Inspection on 23/02/09 for Forest Court Nursing Home

This inspection was carried out on 23rd February 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Forest Court Nursing Home 05/05/10

Forest Court Nursing Home 01/02/07

Forest Court Nursing Home 23/03/06

Forest Court Nursing Home 08/10/05

Forest Court Nursing Home 23/03/05

Forest Court Nursing Home 12/10/04

Forest Court Nursing Home 16/01/04

Similar services:

Fairfields Country Rest Home

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Fairfax House

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Forest Court Nursing Home Bradley Court Road Mitcheldean Glos GL17 0DR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Janice Patrick     Date: 2 3 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home Name of care home: Address: Forest Court Nursing Home Bradley Court Road Mitcheldean Glos GL17 0DR 01989750775 01989750348 Telephone number: Fax number: Email address: Provider web address: www.bupa.co.uk Name of registered provider(s): BUPA Care Homes (CFC Homes) Ltd care home 49 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 49 The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) Mental Disorder, excluding learning disability or dementia (Code MD) Date of last inspection Brief description of the care home Forest Court is a large imposing building situated on high ground outside the town of Mitcheldean in the Forest Of Dean. There are large gardens with an enclosed area that provides a safe and sheltered garden for residents and their relatives to enjoy. There is also plenty of parking with level access into the home. This care home specialises in Care Homes for Older People Page 4 of 33 Over 65 0 0 49 49 Brief description of the care home the care of the older person who has dementia and who requires nursing care. There are qualified nurses on duty at all times and all staff have experience or have appropriate training in this specialist area of care. The home has predominantly single bedrooms although there are rooms that can be shared. There are large communal areas and wide corridors for residents to wander in freely. Daily activities are available and family and visitors are welcome to visit at any time. Public transport goes as far as the town of Mitcheldean. Fees range from 870 pounds to 990 pounds. The majority of people receive funding of some sort due to their very specialised needs. Fees exclude, Chiropody (foot care), toiletries, hairdressing and papers/magazines. Information on the home can be found in the front hall or can be supplied on request. Care Homes for Older People Page 5 of 33 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: two star good 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: This inspection was carried out by one inspector between the hours of 11.30am and 7.15pm. Before visiting the home we sent questionnaires to the home in order to get the views of those living there. As the majority of the people living in this home lack mental capacity, these were completed by relatives and we received five back. We also took into consideration what the service told us in their Annual Quality Assurance Assessment (AQAA). We also considered any additional information gathered since the last inspection in 2007. This includes formal notifications from the home itself and any further information given to us by the general public and visiting healthcare professionals. We reviewed any outstanding requirements made as a result of the last inspection report and the homes previous response to these. Care Homes for Older People Page 6 of 33 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 7 of 33 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 8 of 33 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. Due to the fact that most people who require the services of this care home lack mental capacity, it often falls to the family or is the responsibility of the persons care manager to find appropriate care for them. This decision making is helped by the homes literature being clear and available. People benefit from having their needs comprehensively assessed prior to and during a period after admission. This ensures that their needs are correctly met and the placement is ultimately successful. Evidence: A welcome pack, containing the Statement of Purpose, Services User Guide and a copy of our last inspection report is available in the reception area. Alternatively, this is posted to the potential residents representative if they are unable to visit the home. The service has supplied us with their Annual Quality Assurance Assessment, AQQA. This confirms the practice of making information available to all prospective residents and their representatives. It says that enquirers are actively encouraged to Care Homes for Older People Page 9 of 33 Evidence: look at other care homes to help them make an informed decision. The AQQA also confirms that the majority of the people living in the home receive funding towards their care. The Registered Manager confirmed that everyone, irrespective of how their fees are met, receive a contract of residence informing them of their financial responsibilities and making it clear what the home will provide and what it does not provide. We did not inspect any of these contracts during this visit but have done in the past. People are made aware of any additional nursing contribution entitlements. We looked at pre admission assessments for three newly admitted people. Each of these individuals had been visited in their original locations by a senior member of staff before their admission to Forest Court. The assessments showed that there is a process in place that enables staff to identify and consider peoples needs before their admission. This is so that staff can be sure that they are able to meet the persons needs once they are admitted and that ultimately the placement has good outcomes for that individual. The pre admission assessments appeared to be well balanced in assessing both physical and particularly peoples mental ability, this being a home that specializes in the care of those with dementia. We looked to see if the training provided for the staff and their skills were relevant to the type of person they care for. Staff receive