Inspection on 27/10/09 for Gifford House Care Home

This inspection was carried out on 27th October 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gifford House Care Home 12/12/08

Gifford House Care Home 07/01/08

Gifford House Care Home 23/07/07

Gifford House Care Home 09/01/07

Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Key inspection report Care homes for older people Name: Address: Gifford House Care Home London Road Bowers Gifford Basildon Essex SS13 2DT     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Bernadette Little     Date: 2 7 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Gifford House Care Home London Road Bowers Gifford Basildon Essex SS13 2DT 01268554330 01268498070 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): AMS Care Limited Name of registered manager (if applicable) Alan James Young Type of registration: Number of places registered: care home 61 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Number of places not to exceed 61 in total. One named person known to the Commission, aged under 65 years. Date of last inspection Brief description of the care home Gifford House Care Home is a purpose-built, elegant two-storey building situated in a rural location but within easy access of Saddlers Farm roundabout, and all major local routes including the M25, A127 and A13. Parking is available on site. There is a large enclosed garden area, which is accessible and includes seating a patio area as well as walks. The home provides care with nursing and accommodation for up to 61 older people, Care Homes for Older People Page 4 of 38 1 0 Over 65 39 61 Brief description of the care home including up to 39 people who have dementia. All bedrooms are single and ensuite and sited on both floors. There are also a number of lounges and lounge/ dining rooms, a smoking room and a quiet room/visitors room, as well as several areas around the home where additional seating is available. A passenger lift provides access to all levels within the home. The home has six assisted bathrooms and three shower rooms, and well equipped laundry and kitchen facilities. The homes weekly fees currently range from £555 to £715. Additional charges to residents are for hairdressing and chiropody. There are no charges to residents for staff escorts to hospital appointments etc. Residents make individual arrangements with the local newsagent in relation to newspapers and magazines, provide their own personal toiletries and would also pay the going rate for taxis to appointments. Care Homes for Older People Page 5 of 38 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 site visit was undertaken over a ten hour period by two inspectors as part of the routine key inspection of Gifford House. A specialist pharmacist inspector was also present for part of the day. Time was spent with residents, visitors 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. One inspector spent much of the time on one unit that had nineteen residents, including one and a half hours undertaking a formal observation, as well as looking at records and talking to staff and residents. Following issues identified at the last key inspection relating to care planning and risk assessment a random inspection of Gifford House took place on 16th June 2009, where continued breaches of regulation relating to care planning and risk assessing were observed. As a result of this, documents were taken as part of Code B of The Police and Criminal Evidence Act 1984 and Statutory Requirement Notices were issued on Care Homes for Older People Page 6 of 38 17th August 2009 with dates for compliance to be achieved of the 17th and 24th September 2009. A further random inspection took place on 28th September 2009 where it was noted that compliance had been achieved. The two inspectors identified that further developments to care planning systems were required. The outcomes of the inspection were fed back although the providers disagreed this happened. The manager submitted an Annual Quality Assurance Assessment (AQAA) as required by law prior to this site visit. This provides them with opportunity to inform us what they do well, what has improved and what could be done better. This information was considered as part of the inspection process. Prior to the site visit, we sent the manager a variety of surveys to distribute to residents, staff, care managers and healthcare professionals. Completed surveys were received from eight residents some of who were supported by relatives and also from two staff. The information provided and comments made are included in this 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. At this site visit an immediate requirement was issued to the registered persons in relation to safe administration of medication. A subsequent random site visit undertaken by the specialist pharmacist inspector identified compliance with the immediate requirement. The outcomes of the site visit were fed back although the providers disagree this happened. A serious concern letter was sent to the registered persons following the site visit in relation to effective care planning and risk assessment procedures. This will be followed up at future inspections. The assistance provided by all of those involved in this inspection is appreciated. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: All people in the care home must have their care needs identified and managed effectively to ensure they are met. This would include having up to date care records that show all of the persons needs, how they and any risks to the persons health and well being are to be met in a way that promotes their health and safety, and making sure that staff have the information, training and leadership to be able to meet these. The management team need to support and lead staff competently so that this can be achieved. Medication must be given to people safely in a way which reduces any risk of error and in accordance with good professional practice as one member of staff was observed to administer medication potentially in an unsafe way. Prescribed ointments, creams and dressings must only be used for the person they are Care Homes for Older People Page 8 of 38 prescribed and labelled for. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 38 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 38 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. Prospective users of the service will have an assessment of their needs prior to admission and will be given information to help them make a decision about living at Gifford House. Evidence: There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff and management team are able to meet the prospective persons needs. The managers AQAA tells us that all prospective residents receive a preadmission assessment that identifies their current needs and whether they are able to meet the persons needs. In addition, where appropriate, supplementary information is provided by the persons Placing Authority or Primary Care Trust. On inspection of the care files for the two newest people admitted to Gifford House, records showed that a pre admission assessment had been completed for both people by the registered manager and prior to their admission to the home. There was Care Homes for Older People Page 11 of 38 Evidence: evidence to show that the information recorded was informative and detailed. A letter from the registered manager confirming the placement was provided to each person and this was held on their file. The registered provider said that prospective people are always present during the pre-admission assessment, however there was no evidence available to inspectors to confirm that the person had been actively involved and that their views had been incorporated where possible. There was evidence to show that both peoples representative had provided information relating to their life history and this was seen to be very informative and detailed. The managers AQAA states they are aware that prospective service users require as much information as possible in order that they can make the correct choice of home. Of four completed surveys received from residents, three stated that they had received enough information about the home before they moved in so they could decide if it was the right place for them, including about the contract terms and conditions, the fourth person answered no to both questions. The registered provider considered it highly possible that a dementia sufferer could return a completed survey form without having really understood it and answered no. We were able to confirm to the registered provider at a subsequent meeting that the resident had completed and signed the survey themselves and that the information was included for completeness. A relative of a more recently admitted resident confirmed that, prior to admission, they had received a service user guide, the person had an assessment of their needs and the family had been able to visit. Surveys from three health professionals involved with Gifford House indicated that the assessment arrangements ensure that accurate information is gathered and that the right service is planned for people. In subsequent discussion one of these health professionals told us of some concerns they had regarding the assessment process for people at Gifford House who have specialist needs and were advised to address this directly with the registered provider. This could indicate that a review of the assessment should be considered. A recently admitted resident spoken with told us they have found it very difficult to adjust to living at Gifford House and to fit in as they feel there is no one on the unit they can relate to, other than staff and visitors. They told us this is not for me and stated that the experience of living in a care home is not at this time positive as they would prefer to live independently or in a smaller group setting and with like-minded people. From our observations and review of the persons pre-admission documentation we were unclear as to the rationale as to why they were accommodated on Radcliffe Unit. This was discussed with the registered manager and registered provider who advised that at the time of the pre admission assessment Care Homes for Older People Page 12 of 38 Evidence: being undertaken, information gathered supported the rationale for them being placed on this unit. Another person spoken with who had been admitted to the home several months earlier on Betts Unit confirmed they have found the experience at Gifford House to be positive and are enjoying living there and feel that it is meeting their needs. An assessment of Mental Capacity and Deprivation of Liberty Safeguards has been completed for each person by the registered manager. Care Homes for Older People Page 13 of 38 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. Shortfalls in the organisation and management of risk, care planning, medication and staff skills mix means that all residents cannot be assured that all of their needs would be met and that they would be treated with respect. Evidence: At the previous key inspection to the service on 12th December 2008 we recognised further improvements had been made to the care planning and risk assessing processes by the management team of the home, however some gaps were identified. Following a management review, a decision was made for a further random inspection to be conducted on the 16th June 2009, where continued breaches of regulation relating to care planning and risk assessing were observed. As a result of this, documents were taken as part of Code B of The Police and Criminal Evidence Act 1984 and Statutory Requirement Notices were issued on 17th August 2009. The date for compliance to be achieved was the 17th and 24th September 2009. A further random inspection was undertaken on 28th September 2009 where it was noted compliance had been achieved. The two inspectors identified that further development to care planning systems was required. Care Homes for Older People Page 14 of 38 Evidence: The formal care planning system in place helps staff identify the care needs of individual people and to specify how these are to be met by staff who work in the home. In addition to the care plan, formal assessments are completed in relation to nutrition, pressure area care and falls. Records showed that all people case tracked had a plan of care. As part of this site visit the care files for 5 people were examined (3 in full, 2 of which were recent admissions and 2 in relation to peoples specific care needs). Records available at the site showed that the care needs of some people were not being recorded, detailing all of their specific care needs and the staff support required. In addition records showed that where changes to peoples care needs had occurred, the care plan and/or risk assessment had not always been updated to reflect this or interventions provided. Examples of these were shared with the management team at feedback and at the subsequent meeting as requested. The care records for one person on Betts unit were examined and this showed that both their care needs were recorded and the information detailed and informative. It was noted positively that there was evidence to show that their plan of care