Meals are managed well. Evidence: The residents are supported to participate in a variety of activities including college courses, no one does any work placements at the moment. They are also given the opportunities to take part in a number of leisure activities. This was confirmed by four residents we spoke with who told us about the activities they had been engaged in. They told us that they had been to the local Norfolk show and had a really good day, this was also confirmed by the member of staff we spoke with who told us that they had taken seven residents to the show with other staff members. Two residents attend adult education in North Walsham and are taken there by staff. The lead clinical nurse told us that they encourage the residents to get involved in local community events. Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: We noted that the residents were playing Bingo on the afternoon of our visit and we were told by the care worker that the Provider gives them £25 for prizes for this, he also pays for the residents to go to the local cinema. Some residents engage in horse riding, some like to go swimming or participate in trips to the gym. The residents are able to choose what they want to do and one told us that they had been shopping that morning. We know from past visits and information given to us on the day of our visit that some of the residents who are moving towards being more independent do their own food shopping and cook their own meals under supervision. All the residents we spoke with said the meals were good, the three week menu we looked at was a mix of healthy food and burgers that the residents like. The residents get choices in relation to what they want to eat and we noted that there were drink making facilities in the dining room. Some of the residents choose to buy their own snacks but there are biscuits available for them to eat when they wished. On the day of our visit there was poached fish or beef stew on the menu for lunch and we were told that the residents could have sandwiches if they preferred. One resident had refused their food but it was going to be saved if he wanted it later. One staff member told us that they always inform the nurses if someone is having a problem with eating. We were told that the night staff prepare the vegetables for the next day and the cook works until 1.30pm so the day care staff do the teas for the residents. We were told by the staff that one resident has an issue with food, the GP had been consulted and we noted regular recording of this residents weight. There was also a record in place of food taken and a care plan for this. We talked with one resident who informed us that they still had a fiance who was a resident in another home and that they often meet up and visit each other. Care Homes for Adults (18-65 years) Page 15 of 30 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are well supported and enabled to self medicate safely, however incomplete care plans and medication discrepancies still place residents at risk. Evidence: We have already mentioned earlier in this report that the care plans lack detail in relation to specific needs of the residents, these included personal and health care needs and also mental health needs of the residents; this lack of detail prevents the needs of the residents being met in a consistent way. The inspection of the medication standard was conducted by the Commissions pharmacist inspector Mark Andrews. During the inspection we looked at how the home is storing, administering and recording medicines. We also looked at associated records such as peoples care notes. We were informed that all medicines other than those held by people living at the home who are managing their own medicines are stored in the lower ground floor office in cabinets and a medicine refrigerator. A separate cabinet is also used in one of the outer units of the home. Since the previous inspection a cabinet has been fitted for the storage of controlled drugs. We asked the manager and a senior registered nurse separately about the storage of non-allocated medicines, both said during this Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: inspection that the practice of keeping stock medicines which are not for a named resident has now ceased. We noted that several daily temperature records for the medicine refrigerator and room temperatures had been recently omitted so we could not determine if medicines stored within the refrigerator or at ambient temperatures had recently been stored within the accepted temperature ranges. When we examined medication charts we found that the home is now keeping records for medicines received into the home. We found few gaps in records for the administration of medicines. The home has recently implemented medicine stock counts and quantities of medicines brought forward to new 28-day medication charts to enable audits of medicines to take place. However, when we used these figures annotated on medication charts we found there to be discrepancies where a significant number of medicines could not be accounted for and records did not demonstrate that they were being given in line with prescribed instructions. We were concerned, for example, that a person prescribed a sedative medicine may have a deficit of tablets because more have been administered to them than actually recorded as administered. A senior registered nurse on duty confirmed that they were also identifying similar discrepancies. We noted that people who are known to refuse their medicines on occasion have care plans written providing staff guidance on how to proceed when this happens. However, we found there to be few care plans in place relating to when medicines of a psychotropic nature are prescribed for administration at the discretion of nursing staff (PRN). We also found there to be times when such medicines are used where associated records did not support or justify their use. For example we saw records stating that one person was given a potentially sedative medicine when they became increasingly boisterous and using expletives in the garden. However, we also noted evidence that some people had recently had doses of such medicines reduced by prescribers. There are several people at the home who have control of their own medicines and self-administer them. We looked at how the home is supporting these people to maintain independence with their medicines. We visited the rooms of two people and found that since the previous inspection safes available to store their medicines are now fixed within the rooms. We also noted that people who are self-administering their medicines have had recent re-evaluations of care plans and risk assessments. The home is keeping weekly records of when they supply medicines. One person told us that they were able