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

This inspection was carried out on 23rd February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Forest Place Nursing Home 25/09/06

Forest Place Nursing Home 10/03/06

Forest Place Nursing Home 09/11/05

Forest Place Nursing Home 09/03/05

Forest Place Nursing Home 20/10/04

Forest Place Nursing Home 18/03/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Forest Place Nursing Home Roebuck Lane Buckhurst Hill Essex IG9 5QL     The quality rating for this care home is:   one star adequate 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: Bernadette Little     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 39 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 39 Information about the care home Name of care home: Address: Forest Place Nursing Home Roebuck Lane Buckhurst Hill Essex IG9 5QL 02085052063 02085590193 admin@forestplacenursinghome.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Martlane Limited care home 90 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia learning disability physical disability terminally ill Additional conditions: One named person, under the age of 65 years, who requires care by reason of a learning disability Persons of either sex, aged 50 years and over, who require nursing care by reason of a physical disability (not to exceed 5 persons) Persons of either sex, aged 50 years and over, who require nursing care by reason of a terminal illness (not to exceed 5 persons) Persons of either sex, aged 50 years and over, who require nursing care by reason of dementia (not to exceed 5 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 90 persons) Care Homes for Older People Page 4 of 39 Over 65 60 0 90 0 5 1 5 5 Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 60 persons) The total number of service users accommodated in the home must not exceed 90 persons Date of last inspection Brief description of the care home Forest place is registered to provide nursing care for 90 older people who need nursing care due to physical illness or dementia. This home is a three-storey building with a large extension at the rear of the property. All rooms are single some with en-suite facilities. The home has its own gardens to the side and rear and car parking for visitors. The local shops are a mile away as is the railway station and London transport underground services. A statement of purpose and service user guide is available from the manager. The service user guide advises that the current fees at Forest Place range between £550 and £700 per week, inclusive of personal and nursing care, food and laundry services. Items not included in the fees and that attract additional charges included hairdressing, dry-cleaning, toiletries, newspapers and magazines. Care Homes for Older People Page 5 of 39 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 key inspection of this service was undertaken on 25th September 2006. An Annual Review of the service was undertaken in February 2008 that identified that, based on the information available, we did not need to review our inspection plan. This site visit was undertaken by two inspectors over a nine hour period on one day as part of the routine key inspection. Time was spent with residents, visitors, a visiting GP, the manager and staff and information gathered from these conversations as well as from observations of daily life and practices at the home have been taken into account in the writing of this report. The manager submitted an Annual Quality Assurance Assessment (AQAA) as required prior to the site visit. This is to detail their assessment of what they do well, what has improved and what they plan to do better. The AQAA contained a satisfactory level of Care Homes for Older People Page 6 of 39 information that was considered as part of the inspection process. Some time prior to the site visit, we sent the manager a variety of surveys to distribute to residents, relatives, staff, care managers and health professionals. Where surveys have been returned to us, comments have been incorporated in the main text of the report. A tour of the premises was undertaken and records, policies and procedures were sampled. The manager was present during the site visit and assisted with the inspection process. The outcomes of the site visit were fed back and discussed with the manager and opportunity given for clarification were necessary. The assistance provided by all those involved in this inspection process is appreciated. What the care home does well: What has improved since the last inspection? What they could do better: Clearer systems need to be in place in relation to the management of intermediate care places and the general assessment process to provide appropriate information for each person living at the home. This would enable more effective care planning and support more person centered care in practice, that reflected peoples individual preferences and diverse needs. Staff practice in relation to some aspects of resident care, medication, privacy and dignity should be reviewed and staff supported to ensure that a culture exists where resident care is person centered and not staff or task orientated. Staff ability to communicate effectively with residents needs to be monitored to promote resident wellbeing. One of the comments received relating to this was with the overseas Care Homes for Older People Page 8 of 39 accents (resident) finds it hard to understand. Some parts of the premises need to be refurbished to provide a pleasant living environment for all the people at Forest Place and systems implemented to ensure the safety of residents and staff. Management of records including those relating to complaints, staff training and some aspects of staff recruitment need improvement to demonstrate effective systems to safeguard residents and positive responses to isses raised. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 39 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 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can not be reassured that the assessment and admission process is appropriately planned and considered to ensure their needs can be met at Forest Place and they may not have full information about the home on which to base a decision about living there. Evidence: Copies of the current statement of purpose and service user guide were provided, both of which were signed and dated by the manager in 2008. The required monthly report by the registered person of January 2009 identified that the homes statement of purpose and service user guide were currently being updated and would benefit from being available in alternative formats. A survey received from a relative stated we have received a brochure of what the home offers and one is also available in my relatives room. No further information about the running and organisation of the home has been received, including the Care Homes for Older People Page 11 of 39 Evidence: outcome of inspections etc. The managers AQAA advised that Forest Place provides people with up to date and accurate information, a familiarisation visit with a tour of the home and inspection of available rooms as part of a well-planned process to assist people to make an informed choice in terms of the placement. This is stated to be followed by a comprehensive initial assessment to determine their care needs followed wherever possible by a trial visit. For one recently admitted resident, there was evidence of an assessment undertaken by the deputy manager while the person was still in hospital. This contained very limited information using a tick box assessment with judgment statements and very little individual information about the person other than they were confused, unable to express themselves, had difficulty in communication, had memory loss, that they needed help with personal hygiene and their behaviour was to be monitored. There was evidence that the long-term needs assessment and care plan for this person was written up on the sixth day after their admission to Forest Place. For another recently admitted resident this tick box assessment undertaken on the day prior to their admission to Forest Place did not include for example any information relating to pressure area care or the grade 3 pressure sore recorded later on admission. The format of the assessment did not allow opportunity to record the persons cultural or religious needs, dietary needs and any preferences they might have. The manager advised that since the last inspection, Forest Place now offers eight intermediate care beds. The manager stated that care needs assessments or preadmission assessments are not undertaken on the residents admitted for intermediate care but a care plan is put in place immediately on admission. The manager also advised that a resident had been discharged from the hospital and transported to the home by a relative before any discharge information had been received by Forest Place staff from the hospital about the persons needs, but they felt unable to turn the person away. The manager confirmed that they still have received no information from the hospital regarding this persons needs, some two weeks after their admission, although they had told the staff to get information by fax. The statement of purpose and service user guide give no indication that intermediate care is offered at Forest Place or any information for those admitted to intermediate care beds. The statement of purpose states there is a formal process for admitting a resident to the home including an assessment of needs to determine whether or not Care Homes for Older People Page 12 of 39 Evidence: the home can provide for the individuals specific care needs, explanation of terms and conditions of residence, a risk assessment of the new residents room and its preparation in readiness for the new resident, followed by admission of the person to the home including the procedures to be followed for emergency admissions were these are relevant. The manager confirmed that they do not write to the person as required by regulation to confirm that, based on their assessment of the persons needs, Forest Place can meet the persons needs. Care Homes for Older People Page 13 of 39 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 cannot be assured that all of their care needs, wishes and preferences will be clearly recorded within a plan of care and carried out in practice. Shortfalls identified in medication practices do not best promote resident well-being. Evidence: Care documentation was reviewed for five residents and care plans were in place for all. There was evidence of early assessments in relation to pressure area care, nutrition and moving and handling and these were then clearly cross-referenced into the care plans which is good practice. The care plans available provided clear information for staff on the actions to be taken to meet the care needs in a consistent manner for that person. It was disappointing to note that care plans were not written for some aspects of peoples identified needs such as aggression/verbal abuse, medication, night care needs as well as any cultural/ religious/dietary needs and in some cases social care needs and interests. Daily care records for one resident regularly refer to their catheter until, following a fall where the person was found on the floor during the night, the catheter had become removed. There was no reference throughout the care plan to the catheter and any decision made regarding it following Care Homes for Older People Page 14 of 39 Evidence: the fall. Staff spoken with confirmed the catheter had been in place on admission, had come out during the fall, had not been replaced and confirmed that none of it had been recorded in the persons plan of care. It was also disappointing to note that the instructions in the care plans were not always being carried out by staff in practice and so peoples care needs were not being met. This persons nutritional risk assessment showed them as being at very high risk, records show they were drinking minimally only. The person had a pressure sore on admission and their plan of care required that they be turned two hourly. Staff caring for this person were asked for the fluid and turning charts, as they could not be found in the persons bedroom where they were being nursed in bed. Fluid intake charts were kept at the nurses station and the most recent entry for this person was five hours earlier. Staff said they dont record at the time but would write it up later in the shift when they have time. The latest entry