was drawn up with their involvement and they were being supported by the staff team on that unit to exercise choice and control over their lives. The only area of concern was in relation to their dietary needs. The plan of care clearly recorded that instead of being weighed weekly their preference was for this to be undertaken each fortnight. Records showed that this was being supported, however it was evident that over a 2 month period according to the records, these showed a weight loss of over 6KG. The care plan was not updated to reflect this weight loss and how this was being proactively managed. The registered manager and registered provider were advised of this at feedback. The management team provided supplementary documentation. No additional evidence was noted to demonstrate that the care plan had been updated or demonstrate how it was to be managed for this person. The care plan and risk assessment for one person relating to their dietary needs recorded them as requiring encouragement to eat and having on occasions a poor appetite. Nutritional assessments had been completed and these detailed that their nutritional intake should be monitored each day and that they should be weighed each week. Weight and nutritional intake records confirmed this being undertaken however they also showed that on several occasions recently the person had refused meals (lunch and tea-time meals) and that within an 8 day period they had lost over 8lbs in weight. Neither the plan of care or risk assessment had been updated to reflect the recent weight loss. It was noted positively that there was evidence to show that the Care Homes for Older People Page 15 of 38 Evidence: staff team had acted promptly and contacted the persons GP about the weight loss and nutritional supplements had been prescribed. The management team provided supplementary documentation that was reviewed again following a subsequent meeting but we did not find additional information that was not available at inspection. The subsequent nutrition risk assessment shows different information from that we had recorded from documents made available to us at the time of the key inspection. The same persons pre admission assessment made reference to the possibility of them being resistive to care and/or aggressive towards others on occasions. On inspection of daily care records these showed that since their admission there had been incidents whereby the person became restless, agitated and showing signs of threatening behaviour towards others living at Gifford House. On inspection of their care file, there was no care plan and no risk assessment compiled in relation to their aggression detailing how this manifests, known triggers and steps to be taken by staff to support this person so as to ensure positive outcomes. Records also showed that recently there were occasions whereby the resident was reluctant to take their medication and/or to spit their tablets out. No plan of care or risk assessment was compiled detailing how the latter was to be proactively managed so as to ensure their healthcare needs and wellbeing would be maintained. The care file for another person made reference to the person experiencing pain as a result of their medical condition. Daily care records showed on several occasions that they experienced pain and pain relief medication was prescribed and administered. No plan of care was completed in relation to the persons pain management and how this should be managed, however with the Medication Administration Records (MAR) there was a Variable Dose and PRN Medication Daily Recording record which made reference to the above, however this was seen to be basic. Daily care records also showed in some instances that the person continued to experience pain, yet no further pain relief medication was administered. No rationale was recorded to explain why no further pain relief medication could be administered. As a result of concerns relating to the homes poor care planning and risk assessment processes and following a management review, a Serious Concern Letter was forwarded to the registered provider. Of four completed surveys received from residents, two people felt that they always get the care, support and medical care they need while two people indicated that they usually received this level of service. Five relatives spoken with and information from one survey indicated that they were satisfied with the level of care provided to residents with comments including very happy with the care. Care Homes for Older People Page 16 of 38 Evidence: Two of three completed surveys received from health care professionals indicate a view that peoples health and social care needs are always properly monitored, reviewed and met by the care service. Comments included individualised care plan, capable of delivering appropriate nursing interventions were needed and the patients that I have in Gifford House always appeared well looked after when I visit. The third person indicates they usually are, with positive comments regarding the care planning documentation including the care plans are now personalised and appropriate risk assessments are in place. However in further discussion they state awareness from recent involvement with Radcliffe unit that the manager admitted people there whose needs were unable to be met. These surveys generally indicate that peoples privacy and dignity is respected. Records showed that people living at Gifford House have access to a range of healthcare professionals and services as and when required both at the care home and within the local community. These include District Nurse Services, GP, attendance at hospital appointments, Optician, Mental Health Team etc. As a result of some people with dementia and/or poor cognitive ability not always being able to tell us about their experiences and what it is like to live in a care home, as part of the inspection process, we have used a formal way to observe people in this inspection to help us understand. We call this a Short Observational Framework for Inspection (SOFI). This involved us observing 3 people who use services for a period of 1.5 hours and recording their experiences at regular intervals on Radcliffe Unit. This included their state of well being, how they interacted with care staff and others and what they did during this period. From our case tracking we noted that individuals care plans make reference to their dementia and/or poor cognitive ability but provide limited specific information throughout their plan of care as to how this impacts on their quality of life or activities of daily living. The formal observation was