Inspection on 24/11/09 for The Firs

This inspection was carried out on 24th November 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Firs 08/03/10

The Firs 24/11/08

The Firs 12/08/07

The Firs 10/10/06

The Firs 01/12/05

The Firs 22/07/05

The Firs 01/03/05

The Firs 18/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

Key inspection report Care homes for older people Name: Address: Firs and 16 Margaret Road, The 141 Malvern Road Worcester Worcestershire WR2 4LN     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: Andrew Spearing-Brown     Date: 3 0 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 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 37 Information about the care home Name of care home: Address: Firs and 16 Margaret Road, The 141 Malvern Road Worcester Worcestershire WR2 4LN 01905426194 F/P01905426194 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Eldahurst Limited care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 22 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 22 Dementia (DE) 22 Physical Disability (PD) 22 Date of last inspection Brief description of the care home The Firs provides care for fifteen people. 14 and 16 Margaret Road (known as Fern House) provides care for seven people are separate semi-detached houses that are divided from The Firs by their joint back gardens. The three properties are registered as one care home. The home is located in the St Johns area of Worcester. Both The Firs and Fern House are adapted and extended to provide a comfortable domestic environment for older people. The registered proprietor is the company Eldahurst Care Homes for Older People Page 4 of 37 Over 65 0 22 0 22 0 22 2 4 1 1 2 0 0 8 Brief description of the care home Limited. The responsible individual and the registered manager is Mrs Sandra Lynne Ghalamkari. We did not obtain details on the current fees charged therefore the reader should contact the service directly. Previously we were told that the standard fee does not include hairdressing, chiropody, newspapers or having own telephone in bedroom. Care Homes for Older People Page 5 of 37 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 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 last inspection at The Firs and Margaret Road was undertaken during November 2008. This inspection was what we call a key inspection; this is one when we look at what we believe to be the most important National Minimum Standards. This key inspection involving one inspector and was carried out over two separate days. As part of this inspection, in addition to the visit to the home, we also took into account other information we had received. Prior to our visit we requested an Annual Quality Assurance Assessment (AQAA) from the registered persons. This is a document within which providers of care services are able to demonstrate to us where they believe they are providing a good service and where they believe they could improve in the future. The AQAA also provides us with certain data which we need to know. The AQAA was completed by the registered manager and returned to us. Care Homes for Older People Page 6 of 37 Prior to the inspection we posted out some surveys to residents, their representatives and staff. The vast majority of the surveys sent to residents and returned to us were completed by the persons relatives. We have taken account of the surveys returned as part of this inspection report. During this inspection we had a look at communal areas of the both The Firs and the properties on Margaret Road (Fern House). In addition we also looked at some bedrooms in each of the properties. We read available care plans, daily records and risk assessments regarding some people living in the home. We also viewed other documents such as medication and staffing records. At the time of our inspection the service had one vacancy in a double bedroom in The Firs. We spoke to a number of people in the home including the manager, the deputy manager, the administrator, some other members of staff, residents and visitors. We observed care practices throughout our time in the home. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: Care plans need to be accurate and up dated reflecting current needs in order for staff to have the correct information about people. Risk assessments need to be through and detail means of reducing the risk of injury. Improvement is needed when booking medication into the home to make sure that the records held are accurate. This will assist to ensure that people are getting the medication they are prescribed. Other records need to be accurate and up to date in order to safeguard people from medication errors. Absence of staff should be monitored so that there is no adverse effect on staffing levels any associated risks to the level of care and support provided. Recruitment procedures need some further improvement to ensure that information about new members of staff is obtained. This will assist in ensuring that staff recruited to work in the home are suitable. Care Homes for Older People Page 8 of 37 Management tasks need to be clarified so that it is clear who has responsibility for certain duties. Issues regarding the registration of the company operating Fern House need to be addressed so that part of the service is operating legally. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is available to help people make a choice about whether they would like to live at The Firs and Margaret Road. The care needs of people who may use the service are assessed so that individuals and their relatives can be assured that staff will be able to meet these. Evidence: We asked on our survey whether people had received enough information about the home before moving in. On all the surveys returned to us people stated that they had received this information. People also confirmed that they had received a contract or a statement of terms and conditions. During our visit we saw some people, who were trying to find a suitable care home for a relative, having a look around the home. Information about the service provided at The Firs and Margaret Road is available. We saw copies of the service users guide within residents bedrooms. This is an improvement on previous inspections when information was only available in the Care Homes for Older People Page 11 of 37 Evidence: entrance hall. Currently the information covers the main house, The Firs, and the properties on Margaret Road now known as Fern House. During this inspection we saw work carried out on a lap top computer to produce separate guides for The Firs and Fern House. We were told by the registered provider / manager that the guide for Fern House was not made available sooner as she was waiting for the front of property to be drawn so that a picture could be added to the document. Our previous report stated that the home ensures it receives pre-admission assessments from funding authorities and that people who are self funding are assessed by representatives from the home. During this visit we were told that somebody was recently admitted from a city in the south west of England. The manager told us about the assessment visit carried out by the deputy manager and herself prior to the admission taking place. There have been no new admissions in to Fern House within the last 6 months. On the AQAA, completed by the manager, we were informed that as part of the pre assessment it is suggested that potential residents come to the home for a day so that the home can carry out a trial to ensure that this is the correct placement for both parties for all needs to be met. We saw that the home had a copy of an assessment carried out by the funding authority as well as the one carried out by the manager and deputy manager. We also saw the assessment of another recently admitted resident. The assessments gave brief details of care needs under a range of different headings. The information provided was sufficient for the home to draw up an initial basic care plan for staff to be able to meet the identified care needs. The Firs has a small number of people who attend for day care. This part of the service is not regulated by us. The service does not provide intermediate care and has no plans to do so in the foreseeable future. Care Homes for Older People Page 12 of 37 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have an individual care plan that is reviewed. They can not however be fully confident that their plan will give staff clear guidance about their current care and health care needs and how people should be supported to remain safe. The recording of medication is not always well managed and needs to be improved to ensure that people always receive the medicines they are prescribed. Evidence: Following our previous visit to the service we reported that the care planning process had both developed and improved since earlier inspections. As part of this inspection we viewed the care plans, risk assessments, daily records and other records such as those following GP visits regarding two people living at The Firs as well as two people living at Fern House. A care plan is a document designed to give staff in the home guidance for them to carry out the care required in a consistent way meeting identified needs. Care plans need to be reviewed and amended as required, at least monthly, to ensure that they are up to date as well as an accurate reflection of current needs. We found that a care Care Homes for Older People Page 13 of 37 Evidence: plan or an initial assessment was in place for each person however some needed to be up dated. Following the pre admission assessment, and once people are admitted in to the home, a care plan needs to be devised. One person, who was admitted a couple of days before our inspection, did not have a care plan. The care plan of another person was written 20 days after their admission. This care plan was reasonably comprehensive covered areas such as communication, oral care, foot care, mobility, history of falls and religious care needs. Care plans were generally task orientated and did not give staff information regarding strategies in order to meet needs. Care plans are not particularly person centred. A person centered care plan is one written to take into account each persons individual needs and wishes and concentrates on what people can do rather than what they can not. Although we saw evidence that care plans are reviewed they did not always pick up on some elements of changing need for example recognizing the symptoms displayed by somebody prone to chest infections and caring for the person if one develops. A carer confirmed that the care needs of a resident, who had recently returned from hospital, had changed. The new care plan was completely blank however the person had returned from hospital a month beforehand. The previous care plan was not an accurate reflection of current care needs. For example the care plan on falls said no falls recently however accident records showed occasions when the person was found on the floor. We were concerned to read entries about a person who had sustained injuries from bed rails attached to her bed. A risk