on any of this persons fluid charts was 7.10pm and there were no entries again until sometime the following morning. Staff advised that no turning charts were in place as the person was new, but that they would start one for the person soon. The resident had been admitted almost three weeks previously. All care plans looked at contained a consent for a bed rails form to be signed by relatives, although there was no clear assessment to indicate that this was the most appropriate action. One more able resident, supported by their family, recorded that the bedrails were not to be used. The resident confirmed that this was respected although the bedrails remained fitted to the bed. The manager should ensure that appropriate assessment of risks are undertaken and managed in each residents best interests, however there should not be a culture that assumes bedrails are to be used in all cases. Many of the residents spoken to were unable to express a view on the quality of care and support they received. Other residents spoken with told us they were satisfied with the care received and one said its a good place. Visitors spoken with were also satisfied with the care provided to residents at Forest Place. Comments from discussions and surveys include the care is very good and the carers are kind, as are the nursing staff and care is good, the staff work as a team, their main concern being the comfort and well-being of their residents, and the care is excellent, staff are understandable and respond quickly, in my opinion the home offers a good basic level of care to meet my relatives needs and oral hygiene could be given more priority, chiropody and manual handling is good. A survey received from a GP indicates that staff seek advice and act upon it to Care Homes for Older People Page 15 of 39 Evidence: improve individual healthcare for residents and comments staff tend to be very responsive, spotting problems early on, involving the doctor at an appropriate stage and treating their residents, staff and visiting doctors with courtesy and respect. Residents multi professional visit records show input from the chiropodist, speech and language therapist, optician, dentist, hygienist and contact with the GP following observations of changes in resident conditions such as relating to urinary tract and chest infections. A GP spoken with advised that they attend Forest Place on a weekly basis, see residents that staff have listed and that staff keep these residents in their rooms ready for the visit. The GP confirmed that appropriate visits were requested, emergency calls were appropriate, staff were responsive to instruction and pro-active in accessing healthcare intervention for people living at the home and commented they were surprised at the level of background clinical knowledge the staff have. The managers AQAA advises that, as part of securing the contract from West Essex Primary Care Trust for the intermediate care beds, these patients are seen on a weekly basis by the consultant and registrar. Medication storage and a sample of records were reviewed. It was noted positively, particularly on Maple unit, that daily records were made and showed appropriate temperatures for the storage of medication, an improvement from the last inspection. A weekly monitored dosage system is used. This requires staff to sign for the correct administration of a number of tablets contained in the segment, rather than being able to sign for individually labelled and administered tablets. Folders containing the Medication Administration Recording (MAR) charts also contained a photograph of the resident, a list of of their prescribed medicines, what each one was for and any potential side-effects, which is good practice. A list containing the signature and initials of each staff member that the manager had considered competent to administer medication was available. A sample of controlled drugs reviewed tallied with the register. The system used for recording as required (PRN) medicines was inconsistent with some staff recording a code for the medicine was not administered while other staff were leaving the section blank and only recording with the medication was administered. There were no protocols in place for individual residents PRN medicines to provide guidance for staff on a administering these consistently and when the person required them so their effectiveness could be monitored. PRN medicines, such as for pain relief, were recorded as only being offered on routine drug rounds. Some PRN medications were administered routinely at every drug round. When asked about reviews, the nurse stated that a GP comes into the home on a two monthly basis to assess the patient and review their medication. When asked for records to evidence Care Homes for Older People Page 16 of 39 Evidence: this, the nurse stated that they had no records. It is unclear whether the nurse had sufficient understanding of the English language to understand the initial question, however it was phrased. A handwritten entry on the MAR chart for one resident indicated that the GP had doubled the dose of one medicine and noted the date. This instruction had not been signed to indicate who had made this amendment. A new supply of the higher dose tablets had been received but had not been recorded on the persons MAR chart until it was pointed out to the nurse in charge of the shift, although six of the tablets had already been dispensed. The manager stated her belief that the Nursing and Midwifery Council(NMC) guidance indicated that crushing of some tablets was permitted and that covert medication such as hiding medicine in sandwiches or other foods was acceptable for some people. A tablet crusher that contained a powdery residue and two spoons that could be used for crushing were observed on top of the medication trolley during the medication round. When queried, the nurse administering medication reported that it is never used but could not explain why it was on top of the trolley. Staff told us that if residents cant swallow their medication, advice is taken from the pharmacy, they liaise with the family and GP and create a care plan around the problem. The manager stated that no resident is receiving covert medication or having their medication crushed at this time. Staff were heard to speak