undertaken in the afternoon however we spent a considerable amount of time during the morning also observing staff practices and interactions with people in the home. In general terms where care staff interacted with residents and provided care and support, this was seen to be positive and undertaken in a respectful and dignified manner. It was observed that many interactions by staff with residents remain centred around tasks and routines e.g. providing personal care, taking them to the hairdresser on the ground floor, taking people to and from the dining room, assisting people to eat their meals or to have a drink. During the observation in the afternoon one person requested use of the telephone so as to speak to a relative and asked a member of staff I want to phone my relative, how do I do Care Homes for Older People Page 17 of 38 Evidence: that. The member of staff advised that they would let the qualified nurse on duty know. They were observed to let the qualified nurse know however they stated to the resident you can use the phone later with no rationale as to why they could not contact their relative there and then. When the person was supported to use the telephone after 50 minutes of asking and although no one answered, they visibly relaxed. Also during the formal observation in the afternoon we observed one person to shout in a hostile manner at another resident and to be physically rough with them by pulling at their arms. On inspection of the care file for the person who was displaying inappropriate behaviours, daily care records documented on several occasions evidence that this was not an isolated case and that they regularly targeted the same resident and could also become argumentative with others living on the same unit. No plan of care or risk assessment was evident in relation to their inappropriate behaviours and how these should be managed. One entry within the daily care records also recorded that during one incident, a member of staff intervened by using restraint and inadvertently caused a skin tear to the persons wrist. No record of restraint was recorded and/or available providing further detailed information. As a result of the above we have made a referral to the local Safeguarding Team which has since been closed. We will follow up the homes process for reporting safeguarding concerns during our inspections to ensure people are kept safe. Throughout the day care staff were observed to be very busy undertaking a variety of tasks as detailed previously. The atmosphere on Radcliffe Unit was at times disorganised and chaotic and from our observations we noted there was very little guidance and leadership provided from the qualified nurse on duty on Radcliffe Unit to support care staff. This was discussed with both the registered manager and registered provider during feedback. The management team subsequently stated they believe this was caused by the inspector being in the unit. A member of staff working on this unit had been in post for exactly one month. They confirmed to us that they had no previous experience in care and had been offered no training to date in relation to dementia care or managing behaviours that challenge. The member of staff was told by the qualified nurse in charge of both Radcliffe and Linford Units to take two residents from Radcliffe unit into the garden, both of whom are clearly documented as demonstrating behaviours that challenge. The member of staff told us they found the situation difficult to manage as a result of their lack of experience and knowledge. We asked the three members of care staff on duty if they had read the care file for the two newest people admitted to Radcliffe Unit and they confirmed that they had not had the opportunity. Two of the three staff have worked at the home for some Care Homes for Older People Page 18 of 38 Evidence: considerable time. They told us that they had returned to work on Radcliffe Unit on the day of the inspection. The third staff was relatively new to care and had no training in supporting people with dementia or behaviour that challenges. None of the staff felt they had been given sufficient information about the newest people from the qualified nurse on duty. Completed surveys received from four care staff indicate that they are always given up to date information about the needs of the people they support, for example in the care plan. Most medication is stored securely for the protection of residents. Medication storage facilities are temperature controlled to ensure the quality of medicines in use. Records are kept of when medicines are received into the home, when they are given to people and when they are disposed of. This provides an audit trail of medicines in use and demonstrates that people receive the medicines prescribed for them. However, we saw a record that a controlled drug had not been disposed of properly but expect this to be managed by the home rather than make a requirement on this occasion. In 15 resident bedrooms across all three units we found prescribed creams, ointments and dressings that were unlabelled or had the labels torn off and in some cases the name of the person on the label was not the person whose room it was. People must only be given medication prescribed for them and we have made a requirement about this. Two of three qualified staff on duty were seen giving medication to some people at lunchtime. One of them was seen to do this in an unsafe manner. Medication was assembled for more than one person at once and given to more than one person at once. This practice significantly increases the risk of medication error and an immediate requirement was made to ensure the safety of people living there. We also saw that the records to show that people had taken their medication were signed all together rather than on an individual basis. Where people are prescribed medication on a when required basis or in variable doses, care plans now contain guidance in the use of such medicines but when we looked at two care plans the guidance was repetitive and not person-centred. This could be improved. Records made when medicines are given in variable doses now clearly indicate the dose administered and the requirement made on the last inspection about this has been met. The care plan for one person prescribed medical oxygen was not up to date and the risk associated with the storage and use of oxygen had not been adequately assessed. Care Homes for Older People Page 19 of 38 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. Some people living at Gifford House may not have a satisfying lifestyle or reasonable opportunity to make decisions