assessment was in place but it was not sufficient and did not include information about reducing the risk of injury. We saw no indication that the gaps between the mattress and the rails had been measured to ensure they were within the guidelines issued by the Health and Safety Executive (HSE). Furthermore we saw no guidance for staff regarding safety checks such as ensuring that bumpers were in place and fitted correctly. Due to our concerns we wrote, prior to completing this report, an urgent action letter to the manager regarding the need to carry out a full risk assessment as the safety of the individual when using bed rails needed to be addressed without delay. Records regarding the same resident belonging to the community nursing team were held within the home showing that they make regular visits to the home to provide treatment to pressure sores. We asked whether one resident had a pressure sore risk assessment. The deputy Care Homes for Older People Page 14 of 37 Evidence: manager told us that no assessment was in place as the resident concerned did not have any sores. A pressure risk assessment is however a way of establishing whether people are at risk of developing sores before they occur. The manager has good working relationships with health care professionals. During our visit we saw somebody from the community nursing team who was complementary regarding the care provided within the home. The vast majority of people stated on the survey that they always receive the medical care they need. We asked whether somebody had received an assessment for incontinence aids. Neither the manager or the deputy knew the answer however the manager actioned this without delay. We previously reported that The medication receipt, storage, administration, recording and disposal procedures and practice are robust and protect people from potential harm due to medication errors. As part of this inspection we assessed the current management of medication within the service. A medication trolley is held securely in both The Firs and Fern House. A photograph was in place of each resident and information about any known allergies was recorded. We viewed a number of MAR (Medication Administration Record) sheets. They appeared to be completed satisfactorily for example they showed medication to be booked in and balances carried over from one sheet to another were recorded. However, on closer examination we did come across some concerns about recording and the management of medication. During the inspection we saw carers administering medication and recording that they had done this on the MAR sheets. We later saw a MAR sheet whereby a member of staff had signed for night time medication when administering the morning medication. The drug was not given therefore this was a recording error. On the file of one resident was a discharge note from a local acute hospital detailing the persons medication upon discharge. The information on this list differed from information on the MAR sheet. It appeared that one tablet was withdrawn by medics at the hospital however the MAR sheet showed that staff had continued to administer this drug for five days before recording discontinued by GP at Worcester Royal. We saw some other medication on the discharge note which indicated that a GP needed to review. The relevant MAR sheet showed that this medication was given on 7 occasions, this balanced with the amount remaining, however the MAR sheet was then coded not required for 3 weeks before recording stopped. There was no written Care Homes for Older People Page 15 of 37 Evidence: record that the decision to stop this medication was reviewed by a medical practitioner. A list of medication was part of the care plans. However we frequently found this record to be out of date and they did not reflect current medication or show periods when people were taking antibiotics. One MAR sheet in The Firs had handwritten instruction saying that the dose was reduced from twice daily to once daily. Despite this instruction staff had signed for the drug on three consecutive mornings before recording the error. Correction fluid was seen to of being used when staff had recorded an error. This must not be used. If an error in recording is made it should be crossed out and an explanation given. We saw MAR sheets with creams recorded upon them. The daily records showed that staff were applying cream however the MAR sheet was not signed. Another cream was used on the day of our visit however this cream was not recorded on the MAR sheet. Medication needing to be treated as controlled was securely held. We looked at one item held in the controlled drugs cabinet. The dose to be given differed on the MAR sheet to the controlled drugs register. It was not possible to accurately check the amount remaining as the medicine was in liquid form. The care plan made reference to controlled medication however it had not been amended following the change from tablet to liquid form. When the deputy manager opened a desk in the office we noted some boxes of painkillers. The deputy manager told us that they were brought in by the residents family and as they were out of date they needed to be returned. The tablets were not past their expiry date furthermore they had not been booked into the home and were not securely held. We audited some antibiotic medication and found that the balance held matched with the written records. We also checked the balance held of two lots of other painkillers and found them to be correct in each case. A dedicated fridge is provided for storing medication. At the