to residents with comments such as okay sweetie and theres good girls, which while likely to have been kindly intended, did not respect the dignity of the residents. Some residents names on their bedroom doors were written using their surname followed by their first name. A bowel and bath book was available in a communal lounge. Individual information about residents should be recorded in their individual file rather than a communal book and this personal information should not be readily available in communal areas. Privacy screens were seen around one resident in a communal lounge and when asked, staff said the person was having treatment. To respect peoples privacy and dignity, treatment should be provided in their own bedroom. However it was noted positively that when a resident needed hoisting in a communal lounge, staff used privacy screening to promote their dignity. Care Homes for Older People Page 17 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not everybody living at Forest Place can be shown to be treated as an individual living their chosen lifestyle. Their visitors will be welcomed and they will be provided with a choice of meals. Evidence: A general activity plan was displayed in the hall that showed different activities planned to occur in the different lounges throughout the home over a five-day period. The managers AQAA advises that the addition of the third activity coordinator ensures the time is evenly spread between group and one-to-one activities. Individual records of activities are held for each resident. The information recorded on assessments and care plans regarding individual residents lifestyle preferences and previous interests varied, with clear information for some residents and none for others. The managers AQAA indicates awareness of the need to develop a more comprehensive life story for each person and there was evidence in some cases that this had commenced. There were 86 people from a variety of backgrounds accommodated at Forest Place at the time of the site visit. On some of the files sampled there was no information on peoples cultural, religious or associated dietary needs where this was indicated and so no evidence that these had been considered or were being met was available. Care Homes for Older People Page 18 of 39 Evidence: Comments from relatives on activities and lifestyle included my relative chooses not to mix or go to the day room and I feel there are very isolated, apart from my visits they spend a lot of time on their own. I would like to see the staff stopping by their room and chatting occasionally as the area they are in is very quiet, or they could advise relatives of activities on offer for residents and give more thought to activities designed to mentally stimulate residents, or they will even go to (residents) room and switch on the TV for a specific programme that I think they may enjoy and even take the phone to my relatives bedside and hold it for them to speak to me. They make sure the TV is not on 24/7 as the incessant noise sent my relative mad and they are very flexible to the needs of the clients, if the routine agreed seems to be unsuitable that day, say relative feels unwell they modified the regime and they could do better by being able to arrange some outings for those able to participate, for example a short walk outside the grounds or to the shop. Residents spoken to and able to express a view confirmed there are activities available but that if they prefer to spend time in their rooms, this is respected. It was noted soon after the start of the site visit at 9am that all residents in some areas were already up, washed, dressed and in the dining rooms/lounges and all the beds were made. Staff spoken with told us the night staff get some people up and we get the rest up when we come in at 7am... its a fair division of labour. It was also observed during the site visit that apart from one resident, or where staff were escorting people from one room to another for a reason, no other residents were seen to be walking round or mobilising independently, which is considered unusual. Residents and relatives who commented confirmed that visitors are encouraged and welcomed at Forest Place. Comments included I visit my relative regularly and always receive a warm welcome from everyone, they always offer me at least a cup of tea and often more .. we just cannot believe how lovely everyone is, there is always a smile and welcoming hello, its just great to feel so welcome and they seem to want to work with me for my relatives good. The chef was spoken to and confirmed that residents have a choice at mealtimes including the option of a cooked breakfast and this was indicated on the menu is provided. For one person the chef was able to advise that they preferred their fry up at lunchtime. The AQAA and report following the quality assurance survey indicate that changes have been made to the menu based on residents feedback. The chef confirmed this but advised that due to time constraints, they are unable to visit the dining rooms at mealtimes to observe and receive first-hand feedback regarding the meals. Specialist diets were provided and the chef confirmed that these are liquidised Care Homes for Older People Page 19 of 39 Evidence: separately where required retaining appearance and flavour and that there are also diabetic diets provided. The chef advised that they had no awareness of any resident with a specific cultural or religious dietary need. There was no clear system in place of recording individual residents nutritional intake. Lunch was observed in one unit where many of the people needed assistance from staff to eat their meals. In addition to the qualified nurse, there were five care staff on duty in this unit and the deputy manager and the tissue viability nurse also helped out with meals on different days. It was observed that one resident who was seated awkwardly in their wheelchair, was pulled back by a staff member into the chair, wheeled to the sink and their face wiped over. These actions were not undertaken in a gentle or sensitive manner and that was no interaction with the person while this took place. Residents spoken with said the food is fantastic and the food is very good. Relatives commented the staff are marvellous and they give a choice