mandatory training in several key areas and some additional trainings that are relevant to their role. However, it is only within the staff members induction training, at the beginning of their employment, that they receive basic training in dementia care. As this is a specialist dementia care home we would have expected to see this training as a key subject of learning and for it to be ongoing and progressive. The Registered Manager and her deputy and have identified this as an area requiring improvement and plan to address this by devising further dementia training which staff will be able to complete within the home. We were informed by the Registered Manager that most of the qualified nurses have already completed an accredited dementia care course. We spoke to one nurse who was currently completing this through a well known University. The Deputy Manager is a Registered Mental Nurse and the Registered Manager has commenced a degree in dementia studies. We are also aware that both of these senior staff have completed various other study days on related topics. We are confident that they have the right skills to further improve the knowledge of the care staff. Care Homes for Older People Page 10 of 33 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home generally have their care and health needs met, but staff need to be aware that any shortfalls in care delivery, for whatever reason, can put people at unnecessary risk. Evidence: Although on inspection there were unexpected shortfalls within this outcome, we have taken a proportionate view when considering all of the evidence. We have not made a requirement in respect of these shortfalls as it was very clear at the time of this inspection that the manager was begining to deal with these. She informed us that arrangements will be made to ensure staff are getting adequate day to day supervision when delivering peoples care. Recognition of the need for two nurses to be on duty, in a clinical capacity, will no doubt help this (see Staffing outcome of this report) We looked at various aspects of care for eight people living in the home. This involved reading relevant care plans and then talking with the care staff to see if the written care plan was being adhered to. Some of the areas of care we inspected included Care Homes for Older People Page 11 of 33 Evidence: continence care, pressure relief care and associated records, wound care and relevant record keeping, the planning and monitoring of peoples food and fluid intake and finally the formal observation of certain people. We evidenced good standards of care along with some shortfalls, particularly it would appear in staffs recording of care given and in adhering to some of the care plans. Some of the shortfalls were identified with the Registered Manager present, others were discussed with staff as we identified them. Whilst inspecting the care people were receiving we were concerned at some of the replies staff gave us. For example we asked if one particular person had been helped to use the toilet. It was evident in this persons care plan that they required total support from staff to do this. It was a similar case for a second person. Staff were initially unable to give clear answers as to whether this support had been given or not. To start with individual staff thought other members of the care team had helped these people to the toilet, then we were told that this had not happened but peoples continence pads had been checked. In one case, this would have been impossible for one carer to have done this alone as was first indicated. The only conclusion that we and the Registered Manager could come to was that the care had not been delivered as directed in the individual care plans i.e. people requiring support to use the toilet had not received this. A further example of care not being delivered as expected was more obvious, as in the case of one person who should have been helped back to bed after lunch. The reason for this person needing to go to bed at this time of the day was so that a different position could be achieved, other than that of sitting in an armchair. The idea being that any pressure to the skin of the sacrum would benifit from some relief. This is important care that helps to prevent pressure sores from developing. It was the expectation of the Registered Nurse on duty that this would take place and carers confirmed to us that this should have happened after lunch as originally planned. However, we saw this person still sitting in the lounge at 3pm. This person also requires regular turns from side to side and onto her back during the night. The Registered Manager confirmed that staff should be delivering and recording this care a) to demonstrate that it has been given and b) for staff not to get confused as to the persons next position. We could see that a record of turns had been kept for the early hours of the day of this inspection and of turns carried out on the 20/2/09, but the Registered Manager was unable to find records pertaining to the nights of 21/2/09 and 22/2/09. Because of the missing sets of records and the shortfall observed during the inspection day we are unable to confirm that this person is always receiving consistent pressure relief care. Another shortfall was in the record keeping of formal observations on certain people. These observations are carried out on people who, for whatever reason, are Care Homes for Older People Page 12 of 33 Evidence: considered to be a little more at risk. The observations vary from every fifteen minutes for some and thirty minutes for others and is written as a requirement in their care plan. At 3pm we asked to see the location chart for one specific person. The last recorded observation was at 2pm. In this case the observations were every fifteen minutes and the person was new to the home and therefore, the care staff. The carer responsible for this task explained that she had forgotten to hand over the observations to another member of staff whilst she took her lunch break. As it was, this person had fallen to sleep in the nurses office during this time, where we had been based and was safe. There were similar shortfalls in recording observations for two other people. There seemed to be a general