and choices. Residents enjoy a varied and pleasing menu and their visitors are welcomed. Evidence: An activities programme for October 2009 was observed to be displayed within each of the three units. The programme is in both a written and pictorial format so as to enable people to see what there is on offer each day. Activities include Nintendo WII, dominoes and draughts, old games, television and music, ball games, hands and nails, bingo, religious observance, hoop-la, noughts and crosses, parachute, card games and external entertainers. The activities programme records one main daily activity available to all residents. At the time of the key inspection, some residents attended a church service. Additional individual activities were provided on the units. In addition people were seen to be taken to the hairdresser on the ground floor. Out of 3 care files examined in full, the social care needs for 2 people were not recorded. The activities co-ordinator spoken with on the day of the site visit confirmed to us that a care plan depicting an individuals social care needs and how these are to be met should be located within their care file. The registered provider subsequently Care Homes for Older People Page 20 of 38 Evidence: told us that these had been available on the residents files and sent us records showing the social care needs of both people. Records of activities undertaken each day are recorded within a separate folder and this was examined. We note that a record is completed for each person detailing activities undertaken. Some of the records were were not detailed to demonstrate the significance of events seen to be an activity e.g. smiled which was a meaningful interaction for an individual or when their relative visited and went to their room, and went to lunch. Other records showed that people have the opportunity to participate in games with bean bags, playing with bricks, magnetic darts, cards and listening to music. On Betts Unit people spoken with confirmed they were happy with the level of activities provided. During a tour of the premises people were observed to spend time in their room watching television, listening to music or reading a book or newspaper. One person was observed to spend time on their personal computer and confirmed that they found this satisfying and very important to them. One person on Linford Unit was observed to have Satellite Television installed. One person who had only been a resident on Radcliffe Unit for a short time was overheard to say to staff and other people on the unit during the morning when asked if they would like to participate in activities provided, this is not for me, I am so bored-there is nothing to do and Im bored to tears, Im not used to sitting and doing nothing. The registered provider subsequently told us that the resident does take part in activities and sent us records to show this. Of the four surveys received from residents one indicated that there are always activities provided that they take part in if they want to, two people said there usually area and one person said there sometimes are. A staff survey said the home includes relatives in social activities. Staff surveys received commented on what the home could do better increase staff on the activities for residents, need more activities and more activities for residents. An ancillary staff member advised that they had recently been able to arrange for communion to be brought in to those residents who would wish it. Relatives and residents spoken with confirmed that visitors were, and felt, welcomed at Gifford House. There is a four week rolling menu at the home and this is clearly displayed in the main reception area of the home and adjacent to the dining room on the first floor. The menu shows that people are provided with a choice of meals at breakfast, lunch and supper. We noted on inspection of the menus that the meal provided at lunchtime to people on the day of the site visit, differed from the menus provided. This could be confusing to people in the home. Care Homes for Older People Page 21 of 38 Evidence: The lunchtime meal was observed on the first floor for people from both Linford and Radcliffe Units. People were given a choice of meal and drinks and people had the option of having their meal either in the dining room or in the lounge area on each unit. Meals provided to people were observed to be presented nicely and in sufficient quantity. Where people required a soft and/or liquidised meal, food items were observed to be portioned individually. Where people required assistance to eat their meals, staff were observed to provide support to people that was both respectful and undertaken with sensitivity. Residents were offered a drink mid-morning. Additionally during the morning on Radcliffe Unit staff were observed asking people if they would like a hot chocolate drink. Although the lunchtime meal was to be provided approximately 1 hour and 10 minutes later, people confirmed that they would like a drink. However we were made aware by care staff that one of the qualified members of staff on duty stated that no drinks could be provided. We advised staff that it was not good practice to deny people a drink however they would need to make the decision as to what they should do. Staff were observed to speak to the other qualified member of staff on duty and following this discussion hot chocolate was provided to people on the unit. All but one person was observed to drink the hot chocolate. Resident surveys indicated that three people usually liked the meals at the home and one person sometimes did. Residents spoken with and able to express a view were positive about the meals at Gifford House, stating that while food could be warmer specific dietary requirements were met. Another person said the food is lovely for sure and very fanciable and confirmed they are offered a choice of meals and drinks. Care Homes for Older People Page 22 of 38 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. Residents will have access to a complaints process and be safeguarded by staff knowledge and supporting systems. Evidence: The management team have a clear complaints procedure in place and information about it is readily available in the home and in the service user guide. The managers AQAA tells us that they had received three complaints in the past year, two of which have been upheld and that they log all complaints made, be they verbal or in writing. The complaints file is well organised and includes a log sheet with date, names and actions taken in relation to each complaint. One of the complaints relates to where a carer had put sauce