time of this inspection a carer was seen taking liquid antibiotic medication from it. We requested the records recording the temperature of this fridge. A considerable amount of searching took place looking for these. We found that the last time the temperature was recorded was 1st October 2009. We also brought to the attention of the manager that a record of the temperature in the office should be maintained to ensure that it is not too hot Care Homes for Older People Page 16 of 37 Evidence: to store medication there. We asked whether the home has a gender policy in relation to staff caring for residents of the opposite sex, we were told that one did not exist. During our inspection we saw staff being kind, courteous and caring towards people. Staff were seen to be up holding peoples privacy and dignity. Residents were suitably attired taking into account gender, culture and weather conditions. Care Homes for Older People Page 17 of 37 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to engage in different in house activities as well as occasional community participation. Meal times are relaxed and people generally like the food available to them. Evidence: During our visit we spoke to a number of people who live at The Firs and one person living at Fern House (Margaret Road). Some told us that there is not a lot to do while others told us about people coming into the home to play the piano. Information was on display within both The Firs and Fern House about social activities. Staff on duty at Fern House told us that residents from there walk up to The Firs to join in the activities there. The documentation seen did not support the extent and range of activities provided as described by the manager. On our survey everybody indicated that they believe activities to be always available. One relative wrote I am very impressed with the outings that some of the residents have been on. Another relative wrote Meals excellent. Activities varied. While we were at the home a relative told us that every afternoon something happens. The manager gave us a verbal account of the weekly activities programme. We were Care Homes for Older People Page 18 of 37 Evidence: told that the manager tries to lead a quiz or discussion on a Monday. Tuesday consists of light exercises followed by a small number of people attending a Womens Fellowship. Different musicians attend on Mondays, Wednesdays and Fridays. An activities member of staff works 3 hours each afternoon Monday to Thursday inclusive doing crafts, bingo and nail care. Other entertainment is provided during the year. The Firs has an area available for a hairdresser who visits twice a week. We were told of preparations for a small number of people to go out in the homes people carrier on a shopping trip to Redditch. Previous outings have included Tewkesbury market and a drive to Ledbury. The manager intends to replace the current 7 seat vehicle with a 12 seat one next year. A relative told us that the manager takes people out for shopping trips. We reminded the manager of the need to ensure that risk assessments are in place regarding outings and that staff have appropriate business use insurance if using their own transport for any work based activity. Religious care needs are currently met by a vicar from a local Mission visiting once a month. We were told that currently no practicing Roman Catholics reside within the home. No other religious beliefs are currently represented within the resident group. We spoke to one relative and one visiting professional while in the home. We were told that staff within The Firs make them welcome. We saw others visitors within The Firs but none within Fern House apart from some people having a look around the home. Staff were seen to be warm and friendly to visitors. One visitor was offered a cup of tea or coffee, this person confirmed that it was usual practice within the home for that to happen. Worcester City Council Environmental Health rated the homes food hygiene standards as good when they visited in January 2009. Breakfast was being served when we arrived at the home at 07:40 am. During the day we saw staff offering people drinks and a tin of biscuits was in the lounge. The lunch time menu was on display before lunch was served. We asked residents if they were aware of what they were going to have for lunch but nobody seemed to either be aware or remember what they were going to be having. We joined residents over lunch on our first visit. Residents were offered a drink of squash with their meal. Condiments were on the table for people to help themselves to salt and pepper. People told us that they enjoy the food offered to them, although one person described the menu as repetitive and another mentioned a lack of variety. The meal was a good social time with interaction and banter between residents taking place. Care Homes for Older People Page 19 of 37 Evidence: The menu on our second visit consisted of faggots, mash, mixed vegetables, onion gravy or sausage. This was followed by egg custard or bread and butter pudding. The tea time menu was scheduled to be oxtail soup, sandwiches, cakes, fruit and ice cream. The main mid day meal at Fern House is prepared at The Firs. We were told that the meal comes down in metal containers for staff to serve. However this was not our observation when we were in Fern House as meals were brought down the garden plated up and covered over. Staff needed to microwave meals to ensure they were warm before serving to residents. We have reservations regarding the safety of these arrangements and recommend