shortfall in this task on the day of this inspection, as opposed to it being just one persons ommission. We were informed fairly immediately after our site visit, by the Registered Manager, that specific tasks are now allocated to individual members of staff at the beginning of their shift. This makes it easier for care staff to know exactly what they are responsible for and for senior staff to know who to follow up if needed. In sharp contrast to these shortfalls we observed many good practices. One example was of staff members managing a potentially confrontational situation, in a calm and caring manner. We also spoke to one visitor who confirmed that this caring approach by the staff was not unusual and that in their opinion their loved one was being very well cared for. The homes information to us says that they provide person centred care. A good example of this was when we found a carer helping someone to have their lunch at 2pm. We asked why this person was having their lunch so late. The senior carer explained that this individual had been unable to settle and accept help with their food at the time when the majority were having lunch, so she had returned to try again when she could see that the person looked more settled. The carer appeared to know the person well and explained that they have to give this persons care at a time they are able to accept it. We observed staff and listened to them in several situations and they seemed very aware of peoples individual needs. At teatime we witnessed a carer report to the nurse that an individual had not eaten well all day. This person had been seen by the nurse in the morning and a doctor. The carer asked if she could offer a supplement drink in order to try and improve the persons nutritional intake for the day. We could see by looking at peoples care assessments that there were arrangements in place to monitor and assess peoples nutritional needs, such as we had just witnessed and to monitor their weight. The homes information also tells us that most staff have received some form of training in monitoring and supporting people nutritionally. The cook and kitchen staff have also received specific training and have to adhere to specific protocols set by BUPA in order to ensure that their very specific client group receive the nutritional intake they require. Many require an increased calorie intake compared to the average older Care Homes for Older People Page 13 of 33 Evidence: person because of their illness. We are aware that the paperwork used for assessing and planning care has been altered in the last 18 months by BUPA. The general concept is good, allowing staff to record comprehensively their assessment of an individual and then to plan the care required. It is designed to ensure certain areas of care cross reference with each other so that a holistic approach can be used in planning peoples care. The care plans we read were person centred; as if telling a story about an individuals very specific needs. It does however, seem to be time consuming for the Registered Nurses who need to dedicate a large amount of their time when on duty, entering information and maintaining the system. We found a shortfall in the documentation of one persons wound care. In December 2008 this person sustained an injury to their skin. A care plan was devised giving staff clear guidance on how this injury would be managed. However, in the actions thereafter, three different wound coverings, other than the one stated in the care plan were used. There was no documented rationale as to why these changes had taken place. The records went on to indicate that the wound had healed at some point, but there was no clear indication of when. The last entry in the wound care records was on the 13/2/09 which said: to liaise with GP, dressing removed. Implying there was a wound present again that required dressing. In the daily records on the 17/2/09 an entry said: wound swab taken. This would imply that staff felt unhappy about the wound and maybe its healing process. There was no description of the wound at this point and no record of the wound being redressed after the wound swab, despite an entry on the 19/2/09 in the daily life section saying, dressing intact. There was also no review date. Due to the confusion of events in the record, we asked to view this persons leg. We did this with the Registered Manager present and the individuals permission. We found a dressing in place stained with with fluid from a wound underneath. The Registered Manager agreed that the records had failed to provide the rationale behind the changes in dressings, exactly what treatment had been given and when and the ongoing condition of the wound. She also said it was rare for the home to have to deal with a wound. Our view is that injuries do occur to peoples skin in nursing homes. It would be expected that the qualified nurses employed in the home would be able to manage these or otherwise seek advice from an external health care specialist. It would also be an expectation of any qualified nurse to be able to maintain adequate and relevant records under their responsibilities laid down by the Nursing and Midwifery Council. The Registered Manager confirmed that none of the nurses had been on recent wound care training. Although update training had been booked through the Primary Healthcare Trust, (PCT), the PCT had canceled this. The Registered Manager informed us that this would be rebooked as soon as possible. Care Homes for Older People Page 14 of 33 Evidence: We observed some medicines being administered and inspected the Medication Administration Records (MAR). We were concerned to see that on the day of this inspection the Registered Nurse on duty was just completing the morning medication round at 11:30am. We asked why the morning medication round was ending so late. The nurse informed us that she had started the round at approximately 08:45hrs. She explained that her first priority that morning had been to check on a person that was poorly and organise for a doctor to visit. She also told us that a member of staff had gone off sick that morning and she had spent time arranging a replacement. We were also informed by her that no medications were administered by the agency