Inspection on 01/05/09 for Goatacre Manor Care Centre

This inspection was carried out on 1st May 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Goatacre Manor Care Centre 05/11/09

Goatacre Manor Care Centre 02/05/07

Goatacre Manor Care Centre 12/05/06

Goatacre Manor Care Centre 11/11/05

Goatacre Manor Care Centre 26/05/05

Goatacre Manor Care Centre 02/12/04

Goatacre Manor Care Centre 22/04/04

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

Key inspection report Care homes for older people Name: Address: Goatacre Manor Care Centre Goatacre Lane Goatacre Wiltshire SN11 9HY     The quality rating for this care home is:   zero star poor 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: Susie Stratton     Date: 0 8 0 5 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 61 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 61 Information about the care home Name of care home: Address: Goatacre Manor Care Centre Goatacre Lane Goatacre Wiltshire SN11 9HY 01249760464/454 01249760252 jswainson@goatacre.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr John O`Dea,Mrs Margaret O`Dea care home 42 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: No more than 3 persons in receipt of terminal care at any one time No more than 3 physically disabled residents in the age range 18 - 64 years at any one time No more than 42 persons over the age of 65 years requiring nursing care Date of last inspection Brief description of the care home Goatacre Manor provides accommodation and care with nursing, for up to 42 residents. The majority of these will be people aged 65 and over. The service may also care for up to three adults in the 18 to 64 age range, if they need care due to a physical disability. Both short and long-term placements can be offered. The home is privately owned. The home is owned by Mr and Mrs ODea. The registered manager is Mrs Swainson, she leads a team of registered nurses, care assistants and support staff. Care Homes for Older People Page 4 of 61 Over 65 42 0 0 0 3 3 Brief description of the care home The home is in the small village of Goatacre, near Lyneham, Wiltshire. The market towns of Calne and Wootton Bassett are within a few minutes drive. The larger town of Swindon is also only a short distance away. The home consists of an original property with a purpose built extension. Resident accommodation is on two floors with a passenger lift in-between. There are two main lounge and dining areas, both on the ground floor. The home has wheelchair suitable corridors, bedrooms and communal rooms. Externally there are accessible gardens and adequate parking spaces. Fees charged to service users range between 550 pounds per week to 680 pounds per week. A range of information for people is displayed in the entrance hall. Care Homes for Older People Page 5 of 61 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: zero star poor 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: As part of this inspection, the homes file was reviewed and information provided since the previous inspection considered. We also received an Annual Quality Assurance Assessment (AQAA) from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the AQAA, and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what we should focus on during the visit to the home. As Goatacre Manor is a larger registration and issues were identified during the first day of the inspection, the inspection took place over two days. One inspector performed the first site visit and two inspectors the second site visit. These people are referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The first site visit was on Friday 1st May 2009, between 9:40am and 4:10pm. The second site visit was on Friday 8th May 2009 between Care Homes for Older People Page 6 of 61 9:30am and 1:10pm. Both site visits were unannounced. Mrs Swainson, the manager was on duty for both days of the inspection. We gave Mrs Swainson a feedback at the end of the inspection and gave Mr ODea, one of the providers, a separate feedback end of the site visits, as Mrs Swainson had had to leave the home before Mr ODea had returned. During the site visits, we met with thirteen residents, observed care for six residents for whom communication was difficult and three relatives. We also received two letters from residents relatives immediately after the inspection. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for five residents, including a resident who had recently been admitted and considered specific matters for a further three residents. As well as meeting with residents, we met with four registered nurses, five carers, a domestic, the laundress, the administrator, the chef and the training manager. We observed a lunchtime meal and activities in the sitting rooms. We reviewed systems for storage of medicines and observed two medicines administration rounds. A range of records were reviewed, including staff training records, five staff employment records, the statement of purpose, service users guide and maintenance records. Care Homes for Older People Page 7 of 61 What the care home does well: What has improved since the last inspection? What they could do better: The home need to ensure that people are given full and accurate information about the services provided, as set out in legislation and our guidelines, so that people can be fully informed about if Goatacre Manor can meet their needs. The home needs to ensure that full assessments of all of a prospective residents needs are carried out prior to, or at admission. Goatacre Manor needs to ensure that once people are being cared for in the home, they have regular assessments of their needs, including risk to themselves presented by their condition or the environment. Following assessment, care plans need to be put in place for all of a persons nursing and care needs. Where relevant, care plans need to confirm to local and national guidelines. Where a persons needs change, their care plan needs to be up-dated. Full monitoring systems need to be put in place so that the home can ensure that the needs of frail residents are being met. Residents privacy and dignity must be up-held at all times. Care Homes for Older People Page 8 of 61 The home needs to improve its systems for the management of administration of medicines and be able to demonstrate that residents have been given their prescribed medication. They need to ensure that all medicines are safely and appropriately stored at all times. The home continues not to ensure that registered nurses are fully informed about residents needs in relation to medication prescribed on an as required basis. The home needs to develop its approach to meeting residents social care needs, including a planned approach to the provision of activities. Care plans relating to social care need to be person-centered. The inspection showed that the home are not keeping to its own stated polices and procedures on the management of complaints and concerns, including full