that the Environmental Health Officer at Worcester City Council is consulted about the way food is transported between the properties. Care Homes for Older People Page 20 of 37 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. People are aware of how to make a complaint and are confident that their concerns would be listened to. Although staff have not received recent training they have sufficient knowledge to safeguard residents from potential abuse. Improvements to risk management will provided further protection for people living within the home. Evidence: We saw a file close to the front door at both The Firs and Fern House which contained information regarding complaints and made reference to CQC and our address in Newcastle. The file contained a sheet which could be completed either by the person wanting to make their views known or a member of staff receiving the information. The majority of staff confirmed within the questionnaire that they know what to do if somebody has a concern about the home. The complaints and protection section within the AQAA document was not completed when returned to us however the data set section showed that the home had received no complaints over the last 12 months. The commission have not received any concerns or complaints about the service provided at The Firs and Margaret Road since our last inspection. During our visit people told us that they would speak to the registered manager if they had any complaints. People appeared confident that their concerns would be listened to. We saw the manager engaging with people throughout our visit therefore given people the opportunity to raise any concerns if they existed. Care Homes for Older People Page 21 of 37 Evidence: A copy of Worcestershire multi agency guidelines in relation to safeguarding were in the office. The homes procedures, which were not read, were reviewed during September 2009. One member of staff told us that she would speak to the manager if she had any concerns or suspicions about actual or potential abuse taking place within the home. She said that the police might also need to be informed. The comments made by this member of staff were confirmed by another member of staff who was present at the time of our discussion. Records showed that staff last received training in safeguarding towards the end of 2007. Within this report we have highlighted a number of areas where risk management, procedures and practice needs to be improved. These include the management of medication, care planning and risk assessment and staff recruitment. Care Homes for Older People Page 22 of 37 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well maintained and comfortable environment. Attention to some health and safety systems could assist in ensuring that people are safeguarded further against potential risks. Evidence: The home consists of The Firs which can accommodate up to 15 people and 14 and 16 Margaret Road (Fern House) which can accommodate up to 7 people. The Firs has two double bedrooms. At the time of our inspection work was underway to improve the screening in these double rooms to afford people increased privacy. All the bedrooms in Fern House are single occupancy. Both The Firs and Fern House have a dining room and lounge areas. The dining room in The Firs has pictures of Worcester displayed on the wall as well as photographs taken during a 100th birthday party in 2004. Within the AQAA the manager listed a number of changes to the environment which have taken place since our last inspection. During the course of our visit we saw where most of these changes were carried out. The Firs now has a wet room which makes showering people with limited mobility easier. A bath with a hoist over it on the first floor and a shower unit on the first floor Care Homes for Older People Page 23 of 37 Evidence: remain as they were during previous visits. A similar wet room exists in Fern House. We saw two bars of traditional soap in the wet room in The Firs. Neither of the wet rooms contained any liquid soap dispensers. A hand dispenser in the entrance hall was empty throughout our time in the home. These factors are not in line with good infection control practices and need to be reviewed. A new laundry room is in place, where a former bathroom was, in The Firs. The room contains one commercial washer. We were told by staff that a tumble drier is in the cellar however this area was not seen on this occasion and we did not ask to see the risk assessment regarding carrying wet washing down the stairs. The door in the laundry was propped open and the washing powder left uncover. This could pose a number of risks such as in the risk of fire spreading if doors are open or people gaining access to the chemical. One resident described the laundry as Pretty good. One relative made a comment about some washing going missing despite it being labeled. A new linen room has been provided near to the laundry, this area was neat and tidy. A domestic washing machine is fitted in at Fern House however we were told that a commercial one is to be fitted in the foreseeable future. Other improvements include the redecoration of some bedrooms and the repainting of the frontage of both properties. In addition some refurbishment has happened within the main kitchen, insulation of new gas boilers, some windows replaced and new furniture in parts of the home. A passenger lift is provided in The Firs to afford ease of access to the first floor. Stair lifts are fitted in Fern House. We did not view the risk assessments regarding these however, we did notice that