to monitor their own medicines and knew when further supplies were needed. Care Homes for Adults (18-65 years) Page 17 of 30 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. People can raise concerns about their care but records of complaint handling need to be more detailed. The service needs to promote its whistle blowing policy so that staff feel able to air their concerns. Evidence: We looked at records for complaints, there were five little white notes from residents requesting soft chairs in the smoke room, a comment made in the records in relation to these noted the provider/registered manager told the residents that he did not want them to sit for too long in the smoke room. We noted that there were no other records of complaints that had been made since our last visit to the home. One resident we spoke with told us the care staff listen to us and we have one to ones with them, but the nurses are too busy. The training records that we looked at confirmed that most of the staff had received training in safeguarding in 2008, one new staff member in 2009 and one nurse not had an update in this since 2007. During our visit we did not observe much communication with the residents from the staff except in the afternoon when one care worker was organising bingo for the residents. We did note at one stage of the morning three staff members sitting in the back area having a break, later another member of staff joined them. Care Homes for Adults (18-65 years) Page 18 of 30 Care Homes for Adults (18-65 years) Page 19 of 30 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides a homely and safe environment that suits the residents needs. Evidence: The home provides accommodation in a variety of settings, we found the home clean and tidy with no unpleasant odours. Since the smoke room has had better ventilation there was no smoke permeating to the other rooms. A fire officer has visited the home to give advice about fire protection and we noted that the service had carried out most of the recommendations made by him. The home has a resident who is a potential risk to the environment and we noted that the service had addressed this and put equipment and procedures in place to make the environment safe. We did note that in one of the staff meeting minutes the provider/registered manager had informed the staff that door wedges were not to be used, however we noted that one was being used on the dining room door. Care Homes for Adults (18-65 years) Page 20 of 30 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are supported because staff are trained but need additional training to ensure that the residents receive positive outcomes. The service needs to have all appropriate checks in place for new employees to ensure that they are safe to work with vulnerable adults. Evidence: When we arrived at the home three carers were on duty in the main house, one in number 53 and one in number 57; two nurses were also on duty one of whom was the clinical lead nurse. We also noted that the provider/registered manager was also in the house along with the administrator. We were told in discussion with the provider/registered manager that he does not have anything to do with care issues and that he deals with financial matters, wages, bills, ordering, marketing and maintenance; he went on to tell us I deal with discipline matters and take part in recruitment with the nurse who is the clinical lead. He went on to say I am in and out all the time, most matters are clinical and so nurses deal with them. A senior nurse is on call all the time and the provider/registered manager told us that he lives on the premises during the week but is not in the home from Friday afternoons to Sunday afternoons: he went on to tell us that he often does sleep ins in number 53 or 57. A member of staff told us made that the provider/registered managers hours Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: varied and often does not inform the staff that he is going out. We looked at the clinical leads job description, this was extensive and covered most responsibilities that a manager would cover. The clinical lead has no supernumerary time built in to the duty rosters to accommodate all the duties he has to perform; we were also made aware that the administrator does the duty rosters but meetings and other activities within the home are not taken into consideration. On the day of our visit we noted that the other nurse who was on duty was taking some residents out, so this just left the one nurse who was the lead clinical nurse. He was dealing with visits from social workers, a community mental health nurse, medicines and other administrative duties as well as the clinical work for which he was responsible for. This situation might account for the remark from a resident that the nurses are too busy and that one to ones are left to the care workers. We looked at the training matrix for staff, 83 of the carers have an NVQ qualification; all the nurses have received training in person centred care planning that took place in June 2009. This should help them to be more able to support people more effectively and make decisions about their care. All the nurses except one has had recent training in medication and most of the nurses and carers have undergone training in how to deal with aggression. The care staff have received some training related to specific mental health conditions, these having been delivered by one of the nurses, this was confirmed by one of the care staff who told us the senior nurse does mental disorders. Discussion with the staff and the provider/registered manager that the moving and handling sessions that had been delivered by the manager did not provide information about how to deal with people who had a mobility problem. We are aware from a staff member and the head of care that two residents have difficulty in mobilising due to the nature of their conditions; and for one a slide sheet had been obtained and a bath hoist for the other. We noted that the staff are to receive manual handling training that could be applied to the residents, this was recorded in the staff minutes for a staff meeting.