of three main meals every day and I find that carers do not understand our bland (to them) English menu e.g. rice pudding or semolina needs a little bit of jam.. the jam is left untouched on the trolley, they do not know the connection. I think that all the staff should sample every meal, say in their induction period and have the meals explained to them by the chef. Sometimes food is about the only means of pleasure left to these very ill old people. It was noted positively that where a care plan indicated a resident needed lots of fluid, and had indicated a preference for both coffee and water to be left with them routinely within their reach, this was observed in practice. Care Homes for Older People Page 20 of 39 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. Shortfalls in evidence to demonstrate effective management of complaints, appropriate staff training and some aspects of staff understanding indicate that residents well being may not always be best safeguarded. Evidence: In their AQQA, the manager advises that no complaints had been received in the previous 12 months but that all complaints are recorded in the complaints book and treated seriously, investigated and acted upon. The manager said that they have a high visibility the home so complaints or concerns could be raised without fear. The service user guide contains a paragraph about complaints and compliments and advises that the manager needs people to tell them if the home falls short of expected standards, which is positive. However, it refers to complaining to the Commission and could erroneously lead people to believe that the Commission is a complaints investigation agency. It does not provide information in an appropriate format for people with impaired vision or reduced cognitive abilities on how to make a formal complaint within the home or any advice on taking the complaint to Social Services for investigation. Since the homes last inspection in September 2006, the Commission received anonymous information expressing concern that residents were not mobilised regularly, that staff were overheard to say to a resident they could not go to the toilet Care Homes for Older People Page 21 of 39 Evidence: for another two hours because they had just been taken, that the person wet themself and staff immediately attended to them appropriately. A letter was sent to the manager to advise of this and that it would be looked at at the next inspection. Information had also been provided to the Commission regarding two separate respite residents where there were concerns regarding lack of fluids and medication issues. At the site visit, the manager advised that small complaints are logged in a notebook on the table in reception but that if a formal complaint is received it is investigated in line with the homes policies and procedures and the documents filed on the individual residents file. The manager acknowledged that issues taken up with staff verbally by relatives were not always brought to her attention and therefore were not always recorded. There was no formal logging system available to provide a clear record of any complaints received, outcomes reached and actions taken to support monitoring and quality audits and to respond to the above issues. The manager maintained a compliments folder that contained a number of cards and letters from relatives praising the staff team for the care and kindness shown to people living at Forest Place. A relative spoken with told us they had been encouraged at the relatives meeting last year to bring forward any concerns and it was stressed that if they did not do this then the matter would not be able to be dealt with effectively. Surveys received indicated that people knew how to make a complaint and would feel able to do so and indicate that the service responded appropriately if they had raised any concerns about care. One person commented the response is appropriate and swiftly implemented on the few occasions I have had cause to raise concerns and another comment was I believe this information is available in the brochure in my relatives room. The manager had policies and procedures in place for safeguarding vulnerable adults and for whistleblowing in the event of any suspected abusive practice. The managers AQAA reported that there had been no instances of whistleblowing and no safeguarding issues at the home since the previous inspection but that there had been one disclosure of abuse/harm when one temporary resident hit another causing an eye injury. The manager advised that local Essex County Council guidelines for safeguarding vulnerable people were available to all staff at each nursing station. When staff on one of the units were asked if they had access to the documents, the person did not have sufficient command of the English language to understand the question and so was unable to confirm this. Care Homes for Older People Page 22 of 39 Evidence: The managers AQAA states that the current level of training on safeguarding is well established, that they need to ensure that all staff keep this subject is high visibility and that they will look at updating training as legislation changes. The training matrix provided indicated that seven healthcare assistants, one registered nurse and nine ancillary staff had not attended training on safeguarding vulnerable people. Review of staff recruitment procedures raised some questions on the robustness of the systems used to ensure that residents are safeguarded. Care Homes for Older People Page 23 of 39 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all residents at Forest Place live in a safe and pleasant environment that provides appropriate support for their individual needs. Evidence: The managers AQAA states that the home is clean, well maintained, safe and that refurbishment is now complete. Forest Place is set in large attractive grounds and some residents rooms had views over the gardens. Resident accommodation is offered over three floors accessed by shaft lift. The newer unit, Nightingale, is divided into two wings, Maple and Beech, and there are a number of lounges and dining rooms. This unit was generally well maintained and decorated and many resident bedrooms were spacious and personalised. One resident told us they were happy with their room and