documentation of all matters. Some staff need to be trained in safeguarding vulnerable persons and the homes procedures need to be properly developed to ensure that vulnerable residents are protected from risk of pressure damage. Residents also need to be safeguarded from risks associated with the use of bed-rails. The home needs to improve its approach towards the prevention of spread of infection. They need to ensure that equipment is regularly cleaned and any equipment which cannot be cleaned is disposed of. All equipment to ensure that appropriate infection control practice can be followed, needs to be provided. Risks associated with communal use of a range of items including topical creams, tablets of soap, wash bowls and hoist slings need to be eliminated. Improvements are needed in practice relating to the laundry service, so that clean and used items are fully separated, infected and potentially infected laundry is correctly managed and certain clothing is not used communally. This inspection showed that the home continues not to ensure safe practice in the recruitment of staff. Newly employed staff would benefit from improvements in the induction system. Training in both mandatory and other areas needs development, so that the home can demonstrate that staff have been trained to meet the needs of residents cared for in the home. This needs to include both clear records and staff practice when providing nursing and care. The home must ensure that they meet statutory requirements set out by us and have taken good practice recommendations into account. Their quality audit systems need to be robust, to ensure that quality of service provision is effectively reviewed. Major improvements are needed in ensuring the health and safety of residents, particularly in relation to manual handling practice, infection control practice, the use of bed rails and prevention of risk of scalds. We are concerned about the homes change in quality rating from a good service to a poor service. We will require that they send us a plan to detail how and when they will make improvements in service provision. The next inspection will take place within six months and if improvements in service provision are not identified, we will take action to ensure that residents health, safety and welfare is up-held. If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 9 of 61 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 10 of 61 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 11 of 61 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will not be informed of the services offered by the home and so will not be in a position to assess if the home can meet their needs. Full assessments of individuals needs are not taking place, therefore people cannot be assured that the home is in a position to meet their needs. Evidence: The homes statement of purpose and service users guide are both displayed in the main entrance area. In their AQAA, the home reported that the service users statement makes clear what service the potential resident can expect from the home. We asked the manager to give us a copy of the information, as she would to any person who requested copies of the information. A home is required to have a clear statement of purpose to describe the range of services offered to residents. They are also required to give all people who use the service a copy of the service users guide which will describe a range of matters to assist the person in deciding if the home can meet their needs. Our legislation sets out clear directives on the sorts of areas to be Care Homes for Older People Page 12 of 61 Evidence: included in both documents, to inform people of service provision. We looked at both documents given to us and found that the homes statement of purpose did not provide information on much of the areas which are clearly set out in our legislation. The homes service users guide was approachable in style, informing of significant areas such as the homes smoking policy, supports to family members, religious services and the named nurse and key worker systems. However it does not conform to our legislation in certain areas, for example,among other areas, terms and conditions of residence, the complaints procedure and a copy of our most recent inspection report is not included in the guide. Some areas would benefit from more detail, for example the guide states that residents can bring in their own items but does not include a caveat about electrical items and states that the nurses are highly qualified, without specifying detail about qualifications. People will not be fully informed about the services offered by the home until both documents have been fully revised in accordance with our legislative requirements and guidelines. Many homes place a copy of the information in residents rooms so that people can access the information at their leisure. Goatacre Manor does not do this, so we asked the manager how she could demonstrate that people were able to access information as required. She assured us that people were given this information individually but reported that she was not able to demonstrate this. During the inspection, we discussed with people how they had found out about the home and decided about admission. Some people were too frail to recall their admission process, however other people were able to tell us about how they found out about the home. One person reported to us that they knew about the home from previous respite admissions, saying that they had been been in and out of here for years. Another person reported they had decided to come into this home because lots of people have been telling us about it. A registered nurse described to us how the home supported newly admitted people and that that part of the key worker role was to assist the named nurse on admission and to support the resident in moving in, explaining about the home, what happens during the day and to introduce a new resident to other residents. In their AQQA, the home reported that the pre-assessment form was used to assess a potential residents needs. They described it as comprehensive and needs led. We considered a person who had been newly admitted in detail, reviewing their records, looking at their room and meeting briefly with them. We observed that the person had had a brief pre-admission assessment completed, which included information on such Care Homes for Older People Page 13 of 61 Evidence: areas as their medical condition, manual handling needs and risk of tissue damage. However much of the pre-admission assessment was brief and would have benefited from much more information. For example, it was noted that this person used a specific appliance, but there was no information in the persons assessment about what assistance they needed with the appliance, how it was to be cleaned and by whom. The person also had a medical condition which can be complex to manage, however there was no information in the assessment as to whether they could