` The administrator told us that she sometimes worked some shifts but she did not appear on the training matrix as having done any training in relation to dealing with aggression, moving and handling, infection control and basic care. We also noted that although the provider/registered manager does some sleep ins he has not received any training in relation to some of the situations he could come up against; we also noted that for these shifts he did not appear on the duty roster. We looked at the recruitment files for new staff, one file lacked any identification for the person and another had no confirmation of start date, this was addressed during the inspection. We discussed with the administrator about the recruitment files and the lack of identification and photos, she said that it had never been picked up before. We advised her that it was in the Regulations and that they should also keep a record of criminal convictions and discussions that they had had with staff who had Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: convictions and the reason for employment. We looked at the records for supervision, these confirmed that the provider/registered manager does the majority of them, the lead clinical nurse does some and some of the nurses do each other. The records showed us that all the staff had had three supervision sessions since the last inspection with the exception of two carers, and two nurses; one of the nurses had not received supervision since March 2009 this was a bank member of staff. Care Homes for Adults (18-65 years) Page 23 of 30 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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 management team have clear and well defined boundaries; care should become more consistent when a review of management roles has been undertaken. Evidence: There have been a number of changes in the management of the home over the last four years, the latest being in February 2008 when the registered provider also became the registered manager. After the appointment of the registered manager in February 2008, a head of clinical care was appointed who has since left and a new one was appointed four months ago. When we arrived at the home the administrator received us and went to fetch the registered manager/provider; the manager told us he had other commitments but after some discussion about our responsibility to carry out unannounced inspection was able to make time available to us to discuss running of the home. We asked him how many residents were living in the house and he was unable to tell us and consequently went to find out; this could have implications if he is doing a sleep in in terms of the safety of the residents and what action he needs to take in the event of a fire. We also asked him about his role in the home and we understood from this that Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: there are very clear boundaries between his role and the head of clinical care role; however this could mean that the head of care is not supported in his role. The home is managed by two people with the bulk of the management falling on the head of the clinical area, he told us I have no administrative time built into my role and said that the audits he has to do takes up a lot of time and the other nurse who is on duty may go out with the residents so he is the only nurse left on the floor with the care workers who are on the shift. This means that the acre workers are left to give support to the residents whilst the head of care carries out his other responsibilities. The head of clinical care told us that he had been asked by the manager to get more involved with staff issues, he added it has been added to the role. We looked at health and safety related information these showed that there are servicing arrangements in place for all equipment with the exception of the boiler in no 57 that should have been carried out in June. Fire safety records were in place and the home had recently been inspected by a fire officer who had given the home advice about the maintenance of a safe environment. The home has acted on the advice of the fire officer, both the administrator and the manager told us this and we noted on our tour of the home that certain products ahd been provided in one particular area that would promote the safety of the people who live and work in the home. Care Homes for Adults (18-65 years) Page 25 of 30 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 6 15 The care plan must contain detailed information about individuals care needs. This will ensure that residents needs are met. 16/04/2009 2 20 13 23/04/2009 Care plans must accurately reflect and give guidance on current prescribed instructions when medicines are to be administered at the discreation of nursing staff. This will ensure justification of continued use. 3 20 13 01/04/2009 Medicines must be administered to people living in the home in line with prescribed instructions and reords kept. This is a repeated requirement. This will ensure all medicines can be accounted for in full. 4 20 13 Daily recordings of the 06/04/2009 temperature of the medicines fridge must take place. This will ensure that medcines requiring refrigeration are stored within the accepted temperature range. Care Homes for Adults (18-65 years) Page 26 of 30 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 6 15 The care plans must contain detailed information about individuals care needs. This will ensure that all residents needs are met. 14/08/2009 2 20 13 Care plans must accurately reflect and give guidance on current prescribed instructions when medicines are to be administered at the discretion of nursing staff. Repeated requirement This will ensure justification of continued use. 16/08/2009 3 20 13 Medicines must be 16/08/2009 administered to people living in the home in line with prescribed instructions and records kept. Repeated requirement. This will ensure all medicines can be accounted for in full. Care Homes for Adults (18-65 years) Page 27 of 30 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 20 13 Daily recordings of the medicines fridge must take place. Repeated requirement. This will ensure that medicines requiring refrigeration are stored within the accepted temperature range. 16/08/2009 5 24 13 Doors should not be wedged 14/08/2009 open. This will ensure that the environment is free from hazards and maintains the safety of the residents and the staff. 6 31 17 The manager must ensure he is named on the duty rosters when doing a sleep in likewise also the administrator when carrying out shift work. This will ensure that all records are retained by the service as highlighted in the Care Homes Regulations. 21/08/2009 7 33 4 All staff must be recruited to 31/08/2009 the standards required by the regulations. Shortfalls in this practice can place residents at risk 8 33 18 Staffing levels must be adequate. 20/08/2009 Care Homes for Adults (18-65 years) Page 28 of 30 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 that the residents needs are met in a consistent way and also allow the clinical head of care to fulfil the full range of duties expected of him. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 20 Medicine audits should be conducted more frequently to promptly identify issues arising and enable medicines to be accounted for in full. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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