that the space available to go up and down the stairs was limited. During our look around the home we brought to the attention of the manager a number of matters regarding health and safety. An observation regarding a window restrictor was dealt with immediately. Other concerns were regarding some unsecured wardrobes and a trip hazard due to a shrunken carpet. A call alarm system is in place within both The Firs and Fern House. Some of the leads would not be accessible to people if they were in bed as they were tided up. One resident told us that she was pleased with her bedroom and finds it comfortable. One person told us that she has a key to her bedroom so that she can lock the door. The door has a device whereby people are not able to accidentally lock themselves in their Care Homes for Older People Page 24 of 37 Evidence: bedroom. The garden between The Firs and Fern House is well maintained. One resident has a small garden outside of her patio window. A new summerhouse is in place and patio areas are provided where people can sit out in the warmer weather. Most people believe the home to be clean and tidy. A resident told us that bedrooms are cleaned daily. Care Homes for Older People Page 25 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive appropriative care and support from staff but limited staffing cover at certain times might bring potential risks. In addition people can not have full confidence that staff are suitable because not all recruitment checks are done. Training is provided to ensure that staff have the skills and knowledge they need to carry out their job. However improvement is needed in induction training to ensure newly recruited staff receive training upon starting work at the service. Evidence: The home does not use agency staff and many members of staff have worked within the service for several years therefore the home has the ability to provide consistency in care delivery. However we were concerned on staffing levels at certain times of the day due to the fact that some staff were taking annual leave and their shift was not covered. On our survey we asked people living in the home whether staff are available when needed. Of those surveys returned five people replied always. One person answered usually and one sometimes. The majority of people did however inform us that staff listen to people and act on what is said to them. During our visit one resident told us that the home is short staffed. The manager informed us that 3- 4 carers are on duty each morning at The Firs along Care Homes for Older People Page 26 of 37 Evidence: with other staff such as catering and domestic staff. We were told that this number is reduced in the afternoon. We were told that Fern House has 2 carers on duty. We asked about night staffing levels. We were told that 1 member of staff is awake at both The Firs and Fern House in addition to somebody sleeping in at Fern House. The manager said that she is on call and can get to the home quickly if needed. We asked how many staff need to have 2 or more carers to meet their care needs. We were told that 4 people do during the day time but nobody during the night needs this level of support. The staffing levels at night gave us some concern as only one person is on duty at The Firs. This concern was increased when we found that on the night before our second visit there was no sleeping in person at Fern House therefore no back up was provided in the home. We were told that this was due to staff holidays. On looking at the rota we found times during the day time when the staffing levels were not in line what we were told happens. The manager and deputy manager told us that some of the gaps had been covered but the rota was not up dated. However on other occasions it was apparent that staffing levels were low due to staff on leave. On the morning of our second visit there were 2 carers on duty in The Firs as one was covering the cook who was on leave. We saw accident records when staff at Fern House had recorded that they needed to obtain help from big house when people had fallen which demonstrates a need for staff to be called from one house to another. Over recent inspections we have highlighted the need to improve recruitment procedures within the service. We have seen improvement in relation to obtaining CRB (Criminal Record Bureau) disclosures as well as having references. Staff confirmed within our survey that the employer carries out checks, such as CRB and references before starting work at the home. Following our previous inspection we wrote In a number of staff files there was an absence of information about employment gap, which is known to be a major safeguarding issue that must be addressed as part of the recruitment process. We did not make a requirement regarding this matter however a clear recommendation regarding this shortfall was included within the report. During this inspection we viewed the staff files of three people appointed since our last visit. The application form consisted of a number of loose sheets of paper. Gaps in employment were evident on the forms seen. The manager said that she was not aware that a ten year employment history should also be obtained but acknowledged that we made Care Homes for Older People Page 27 of 37 Evidence: reference to gaps in employment within our last report. The vast majority of staff said on our survey that their induction covered everything they needed to know to do the job. Within our previous report we stated that The home needs to acquire the new induction standards to ensure that new staff reach the