on the chips prior to serving them so that people did not have a choice. The outcome records that this practice has now stopped. The second complaint refers to dignity issues for a female resident where only male staff were on duty in an upstairs unit. This complainant refers to a similar previous incident. The manager advised the previous incident was a verbal report and not a complaint and so was not recorded, and that it was not accurate as the rota shows there were female staff on duty in the home. The registered person subsequently sent us a memo that had been distributed to qualified night staff after the first incident telling them that a female carer must be available to attend to the needs of female residents who do not accept care from male staff. The other issue relates to a verbal concern from a relative to a nurse, who had raised it, and it was recorded. Care Homes for Older People Page 23 of 38 Evidence: Information from residents and relatives spoken with as well as in surveys received indicate that people know how to make a complaint and feel able to do so. Some people said they would speak to the nurses if they had any concerns as they are very approachable. One person said that when their relative got a black eye in one unit they spoke to the manager and agreed a move for the resident to another unit where it was quieter. Another relative said that the manager told us to tell him if there is anything that concerns us and that they would feel able to do this. A compliments folder was available that contained a number of thank you cards and comments include gave us great peace of mind to know that they were so well cared for and providing such care and commitment. The managers AQAA tells us that there have been two referrals made under safeguarding procedures in the past year, both of which were investigated by the safeguarding team. One of these was made by the manager some time after the event on the advice of a professional visiting the home and it related to a member of staff having been found asleep on duty and being involved in a medication error. The member of staff in question was disciplined and dismissed from Gifford House prior to the safeguarding referral. The second referral was made by the community mental health team. We were informed by the safeguarding team that the outcome of the investigation upheld in part the allegation of neglect in that, while the manager had taken some actions, they had failed to act to manage effective and appropriate interventions to ensure services to support a residents specific needs, including in relation to behaviours that challenges. As noted previously, subsequent advice from another involved professional also raised concern regarding this issue in one unit at Gifford House. As noted in this report, we raised a safeguarding alert due to concerns identified during this site visit. The managers AQAA tells us that their relationship with the safeguarding adults team has developed in a positive way. In response to a number of incidents relating often to the effects of challenging behaviour by some residents on others, and a failure in communication, a system has been set up whereby the qualified nurse reports to the manager within 24 hours of any incident and the safeguarding adult team are informed. The manager provides initial induction training on safeguarding and whistle blowing to staff and this is confirmed in the managers AQAA. A member staff spoken with confirmed this, indicated an understanding of what may be abusive in practice and Care Homes for Older People Page 24 of 38 Evidence: confirmed they would report it to the manager or if necessary to the Commission. Two other more senior staff spoken with confirmed that they had attended training on safeguarding recently, one of whom attended a two-day course, and were aware of relevant issues. All surveys received from staff confirmed that they would know what to do if anyone had concerns about the home. Files reviewed for two care assistants demonstrated that safeguarding had been covered as part of their induction and files for two nursing staff demonstrated they had attended additional training on safeguarding vulnerable people. At the time of the last key inspection, records showed that a number of staff had completed training on risk and conflict management. The deputy manager is trained to provide training to staff on managing challenging behaviour in the workplace including a person centred approach for people living with dementia. The registered provider confirmed that this had expired some months previously and that as the deputy had had some sick leave, they had been unable to update their training and so provide this training to new staff. The registered person subsequently demonstrated that training had been booked for staff with an outside training company to include managing aggression in January and May 2010. Care Homes for Older People Page 25 of 38 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. Gifford House provides residents with a pleasant and well maintained environment that meets their needs. Evidence: Gifford House is purpose-built and all resident bedrooms are single occupancy and have en-suite facilities. Residents we spoke to told us that they were satisfied with their rooms. Many of the rooms were personalised to varying degrees including for example one resident who had their own fridge. Residents have their photograph along with a room number on their bedroom door to indicate the persons private space and, for some people, to help them to recognise it. A photograph was seen to be on the door of an unoccupied room. The registered provider subsequently told us that this resident was in hospital. There is opportunity to develop the environment in the specialist units further, for example to include more signage and use of colour to better meet the needs of people living with dementia. Each unit has its own communal lounge and dining area that are well furnished and equipped. Staff told us that the new serving counter in the dining room downstairs was much better as it was easier to serve residents. A toaster was available and they make toast for residents as required. Staff also advise that residents of Betts unit come to the dining room first and then people from upstairs about 15 minutes later for Care Homes for Older People Page 26 of 38 Evidence: lunch as this allows a faster service and less waiting for residents. Each of the upstairs units also has a satellite kitchenette leading off the lounge area, which makes it easier for staff, relatives, and residents who are able, to make drinks and snacks as required. There