liked having their own things such as photograhs around them. A relative said that the premises were very nice. Kingfisher is divided into two units or four areas based on the different colours of the corridors. Apart from this there was very little appropriate signage to help people living with dementia to find their way around and tell them where relevant rooms etc were. This unit is not as well maintained or decorated and it presented as tired. A potential tripping hazard for residents was identified and at our request was made safe Care Homes for Older People Page 24 of 39 Evidence: immediately. As noted later in this report, following the most recent quality assurance survey, the action plan records that refurbishment and issues such as carpets will be addressed by the end of March 2009. Net curtains in communal hallways in the old part of the building were dirty. Some residents bedrooms were personalised but many were untidy with boxes of continence pads piled up and excess used cups and glasses left around. A relative told us that there are no smells in the home but the place could do with smartening up. The manager advised that planning permission has recently been granted to develop the administration block to provide resident accommodation so that the old established part of Forest Place, which was an old hospital building, may be demolished and rebuilt. Surveys received contained comments such as the place is always clean or it is always clean and fresh. Other comments included part of the home could do with some redecoration/modernisation. They could provide digital or satellite TV to rooms particularly as so many residents spend a great deal of time in their rooms/bed and it seems to be reasonably modest and basic in both accommodation and care but it addresses my relatives needs. Some of the rooms for people living with dementia did not have a light that they could reach to turn on from their bed. The manager advised that this was because they could knock it over. The manager stated that all residents have their bedroom doors open so that the light from the hallway ensures their safety should they get out of bed and their agreement is recorded in the care plan. Those residents we spoke to regarding this were unable to give their opinion. No individual risk assessment was available on resident files sampled regarding this and the possible associated fire risks. Of the care plans viewed only one recorded a note that the person wanted their light turned off and curtains closed while they are sleeping, but made no comment about a preference to have the bedroom door open and the light shining in from the corridor. Areas of the premises did not present as homely due to the large number of notices displayed, for example reminding staff not to chew gum on duty. Notices openly displayed about individual residents such as (residents name) likes to have their food hot do not respect the persons dignity. There were also additional notice boards for staff within residents areas. The manager agreed that notices relating to the management and running of the home were not appropriate in the residents communal areas. Care Homes for Older People Page 25 of 39 Evidence: Fridges in satellite kitchens around the home were generally dirty. Food storage in these areas did not demonstrate good food hygiene and storage practices to promote residents well-being. In the dining room fridge in Kingfisher unit dishes of what may have been prunes were loosely covered with cling film but were not labelled and dated and so it was unclear how long the food had been there or who it was intended for. The fridge in the servery area of Kingfisher contained two jugs of what could have been porridge or rice pudding, again unlabelled and undated. There was also a ready meal containing prawns that was not sealed or labelled and a gravy boat full of margarine/butter that was loosely covered with cling film. The manager acknowledged that fridges were not up to standard. Care Homes for Older People Page 26 of 39 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 living at Forest Place can expect to be cared for by adequate numbers of caring staff, but who may not be competently trained, safely recruited or be able to communicate effectively with them. Evidence: In their AQAA, the manager advises that Forest Place offers four places on the Overseas Nurses Programme. The manager also advises of encouraging and supporting staff on NVQ and of ensuring the off duty is flexible to the needs of staff and that due consideration is given to those staff from overseas that wish to take extended holidays back to their home country. Review of two weeks staffing rotas indicated a staffing level of four qualified nursing staff on duty at all times, with 18 care staff on the morning shift, 17 care staff on the afternoon shift and six care staff at night. Nursing and care staffing levels observed at the site visit were considered satisfactory to meet the needs of the residents and to provide appropriate supervision. The manager confirmed there is a stable core staff group and that no agency staff are used. This offers consistency of care for residents. However, it was noted from the rotas that for example, on several days the majority of staff on duty in Maple unit worked from 7am to 9pm with a one hour break.This could affect staff competence to deal most effectively with those residents who have the more demanding and complex needs. Care Homes for Older People Page 27 of 39 Evidence: Residents spoken with offered positive comments about the staff such as they were helpful or nice. Relatives surveys indicated that staff have the right skills and experience to look after the residents. Comments included the staff nurses in charge seen to be very competent and of course the manager is always on hand to support them in an emergency. All the professional staff, both caring and nursing are foreign. There is a problem with language with most, to varying degrees, though staff with higher qualifications and responsibilities are the most fluent but have accents that take time to adjust to. One or two others really can hardly hold a conversation... fortunately there are enough staff members to cover this and most residents in my relatives section have very little conversational