initial level of competency within their probationary period deemed necessary to provide safe care to vulnerable people. We found that the Skills for Care common induction standards were available. We were told that one member of staff had taken her copy home. However, it was confirmed that nobody had commenced on these induction standards despite having working in the home for a considerable period of time. Training records are maintained. Information was on display within both The Firs and Fern House about forthcoming training scheduled for November and December 2009. The manager told us that staff prefer to undertake all their training within the latter part of the year. As a result the records showed that very little training activity had taken place to date during 2009. We identified that fire awareness training had not happened, other than some in house training, since January 2008. One member of staff commented that she had not received any such training since April 2009. While we were in the home the registered manager arranged a date for fire awareness training to be carried out. Records showed that some staff had received training in epilepsy. One resident has epilepsy and the care records made reference to placing in recovery position however the rota indicated that at times people without any training in epilepsy were on duty by themselves. The manager told us that all staff have done first aid training and that it includes how to deal with choking. The manager expressed a desire to have additional training regarding dementia care within the home and mentioned a number of potential sources she is currently seeking or considering to access this training. As the home is registered to care for people with a dementia illness it is important that up to date training is provided for staff. We sought up to date information regarding the number of carers who had completed their NVQ (National Vocational Qualification) training. Currently twelve out of twenty six people have at least a level two. This total is slightly below the expectation within the National Minimum Standards. Care Homes for Older People Page 28 of 37 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People generally get the support they need from the care home because the manager knows them well and runs it in a very personable way. People are not, however, always safeguarded to the extent that they should be because essential management tasks are not carried out fully enough. Evidence: A member of staff described the manager as helpful and conscientious. The manager has completed the Registered Managers Award (RMA) which is a level 4 NVQ (National Vocational Qualification) in management. We previously wrote that despite the manager having completed the RMA it did not seem to have inspired her to increase priority for administration aspects of the manager role. During our time in the service it was evident that the manager prefers to be more engaged in the hands on work rather than devoting time to managing the service delivered. The majority of administration duties are done by the administrator or the deputy manager, who works 18 hours per week. However there is a lack of clarity in the home about who is Care Homes for Older People Page 29 of 37 Evidence: doing what and ensuring that tasks that need doing are done. These administrative duties are important because they help to provide some of the safeguards for people using the service for example staff recruitment. The AQAA (Annual Quality Assurance Assessment)was returned to us prior to the inspection visit. The detail within the document was in many areas scant and it did not give a full reflection of where the service is doing well. A certificate of registration was on display in The Firs. Although this would be the most up to date certificate it is now not an accurate reflection of the situation at the service. The service formally comprised of The Firs and 16, Margaret Road. An application was subsequently received and approved to also use 14 Margaret Road. We have since been told that a different company is operating 14 and 16 Margaret Road. The manager confirmed that two separate companies are involved, but one is not registered. We informed the manager that it is vital that this company applies for registration as Fern House is operating outside of the law. We informed the manager that she would need to apply for a new CRB via us as the one done a year ago would no longer be valid. It is our understanding that an appointment has been made at our Regional office in Birmingham for this process to commence. Once Fern House registration is approved the registration at The Firs will need to be amended to remove Margaret Road. The inspection report following our visit in November 2008 states the following: Quality Assurance is an area that needs further development to show clearly how the home identifies areas for improvement, what is done to effect change and how these changes subsequently benefit those living at the home. It should also show the process used by the manager to monitor practice and care standards. Despite the above comment it is disappointing that little progress has taken place over the previous twelve months. A quality assurance manual purchased a few years ago is not used. We were told that some surveys we sent out however it was not possible to establish when this was and the results of the survey were not collated in order for the home to establish what people thought of the service provided. The service does have a collection of thank you cards and compliments received