are also a number of quieter place to sit around the home, including a quiet lounge and there is also a smoking lounge for residents. It was noted positively that this room was as well maintained and pleasant as the other areas in the home. There is also well maintained and enclosed garden where people can walk and sit. The garden now has a sensory area and water feature. Each unit has its own bathroom and toilet facilities. The managers AQAA tells us that bathrooms have added projectors that show scenes alongside music to enhance the bathing experience. The managers AQAA tells us that, as the home is now three years old, they have started a complete redecoration programme to ensure the home remains as pristine as it was on opening. This was observed at the time of the site visit. Some of the carpets in the communal areas were badly stained but it is expected that this will be dealt within the schedule of works. In Radcliffe unit one of the call bell cords was stored in a bedside cupboard, the interior of another bedside cabinet was soiled and dirty. Although there was evidence of a persons belongings in the room the provider advised that the resident was in hospital and the room was being re decorated. In Linford unit the door to the sluice room was found unlocked. Overall however, the home was clean and no health and safety hazards were identified. Residents and relatives spoken with said they were satisfied with the premises and one person said the place is nice. All surveys received from residents said that the home is always fresh and clean and a survey from health professionals said the home is spotless and never smells of urine. Care Homes for Older People Page 27 of 38 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. Residents can expect to be supported by caring staff that are safely recruited but who, in some cases, may be not competently led or trained to meet their specific needs. Evidence: Staff spoken with on Betts unit confirmed that current staffing levels of one qualified and four care staff on the morning shift was suitable, supported by ancillary and activity staff, as dependency levels were low, for example with very few residents needed hoisting. Staff on all units were observed to interact positively with residents. Two staff surveys received on what the home could do better included the comments skill mixing of staff, more support and praise for staff and off duty could be better organised with better skill mixing and more staff available at any one time. Staffing levels were observed to be adequate at the time of the inspection site visit but there was some evidence that staff skills mix was not best managed. Staffing levels on Radcliffe were three care staff and one qualified nurse at the time of the site visit. One was newly recruited, inexperienced and untrained in relation to the specialist needs of people in the unit. The staff told us they had not had opportunity to read the care plans of people recently admitted to make themselves fully aware of these peoples needs. The care staff interacted with residents and endeavoured to meet their needs. Staff were not always effectively led and managed by the qualified Care Homes for Older People Page 28 of 38 Evidence: staff, with, for example an untrained and inexperienced member of staff being left on their own in the communal rooms with residents, or staff being unsure whether they were able to give residents a drink on request. Relatives and residents spoken with throughout the home spoke positively about the staff with comments such as staff on the whole are nice and staffing levels seem fine and staff are very nice and in the way they speak to residents. Information from resident surveys generally indicates that staff are usually available when needed and listen and act on what residents say. Information from care staff surveys generally indicate that there are usually enough staff to meet the individual needs of all the people who use the service. A health professional survey contained a comment staff seem very concerned for patients well-being and emotionally attached to their patients. The manager provided information which, when compared with the current rota, indicated that of thirty four care staff, five had achieved NVQ level II, one had achieved NVQ level III and one had commenced NVQ level II. The recruitment files were reviewed for three staff employed since the last inspection to consider if a robust recruitment procedure was in place to safeguard residents. It is noted positively that the files contained all the required information, references and checks and evidence that these had been obtained in a timely manner. Two of the files reviewed were of care assistants. These demonstrated that the manager has used an induction process to skills for care standards. Both files showed that the person had a first-day induction that included training by the manager on safeguarding, fire and health and safety at work. Appropriate initial induction training was also identified on file reviewed for one of the qualified nurses. Surveys from staff indicated that their induction generally covered what they needed to know to do the job when they started and that they are being given training that is relevant to their role and helps them to understand and meet peoples individual needs. Staff spoken with confirmed the information in the managers AQAA that there has been an improvement in the training provided to staff, for example some carers are currently undertaking distance learning regarding medication. A member of staff also told us that the recruitment of additional permanent staff had a positive impact, and they are staff who are willing to work and do their bit and everything works much better Surveys from health professionals state that the manager and staff usually or always Care Homes for Older People Page 29 of 38 Evidence: have the right skills and experience to support peoples needs, although following more recent experience one person subsequently questioned this. Information regarding staff training provided by the manager indicated that the majority of care staff have attended basic training such as moving and handling, safeguarding, health and safety, fire, basic food hygiene and infection control. Records indicated that all but five of the care staff have attended training on dementia care and challenging behaviour. Care Homes for Older People Page 30 of 38 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. Shortfalls in aspects of management and leadership identified during this inspection process could adversely affect outcomes for residents. Evidence: The manager