ability. Other comments included the home appears to have residents with a wide range of differing needs. In my opinion and through observations while visiting, staff appear to be very flexible and sympathetic to the needs of residents and with the constant turnover of staff there are always one or two new trainees, but these appear to be supervised well. Overall the staff appear competent in looking after the needs of their residents. Recruitment documents for four staff were requested for review to assess the robustness of the managers recruitment process to ensure appropriate checks and references are undertaken to safeguard residents. Accessing the records presented some difficulty for the manager but they were eventually provided. Each of the four files contained an application form, evidence of identity and confirmed that a Criminal Record Bureau check was in place prior to the person working at the home, which is good practice. None of the files contained the required two references at least one of which had been received/confirmed from the most recent employer. The reference request used form was a tick a box style allowing very limited opportunity for comment. A completed survey was received from one staff member that indicated overall satisfaction with their induction, training, and the information and support provided to them. The managers training matrix was reviewed to assess the training provision for staff at Forest Place. The matrix was unclear, they were a large number of amendments made to the printed record such as because of people having left the employment of the home and where courses had been attended that had not been included in the printed matrix. Additionally, the matrix did not include the name of one of the current qualified staff employed at the home. The matrix indicates significant shortfalls in the training necessary for the staff team to safely care for the resident group living at Forest Place. Care Homes for Older People Page 28 of 39 Evidence: This includes for example indication that four nurses, eighteen healthcare assistants, the manager, three activity coordinators, three domestic staff, one cook and two caretaking staff had not attended training on moving and handling. There were also significant numbers of staff not recorded as having undertaken training in infection control, fire, health and safety, food hygiene and twenty one care assistants, five registered nurses and the manager are recorded as not having attended dementia care training. Care Homes for Older People Page 29 of 39 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. Residents of Forest Place cannot be reassured that the home will always be effectively managed to promote their best interests and well-being. Evidence: The manager of Forest Place has been in post since 2002 and so is established in that role. The manager reported thay had undertaken some of the basic core staff training alongside the staff team including moving and handling, safeguarding vulnerable people, health and safety and tissue viability. The manager has also attended Gold Standard Framework in Palliative Care. The manager is supported by an assistant manager whose role is primarily administrative and also by a deputy manager who has completed the Registered Managers Award, is a Qualified Social Worker, State Enrolled Nurse and also a Registered Nurse Mental Health. The registered provider has a quality assurance system in place that includes obtaining the views of residents, relatives and staff. A copy of the report of the March 2008 survey was made available and demonstrated a good level of satisfaction with Care Homes for Older People Page 30 of 39 Evidence: for example staff respecting peoples privacy, quick and effective response to complaints, good training and management support for staff and good ambience and cleanliness of the home. Lesser satisfaction was indicated with such areas as poor decor and carpeting of the home, poor laundry services, more outings for residents needed and disposal of medical waste needed to improve. The action plan identified that all issues have been addressed with the exception of the decor and carpeting which was identified for completion by March 2009. Regulation 26 reports viewed showed that the registered provider arranges for detailed monthly reviews and reports of the home as required to reassure themselves that the home is running as it ought to and that residents views are also sought at this time. It is clear from the findings of this inspection that more thorough and widespread audits need to be in place and be monitored effectively by the management team to ensure quality care outcomes for residents. The manager holds small amounts of personal money in safekeeping for residents and routinely audits the records with either the administrator or the deputy manager. Records and balances inspected for three people were well maintained with receipts available and found to be in order. There is a system in place to ensure that residents have access to their money when the manager is not on site. Records were noted to be securely stored with care plans in a locked facility on each unit and staff files securely stored in locked cabinets. Records of routine safety checks were requested to ensure a safe environment was maintained for residents and staff. Routine safety inspection certificates such as relating to the fire alarm, passenger lift, gas and electrical installations, hoists/slings and call bells were available. The Control of Substances Hazardous to Health risk assessments had been reviewed. One person has designated responsibility to undertake a walk-around audit of the building to monitor health and safety issues and repairs required. The log of issues reported identified the location and description of the issue and an assigned date but did not record when the repairs had been effected. The log had ceased to be recorded in November 2008. A rickety wardrobe was seen in a corridor by residents bedrooms. Concern was advised to the manager early in the day of the potential risk of falling and a request Care Homes for Older People Page 31 of 39 Evidence: issued that it be made safe or removed. It was disappointing to note that the wardrobe remained in situ late in the afternoon. The carpet between the corridor and two resident bedrooms presented a potential tripping hazard as it was lifting. Some staff nearby were asked about the availability of a maintenance person but clearly did not understand. A handyman was eventually located and repairs requested were undertaken immediately to ensure the safety of residents. Care Homes for Older People Page 32 of 39 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 39 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 1 4 The statement of purpose 01/05/2009 must be reviewed and updated and a copy sent to the Commission as required. To provide accurate and upto-date information regarding the aims and objectives and services and facilities to be provided at Forest Place. 