night nurse which, she told us would have helped to reduce the number that needed to administered by her in the morning. Due to the lateness of the morning medication round we were concerned if the required gap of 4 hours between certain pain relief medications was being maintained, particularly if the next medication round was due to start in an hours time. The nurse explained that any medications requiring a 4 hour gap would have been given at the begining of her round and if needed, the next dose due would be given later to accommodate the required gap. On looking at the medication administration records we could not evidence any indication that medicines are given earlier than 8am. We have been subsequently informed that there is not a set medication round any earlier than 8am, but in some circumstances, if some one has got up particularly early it maybe appropriate for them to have their medication, in which case this maybe given by the night nurse. We looked at the records of one person who requires pain relief at times (as required). We noted that there was an associated care plan for this medication as the person cannot indicate verbally when they need this. This gave guidance to the staff on how to monitor and assess the need for pain relief in other ways. None had been required that morning. We noted that there was only one gap in the signing of the MAR sheets among many inspected. We also observed safe practice in the locking of the medication trolley each time the nurse went to administer any medications. We also saw the records pertaining to someone who was diabetic. This showed that nurses were routinely monitoring this persons blood sugar levels before administering the prescribed insulin. This person is relatively new to the home and this twice daily monitoring of their blood sugar may alter in the future, following the homes initial assessment and after discussion with the doctor. We are also aware that the medication system and administration records are audited monthly. People newly admitted to the home have all of their medication reviewed within a month by the local doctor and then by a Consultant if required. It is the homes aim to reduce the amount of medication anyone is taking after admission. It will also endeavor to manage challenging behavior, that may come with some peoples illness, in other ways other than using medication. Care Homes for Older People Page 15 of 33 Evidence: We could see from reading additional care records that the home refers to and works closely with a range of external health care professionals to meet peoples needs. At no time during this inspection did we observe anyones privacy or dignity being compromised by staff. In situations that could potentially be confrontational staff remained polite and calm and addressed the person in a respectful manner. Care Homes for Older People Page 16 of 33 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 benefit from living in a home where staff recognize their very specific needs. This includes the rights of those who lack mental capacity to be supported to make choices and have their preferences safely met. People living in the home will also benefit from activities being provided at weekends as not all people living in the home receive visitors and some still require some form of interaction and diversion at this time. Evidence: People living in the home are supported to make daily choices and have taking into account the feedback we have received, usually their preferences met. We observed people walking around the home without restriction and talking to who they wished to talk to. A good example of this was seen several times during the day when people entered the nurses office. It was clearly not viewed as an area that was out of bounds and those that visited were welcomed each time they entered. In the case of some people this was a repetitive action and each time they received the same welcome. We observed the same welcome in the case of one person who walked in to the managers office and who walked back out again. We observed staff asking people where they wished to be and helping them to get to those places. We saw choices being given when food and drinks were provided. We also saw people being Care Homes for Older People Page 17 of 33 Evidence: encouraged to join in an activity, but equally so, not forced if they did not wish to. We noted that any refusal was clearly acknowledged by staff. Depending on the situation, staff sometimes returned a little later to try and encouraged acceptance of what was being offered, this particularly related to certain care needs or when food and drink was being offered. This aim of maintaining peoples autonomy and freedom as much as is safely possible with people who lack full mental capacity is reflected in the care plans for individuals. To assist in achieving this, staff request that relatives complete a life profile on the person living in the home. This enables staff to learn about the individuals life history and significant events within that and to try and be aware of preferences and what was important to that person before they fell ill. This information is then considered when deciding how best to meet the persons current needs. The home provides a dedicated activities coordinator between 8am and 4pm, Monday to Friday. When we initially looked around at 11:45am we found 10 people in the main lounge, there was no music on or staff in the room and several people were asleep. We were then drawn to the far lounge because someone was shouting. Here we found 4 people, again no music on or staff close by. We were informed that the activities coordinator had gone shopping for pet food in the morning. The home has several guinea pigs, which we were told the people enjoy watching and handling. We asked why this shopping trip had not been used as an activity for someone. It was explained that most people would require a member of staff to be present, as well as the person driving and this cannot always be achieved. We saw the activities coordinator carrying out a one to one activity just before lunch. A mixture of one to one work and group activities are recorded, indicating that the absence of the activities coordinator as seen during this