has been in post since Gifford House was first registered in August 2006. The manager is a qualified registered nurse, including mental health, and has recently achieved NVQ qualification, Registered Managers Award. The register provider is regularly involved in the home and undertakes the required monthly visits and reports to ensure the home is running to an appropriate standard. A deputy manager is now in post and the management team advise they are recruiting to a new post between the registered manager and the deputy manager. The rota indicates that the registered manager and deputy manager have undertaken some weekend shifts in the home. The registered person stated that this helps to maintain a presence in the home and looks at consistency. Care Homes for Older People Page 31 of 38 Evidence: The AQAA tells us that the management team have recently reviewed the role of one of their clinical leads, giving the person extended duties to support staff and management in both Linford, and additionally, Radcliffe unit, looking to provide more consistency in care planning and medication administration. While the role change had been implemented, the outcome was clearly not achieved at the time of this site visit. There have been ongoing concerns with the management of care planning, risk assessment and medication and care outcomes for some residents. This resulted in Statutory Requirement Notices regarding care planning and risk assessment being served on the registered manager and registered provider since the last key inspection. An additional random inspection indicated that compliance had been achieved in the specific instances but that weaknesses still remained that would be reviewed at this inspection. While improvements have been noted in several areas over the past two years, and the management team express willingness to comply with Regulation, it is disappointing that care planning, risk assessment and safe management of medication to support positive care outcomes for people living at Gifford House continue to remain ineffectually managed in some instances. The management team have a quality assurance programme in place that includes obtaining views from residents and relatives. The outcome of the relatives of a resident satisfaction survey for the six-month period to May 2009 was readily available and displayed in the home. This includes clear graphs and comments, both positive and negative on questions answered in relation to environment, care, social and recreational activity, meals and opportunity for involvement in care reviews and information sharing. The information shows that many aspects are responded to favourably. The registered provider told us that surveys had been given to all 61 residents/their relatives and that 26 responses had been received. The manager looks after small amounts of money for some residents. The record of monies looked after for two residents were sampled and the system found to be satisfactory. Safe storage was available and records of money paid out was supported by two signatures and individual receipts. The managers AQAA states that all staff receive supervision every eight weeks and that records are kept in their personnel files. Two staff files sampled indicated that the staff received regular formal supervision that included review of practice issues and training needs. Aspects of health and safety were reviewed to assess that systems were in place to safeguard residents. Current safety inspection certificates were available in relation to Care Homes for Older People Page 32 of 38 Evidence: the lift, fire alarm, gas, nurse call and hoists. Records were available of weekly checks of the fire alarm in each unit. Risk assessment relating to safe working practices were in place and some were due for review. A recent letter was available from Essex Fire and Rescue Service confirming a satisfactory standard of fire safety in the home. The managers AQAA states that the most recent Environmental Health inspection report was positive. Records were available to demonstrate weekly checks of the fire alarm, fire extinguishers and automatic door closures as well as regular fire drills for staff. Care Homes for Older People Page 33 of 38 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 34 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must identify all 01/02/2010 their individual assessed needs, be up to date and supported by risk assessment and provide staff with sufficient information to enable them to offer residents proper and consistent care and assistance. This includes areas identified in the report such as management of behaviour that challenge, medication, restrictions, care and social care needs and interests. So that residents are cared for safely and in a way that meets all of their care/nursing needs. This is a repeated requirement. 2 8 17 Ensure that where any restraint and or intervention 15/11/2009 Care Homes for Older People Page 35 of 38 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 is used on a service user there is a clear record detailing the rationale for this, the time frame, type of intervention used by staff and outcomes. To ensure the safety and wellbeing of the person. 3 9 13 People must only be given medication from containers supplied and labelled for them. This will ensure people receive the correct medication. 4 9 13 Medication must be given to 27/10/2009 people safely in a way which reduces any risk of error and in accordance with good professional practice. This will safeguard people from harm. 5 14 12 Ensure that staff respect and 15/11/2009 support peoples right to make and exercise choice. To ensure their health and welfare. 6 31 10 Ensure the care home is carried on and managed competently with sufficient care, competence and skill. 15/11/2009 15/11/2009 Care Homes for Older People Page 36 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure the wellbeing of and quality care outcomes for residents. 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 3 The manager should review and reconsider the effectiveness of the pre admission assessment process to ensure that they only admit people to Gifford House whose needs they can meet there. Ensure that all people living at the home, including those people who have cognitive impairments, have their social care needs met. 50 of care staff should achieve NVQ Level 2. To safeguard residents, ensure that the service is managed effectively and that skilled and competent staff are available to support residents. 2 12 3 4 28 30 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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