2 3 14 A full assessment of the 01/04/2009 persons needs must be undertaken and the manager must ensure they have adequate information about the person to inform a plan of care. To ensure that the persons needs can be met at Forest Place. 3 7 15 Care planning at the home must identify and be effective in meeting all the residents assessed needs and preferences. Staff must 01/04/2009 Care Homes for Older People Page 34 of 39 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 ensure that care instructions within individual care plans are carried out. This requirement is outstanding in part from the last inspection. To ensure that residents needs are met and their preferences respected. 4 9 13 Records of medicines received and administered must be accurate and complete. This will show that residents received the medication prescribed for them. 5 18 13 The manager must make arrangements for staff to attend training on safeguarding and ensure that they have sufficient comprehension of the English language to understand it. To safeguard residents. 6 19 23 Ensure that the premises and facilities are sound and kept in good repair, including carpets to prevent potential tripping hazards. To ensure the safety and well-being of residents. 15/04/2009 15/04/2009 01/04/2009 Care Homes for Older People Page 35 of 39 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 7 19 23 A planned programme to be 15/04/2009 implemented to ensure that all areas of the premises are well maintained and reasonably decorated. To provide residents with a pleasant living environment. 8 27 18 Competent staff must be on duty at all times. This includes staff ability to communicate with the resident group and also to carry out effectively the instructions of the care plans. To safeguard residents and promote their well-being. 01/04/2009 9 31 9 Effective systems need to be 15/04/2009 implemented and audited regularly by the management team in relation to all aspects of the care, facilities and services provided to residents. To ensure safe, quality care outcomes for people using the service. 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 1 The statement of purpose and service user guide should be Page 36 of 39 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 available in a range of formats to meet the needs of people using, and likely to use, the service. 2 3 The registered person should write to each person to confirm to them that, based on their assessment, their needs can be met by Forest Place. Clearer information and systems need to be implemented in relation to the management of intermediate care offered at Forest Place. A more detailed assessment in relation to bed rails that identifies the potential hazard, a relevant history and any factors that might impede the use of bed rails should be included where these are to be used, and reviewed regularly. Fluid and turning charts should be completed routinely and in accordance with the prescribed plan of care to ensure the residents well-being is promoted. Where handwritten changes are made to the MAR chart, these should be signed by the staff member and preferably co-signed by a second member of staff to confirm the doctors instructions. One system should be used for the recording of as required medication. Protocols should be in place to provide guidance to staff and allow effective monitoring for medicines prescribed on an as required basis. The issue of staff practice in relation to residents privacy and dignity should be revisited and reviewed. Routines of daily living should be flexible and demonstrated to suit resident preferences. The interests of all residents should be recorded and they should have opportunity that suits their capacity for stimulation to meet these, both in and outside the home. Information should be sought regarding any specific religious or cultural dietary needs and preferences, and recorded in assessments and care plans so that staff have full information so that these can be met in practice. A detailed record should be implemented to demonstrate the actual nutritional intake for all residents. 3 6 4 8 5 8 6 9 7 8 9 9 9 10 10 12 11 15 12 15 Care Homes for Older People Page 37 of 39 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 13 16 The complaints procedure should clarify the role of the Commission in relation to complaints investigation as advised at the last inspection, and should include information for people that they can take their complaint to Social Care. The complaints procedure should be available in different formats, suitable for the client group at Forest Place. The manager should retain a log of complaints and be able to advise the Commission of a summary of the complaints made during the preceding 12 months and the action that was taken in response. Net curtains should be clean and resident bedrooms kept tidy to improve the overall environment for people living there. Better signage could be implemented to support effective orientation for those people with impairments, including those living with dementia. Cleaning schedules should be implemented to include satellite kitchens and food storage should be improved, with staff provided with training/updates as required. The manager should ensure that there is evidence of robust recruitment procedure including obtaining appropriate references. The managers should ensure that there are is evidence of staff training and that records are kept up-to-date. 14 15 16 16 16 19 17 19 18 26 19 29 20 30 Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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