inspection, was not a regular occurrence. This varies from one particular person being escorted to specific activities outside of the home, to sitting and chatting with an individual, to holding art and music sessions with a group. The latter was seen during the afternoon of this inspection. People who were immobile or unable to verbally communicate effectively were seen enjoying the music and joining in with the use of a simple instrument or by simply tapping their feet. There is a designated activities room where individuals or small groups can enjoy time with the coordinator. We were also informed that because the area is separate from other communal areas, it makes it easier for people to concentrate on the activity being provided. The home is currently advertising for another activities coordinator. The aim is to also provide activities at weekends. We did note that one person requires alot of input from the activities coordinator and we wondered how much other people may miss out during this time. The reminiscence lounge is a room decorated and furnished in a style that would be familiar to the current people living in the home. The Registered Manager said this is popular with people who prefer a quiet environment. It is also an area Care Homes for Older People Page 18 of 33 Evidence: where visitors can share a cup of tea with their loved ones quietly, as was seen during this inspection. A small group or individuals can also eat meals in here at the dining room table provided. We were informed that there are plans to turn the end lounge into an Alzheimers Style Cafe. This we were told will be a room for people to sit and have refreshments with their visitors. From this room they will be able to access a safe and enclosed area of the garden. The plan is that the cafe and its approach will be decorated and furnished in a style that will stimulate the memories of those living in the home. Some alterations are planned to the existing enclosed garden area so that people living in the home and their relatives, will be able to access the area without having to find a member of staff to unlock the outside door. This is another example of the home trying to achieve a mixture of safety at the same time as trying to increase peoples freedom. BUPA have several arrangements and initiatives in place to ensure people get the nutrition they require. This includes catering for people who may eat as they walk, people who are active during the night and people who are generally unable to rest and who therefore require more calories than the average older person. We saw the menu for the day of our visit. There were two cooked options and one cooked vegetarian option at lunchtime. The Registered Manager explained that in order to enable choice this may involve placing a choice of food in front of the person at the start of the meal. We were informed that there is always a hot option at teatime. We observed staff helping people to eat in a kind and unrushed manner. Those that did not want to eat in the dining room were free to eat where they wished to. Relatives and friends are free to visit whenever they wish to. The Senior staff on duty explained that many family members require alot of support themselves, when they visit their loved ones. Some find it difficult and distressing. One of our pre inspection questionnaires to relatives was returned and confirmed this very support. The Registered Manager explained that she would like to improve the number of connections the home has with the local community, but there is an acknowledgment from her that, due to the type of illness the clients have and the location of the home, this is not easy to achieve. Care Homes for Older People Page 19 of 33 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in this home benefit from the many arrangements already in place to ensure their safety and protection from harm or abuse. Managers are also aware of new criteria that will further ensure peoples rights and safety but, for these procedures to be fully effective, each member of the team must be fully aware of their content and have a clear understanding of what is required from them. Evidence: BUPA have a complaints policy with written procedures. The homes Annual Quality Assurance Assessment tells us that this policy is currently being reviewed. A summary of the current procedures are displayed in the home for visitors. This makes it clear how to make a complaint and who to address this to. This procedure is also within the welcome pack, which we are informed is given to all relatives and representatives. We saw the homes complaints file, which contained a complaint received in 2007 and which was responded to within four days by BUPA. Both the Registered Manager and the homes Annual Quality Assurance Assessment confirm there have been no further complaints and we are not aware of any being received by the Commission. The Registered Manager said that by having an open door policy this meant that she sees many relatives and visitors on a regular basis and small concerns get resolved quickly. The returned pre inspection questionnaires confirm that people know how to make a complaint and know who to talk to if they are concerned about anything. Only one said they did not know how to make a complaint. Care Homes for Older People Page 20 of 33 Evidence: BUPA have various policies and procedures that work alongside their Safeguarding Adults Policy. These are designed to help protect vulnerable adults from harm or abuse and include for example, safe recruitment procedures. BUPAs corporate Safeguarding Adults Policy has been reviewed in the last year to bring it in line with current good practice and various regional protocols. We have received a copy of this and have made a comment about one aspect of the procedure via appropriate communication channels set up between BUPA and the Commission. We asked the nurse on duty if she was aware of the revised policy and its procedures. She was not sure at the time of being asked but the Registered Manager later confirmed that all staff had been informed of these. This particular nurse, who has worked in the home for nearly a year, also confirmed that she had not attended any training on abuse or the Protection of Vulnerable Adults. As