from relatives however as these are not dated it was not possible for us to easily establish which of these were new from our last visit. Risk assessments are in place in relation to aspects of the home however the quality Care Homes for Older People Page 30 of 37 Evidence: of these continues to need further work upon them to ensure that they fully identify the risk, record possible strategies or actions to reduce the risk and detail what action was selected in order to reduce the identified risk. We viewed the risk assessment dated August 2009 on pipe work feeding radiators as we found them to be very hot to the touch. The risk was assessed as low. The action recorded stated that staff observe residents and walk with them. Our observation was that this is not the case as a number of residents were walking around the area concerned and could potentially grab hold of these pipes some of which were not fully secured to the wall. We were told that the deputy manager has a book to record any money held in safekeeping for residents. However the deputy manager said that she did not hold any records as any expenditure such as hairdressing is added to peoples invoice. We did however see an envelope pinned to a shelf which contained some money for one resident to use when she went out on the shopping trip. This money was not held securely and no record existed of this money in order to safeguard all those concerned. The manager confirmed that she is not appointee for anybody residing at the home. On the staff survey we asked whether the manager gives enough support and meets with them to discuss how they are working. The majority of staff replied either often or sometimes. We asked the manager about staff supervision who said for us to speak to the deputy manager about it. The deputy manager told us that supervision of staff as described within the National Minimum Standards was not happening. Documents showed that lifting equipment was recently serviced. Guidance from the Health and Safety Executive (HSE) regarding the servicing of hoisting equipment states that The Lifting Operations and Lifting Equipment Regulations 1998 require that personal lifting equipment (hoists and lifts for people) are thoroughly examined every six months unless a separate thorough examination scheme is devised by a competent person. The engineer who had carried out the gas landlord check confirmed there were no safety issues with equipment in the home. Records regarding the testing of portable electrical appliances were available and showed no items as having failed. At the time of our last inspection we found that hazard data sheets were not available regarding cleaning materials used. Data sheets (COSHH) give advice on how to deal with emergencies such as splashes or ingestion. We checked the substances in one Care Homes for Older People Page 31 of 37 Evidence: cupboard and found the manager held a data sheet for most items. The exception, where no data sheet was held, was an item purchased from a supermarket. Care Homes for Older People Page 32 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 33 of 37 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 7 15 Regulation 15 (2) All people living in the care home must have a care plan which is reviewed and up dated so that it accurately reflects their health and welfare needs and provides clear guidance for staff to follow. This is so staff have the relevant details available to them in order to meet identified care needs. 29/01/2010 2 8 13 You must have a full and 28/12/2009 detailed risk assessment in place regarding the use of bed rails to ensure that risks are identified and eliminated. A full and detailed risk assessment must be in place regarding the use of bed rails to ensure that risks are identified and eliminated. Care Homes for Older People Page 34 of 37 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 is to ensure that people are safe from injury 3 9 13 Regulation 13 (1) The service must make arrangements to ensure that Medication Administration Records are accurately maintained showing the current medicines people are prescribed by a medical practitioner. This is so people receive their medication as prescribed. 4 29 19 Procedures within the home must ensure that the recruitment of staff includes obtaining an employment history and references from the most recent employer. This is so that suitable people are employed in the care home. 5 37 37 Arrangements must be in place to ensure that injuries and incidents whereby people could be harmed are reported to the relevant authorities. This is to ensure that people are safeguarded from the risk of harm. 29/01/2010 31/12/2009 31/01/2010 Care Homes for Older People Page 35 of 37 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 15 Advice should be sought from Environmental Health food safety officer regarding the current arrangements regarding the transportation of food to Fern House. Infection control within the home should be reviewed in line with good practice and the outcome of the findings implemented. Staffing levels should be reviewed to ensure that they do not fluctuate during times of staff sickness and planned annual leave. A full review of staff training should be undertaken to ensure that staff have the skills and knowledge in order to meet the identified needs of people using the service. Systems used to identify and address risks within the service should be reviewed to ensure that people are safe. 2 26 3 27 4 30 5 38 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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