evidenced in this outcome this one persons lack of awareness seems to be an isolated case. We would suggest that adequate and appropriate training is given to this senior member of staff as soon as possible. We have confidence in the management that this will be addressed and have therefore not made a requirement in respect of this. A recommendation has been made to not let, particularly senior staff, go for long periods of employment without receiving appropriate training on the subject. The Registered Manager has however attended training on the subject which was provided by the countys Safeguarding Adults Team and the Deputy Manager has attended training provided by BUPA. This provides her with the skills to teach this to other members of staff. We saw on the training record that one member of the care team had, for example, received this training in 2007 as had others at various times. One other carer, who started work at the home in January of this year had not yet received this training. It was explained that this person will receive this within their induction training. We discussed with the Registered Manager, a situation that BUPA are currently investigating that we also received information on. The information given to us implied that a person living in the home may have been placed at risk of harm. This specific piece of information seemed to differ from that initially given to the Registered Manager. As soon as she was made aware of this appropriate action was taken by her and the case discussed with the Safeguarding Adults Team. BUPA also have a Whistle Blowing policy. This promotes staffs ability to raise concerns they may have with senior staff within the company or with external agencies without fear of reprisal. Training in relation to the Mental Capacity Act 2005 is being provided. The Registered Manager is also becoming more aware of the new criteria relating to Deprivation of Liberty Safeguards and knows that these will require consideration and inclusion within the homes practices and documentation. Care Homes for Older People Page 21 of 33 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. Good arrangements are in place to keep the environment clean and safe and to make improvements to this as they are required; for the benefit of those who live in the home. Evidence: During this inspection we commented that we felt that the general decoration and soft furnishings, in places had deteriorated from when we last saw the home in 2007. There was also evidence of odours on the ground floor, which we have not been aware of before. The Registered Manager explained that BUPA are due to commence a full refurbishment of the home this summer. She also explained that problems with the last delivery of armchairs to the home is being sorted out and these are due to be replaced by the supplier. The current odour, in one area, she felt was possibly coming from a corridor carpet that is due to be replaced. We were informed that these are being cleaned as usual. We know that alot of work has already been carried out with respect to fire safety within the roof space, however, it was explained to us that further requirements have been made by the Fire Safety Department. This work will also be carried out as part of the refurbishment and will further aim to improve fire safety within the building. Externally, paving will also be laid from the fire escape to the assembly point, making it easier and safer to walk around the building in the event of needing to use the fire escape. Another plan is to swap the present dining room with the main lounge area. This is so that the far reaching views from the Care Homes for Older People Page 22 of 33 Evidence: current dining room can be enjoyed for longer periods by those living in the home. It is also a larger room with more natural light. We have already reported on other planned improvements such as the Alzheimers Cafe and enclosed garden. All corridor carpets are to be replaced and the lighting in some places will be enhanced. The bedrooms that we visited were well decorated, but we were informed that all bedrooms are to be fitted with laminate flooring to make them easier to keep clean and more hygienic. The Registered Manager told us that relatives have been made aware of the planned refurbishment. The Registered Manager is very aware of the disruption and problems that this could cause and assures us that BUPA will make sure that the work is carried out safely and with as least disruption as possible. As it is clear that BUPA have plans to improve the environment fairly soon, no requirements have been made in respect of this as we have confidence that this will carried out as planned. BUPA have various procedures and policies that aim to promote good infection control. We did observe staff using protective aprons and gloves for some care tasks. A different colour plastic apron is worn when serving food and on entering the kitchen. The kitchen has been awarded the highest award of five stars by the Food Safety Officer. We did not speak to any cleaning staff on this occasion but we have been informed that the same safe cleaning systems are still in place. These systems are designed and are risk assessed with good infection control practices in mind. For example all equipment is colour coded, washing for the laundry is segregated and appropriate equipment is in place to sluice and clean this. The homes Annual Quality Assurance Assessment tells us that the laundry floor has been replaced in the last year. All staff complete Infection Control Training, which is done by distance learning and requires a test to be taken on completion. There are some new staff who now need to complete this however the Registered Manager is aware of this and the training works on a rolling programme. We will monitor this via the homes next Annual Quality Assurance Assessment. All outlets that provide hot water, in areas where the people living in the home have access, are individually regulated; each being set at a recognized safe temperature of 43 Celsius. The temperature of the water coming out of these outlets is also checked every six months to ensure the regulators are doing the required job. These precautions are to prevent scalding injuries to older skin. Records also show that maintenance is carried to reduce the risk of Legionella. New boilers are also due to be fitted as part of the refurbishment work, but this will be carried out when the weather is warmer. Emergency lighting is fitted throughout the home and records show that this is checked and maintained regularly. All electrics and utility supplies had a routine check by an external contractor in February 2008. Care Homes for Older People Page 23 of 33 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We are confident that peoples needs are usually met. There may however be times, when more thought needs to be given to the numbers, mix and abilities of the staff on duty in order for the home to run smoothly. Evidence: We inspected the duty rosters. We noted that for the five weeks seen during this inspection, neither the Registered Manager or Deputy Manager were recorded to work a weekend. We noted that the Deputy Manager would have been on duty one of the days of a weekend but had taken Annual Leave. One Registered Nurse (RN) explained that it is difficult to complete all nursing tasks and manage staff when there is just one RN on duty. The inference was that this was also the case, even when the managers (who are both RNs) are on duty because they are carrying out management duties as opposed to carrying out nursing tasks. On the day of this inspection the Registered Manager was elsewhere in the county carrying out work related to BUPAs new audit tool. She returned to the home soon after our arrival. Both of the above relate to concerns we had during this inspection, as to whether care staff are receiving adequate supervision, following some of the shortfalls we evidenced and have reported on in the Health and Personal Care outcome of this report. We also noted that the RN on duty during this inspection was very busy and went from one nursing task to the other, such as administering medication, writing in the care documentation and escorting the doctor when he visited a person who was quite poorly. This did not Care Homes for Older People Page 24 of 33 Evidence: allow her time to work alongside the care staff. We are aware that some of the care staff are employed as senior care staff and it would be part of their role to supervise less experienced staff. This RN confirmed that on the day of this inspection there were 39 people resident in the home and that all have dementia or mental health problems. Two were in bed because they were frail and one other was in bed because she was poorly. One had recently returned from hospital and several were low with coughs and colds. She confirmed that one carer had gone off sick first thing in the morning, but she had managed to organize a replacement. By the time we arrived the home had a full compliment of staff on duty. The duty rosters recorded four days in February, as well as the day of this inspection, where there had been one RN on duty. We noted that between these dates, three new people had been admitted to the home. On the actual days of peoples admissions there had been two RNs on duty, however, new people to the home can be disruptive to the existing group and for those newly admitted, there is a period of needing to settle down. For example, one of the new admissions has had extremely disturbed nights. The duty rosters recorded, sometimes seven care staff on duty in the morning and sometimes six. This dropped to five, sometimes six care staff in the afternoon. The activities person was extra to these numbers as was the RN on duty. The Registered Manager explained that she works Monday to Friday and is extra to any of the care staff or nurses on duty. She also confirmed that the Deputy Manager does work some days, of some weekends, but a longer period of no weekends worked had originated from the Deputy taking Annual Leave over one of these. She also explained that although the Deputy Manager does have some designated time for training staff and other management tasks, she does work as a RN, carrying out clinical tasks quite frequently. We could see from the roster that she was recorded as the second RN on duty at times. The Registered Manager did confirm that more often than not, there are 2 RNs on duty who are designated to clinical tasks. The rosters demonstrate this. The Registered Manager explained that she has acknowledged that there is a need for two RNs to be on duty and that following BUPAs agreement she is currently advertising and going through recruitment processes with individuals to try and address this. The Registered Manager considered there to be enough care staff on duty to meet the needs of the people living in the home on the day of this inspection. She also considered the staff on duty to be generally competent and caring. During this inspection there were senior care staff on duty as well as those less experienced. She agreed that some staff are requiring additional support within their work. These staff had already been identified and were receiving additional staff supervision. Over fifty percent of the care staff have achieved the National Vocational Qualification Care Homes for Older People Page 25 of 33 Evidence: (NVQ) in Care level 2 or above and there are currently more staff due to commence the course. We inspected two peoples recruitment files. One person had started work already and another was still going through various checks. The person that had already commenced work had satisfactory clearances from the Criminal Records Bureau (CRB) and against the Protection of Vulnerable Adults list (POVA). They also had satisfactory references and gaps in past employment had been explored. The second person had not yet completed the recruitment process and further exploration and checks were yet to be completed by BUPA. We are aware that BUPA staff all attend a set period of Induction Training at the beginning of their employment. We saw on the training records of a new member of staff that she had attended some basic trainings and had received the Induction Booklet. She will complete this and there is an expectation that if completed successfully, she will go on to study for the NVQ in Care. Care Homes for Older People Page 26 of 33 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a home that is well managed and where there is a genuine desire to maintain peoples safety and quality of life. Evidence: The manager of the home is registered with us and is a Registered General Nurse. She was previously the Deputy Manager and knows many of the people who live and work in the home, well. She demonstrates strong leadership skills and is able to communicate her expectations and wishes for the service clearly. She is currently studying for a degree in Dementia Studies. The Deputy Manager is a Registered Mental Nurse (RMN). She supports the Manager and is responsible for several other areas of work such as staff supervision, some staff training, as well as some management responsibilities. The home and management staff are then supported by the administrator who is full time and who has worked at the home for several years. Both these managers have a very good understanding of the specialized needs of the people that live at Forest Court. Care Homes for Older People Page 27 of 33 Evidence: Members of the care team were unable to give direct and clear answers regarding some peoples care during this inspection. This concerned us and we have already given some feedback to a senior manager within BUPA regarding this. We were subsequently made aware that senior staff within the home itself, have explored the issues identified with the staff concerned. There is evidence that staff supervision sessions are provided and that where additional supervision and support is required, it is given. We suggested that the staff supervision records be kept in a secure location and not accessible to all staff in the main office as was the case on the day of this inspection. Communication with relatives and other visitors is maintained by a successful open door policy. We know this system works well as relatives have told us so in their returned questionnaires. The Registered Manager thinks this is probably the reason for the past, poor attendance at the formal relative meetings. However, she explained that the home will continue to offer an annual meeting. To help communication further, a newsletter has been started. This informs relatives of future dates to be aware of and updates them on things such as the planned refurbishment. Staff meetings, across all departments, take place frequently, as is expected by BUPA. Staff are involved in several initiatives that help improve individual performance and which acknowledge individual achievements. The company has recently introduced a new Early Warning Audit Tool. The various areas for review and assessment are cross referenced with relevant Care Home Regulations and Minimum Standards. This has been designed to identify any shortfalls in the homes systems, quickly. It also helps staff to plan and action any improvements required in the service. As part of the quality assurance system, BUPA also comply with Regulation 26 of the Care Homes Regulations 2001, which requires a representative of BUPA to carry out an unannounced visit on a monthly basis and submit a report on various areas of the service. This is submitted to BUPA and retained for us to view if we wish to. There are no individual amounts of personal monies kept for people within the home. If someone requires toiletries, clothes or anything else, these are purchased, the receipt kept and an invoice is sent at the end of each month to the person responsible for that individuals monies. The amount is then deducted from any monies being held in a central account. The interest made from this account is then calculated for each individual and the amount added to their individual balance. The administrator keeps electronic records of these accounts and transactions which were not inspected during this inspection, but have been in the past. BUPA carry out audits on this system. BUPA have many policies and procedures that come under the heading of Health and Safety. They also carry out weekly and monthly checks, along with regular maintenance both in house and by external contractors to ensure peoples safety. Many of these records were inspected and were seen to be well maintained. This is Care Homes for Older People Page 28 of 33 Evidence: also an area audited on a monthly basis by BUPA. We receive notifications appropriately from the home under Regulation 37 of the Care Home Regulations 2001, whenever there has been an adverse event, a death or a serious injury to someone. We observed staff carrying out safe moving and handling maneuvers. Care Homes for Older People Page 29 of 33 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 30 of 33 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 8 17 You must maintain an 31/05/2009 accurate record of any care given in relation to nursing care i.e. wound care, pressure relief care and any other care required as stipulated within a care plan. There is a legal requirement for concise records to be maintained. Concise and well documented records also help provide an audit trail of the care delivered. They also help staff to know what care has already been given and what care has to be given in the future. 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 4 Consideration should be given by the Registered Provider for training relating to dementia; the illness and the care of those with it, to be ongoing and recognized as a Page 31 of 33 Care Homes for Older People 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 progressive learning need in a home that specializes in this area of care. Consideration should also be given to affording staff the time to attend this and making its location practical for them to attend. 2 3 8 18 Further arrangements should be considered to ensure that staff are delivering peoples care as has been planned. Consideration should be given to making sure that all staff, but in particular, senior staff have a clear understanding of their role within the Safeguarding process, early on in their employment. If managers have recognised that there is a need for two nurses to be on duty for the benefit of the people in the home, then consideration should be given to maintaining this once appropriate staff have been recruited. 4 27 Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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