manage this medical condition, if they needed full supports, any history of how stable or unstable this medical condition had been in the past or any indicators of how long they had experienced this condition. The persons pre-admission assessment also did not give any indication of their past life or interests. It is appreciated that, for a range of reasons, it is not always possible to obtain full detailed information on a persons needs prior to admission and in such cases, staff expand and develop outline information as soon after the persons admission as possible. This had not happened for this resident. By five weeks after their admission, there was still no assessment or care plan relating to this persons appliance and no evidence in the persons daily record that the persons appliance was being cared for. This was surprising as the persons daily record noted that the persons relative had asked about management of the persons appliance soon after their admission. When we visited the persons room they had a topical application with their name on it, prescribed prior to their admission. This application was also noted in the persons transfer letter to the home. We observed notes in this persons daily record relating to a sore area, but by five weeks after this persons admission, there was still no assessment or care plan about use of the topical application or any sore area. This is of concern, as elsewhere in this persons records it was noted that there was some query that the person might have an infection, although the site of the infection was not documented. Care Homes for Older People Page 14 of 61 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are at risk of not having their needs met, as the home does not have clear systems for ensuring that assessments and care plans, which comply with local and national research-based guidelines are in place. Systems for management of medicines needs improvement, to ensure peoples safety. Peoples privacy and dignity is not always respected by procedures in the home. Evidence: During the inspection, we met with a range of residents and some of their relatives and discussed with them how the home met peoples nursing and care needs. One residents relative informed us that they were very impressed and grateful for the medical care that XX is receiving and also for the TLC and special attention XX has from the nursing staff and the carers. Another relative described the care as exceptionally high. A person informed us oh yes, they would get the doctors in if I were poorly. A resident said how much they had enjoyed their hair wash and bath that morning. Another resident commented on how the home had ensured that they had had their eyes tested. Care Homes for Older People Page 15 of 61 Evidence: A registered nurse informed us that they supported residents by having a named nurse and key worker system and showed us the record of allocation which detailed which members of staff linked to which resident. A carer informed us that they found out about residents needs at handover and that if they were not sure about something, you can always ask the nurses. Another care assistant reported that the registered nurses filled in the care plans and kept them up-to-date and that care plans were always accessible. During the inspection, we observed a handover and noted that all staff on the afternoon and evening shift were involved. The registered nurse handing over the shift reported on different residents current and changing conditions. We observed that all carers consistently knocked on residents doors and awaited a reply before going into the residents room. All personal care was performed behind closed doors. We met with one resident who had very little ability to converse and observed that they had been nicely turned out, including clean spectacles. We observed a carer gently waking a residents up, giving them time to awaken, checking if they wanted the toilet and getting their permission to take them there. We were concerned however, as detailed in Environment below, that some residents had stained commodes, one communal bath which had been used was not in a clean state on both days of the inspection, a bathroom had a hairbrush in it which gave appearance of being communally used and that certain items of clothing were being used communally. Such practice does not up-hold residents dignity. In their AQAA, the home reported on their detailed care plans, with the resident at the centre of the care plan, that the care plans are reviewed when the residents care needs change and otherwise on a regular basis and that all areas of risk are assessed and documented in the residents file and reviewed on a regular basis or when changes occur. They reported that currently they were commencing the use of a nutritional risk assessment tool, to identify people who may be at risk of malnutrition. During the inspection we met with several residents and reviewed some peoples documentation in detail. We observed that the home has systems for assessing the needs of resident, identifying risk and drawing up care plans to direct staff on how a persons needs are to be met and/or risk reduced. Some of the documentation was detailed and provided clear directions on how individuals nursing and care needs were to be met. For example, one persons personal care plan was very person-centred and documented what personal care they were able to perform for themselves and what areas they needed assistance with. Residents records provided evidence of regular contact with their GPs and also other healthcare professionals such as the speech and Care Homes for Older People Page 16 of 61 Evidence: language therapist, tissue viability nurse and dietitian. We observed that residents are assessed for risk, including areas such as manual handling and risk of pressure ulceration. None of the people we reviewed had yet had an assessment for nutritional risk. Many of the assessments reviewed needed attention. For example one persons risk of pressure damage had not been totaled or signed by the person completing the assessment, another persons manual handling assessment had not been reviewed when they started spending much of their time in bed. Four of the people clearly had issues relating to dietary risk but they had not had an evaluation of this risk completed. None of the residents had had an assessment for risk of falls, although the accident book indicated that several residents would benefit from such an assessment. Although several residents clearly experienced needs relating to continence, we did not observe any continence assessments in the records we reviewed. Where a resident had a need or risk, there was a failure to develop care plans to direct staff on how peoples needs were to be met. Four of the people met with had assessments which indicated that they were at very high risk of pressure ulceration. None of them had care plans to direct staff on how risk was to be reduced. This is of concern, as the homes AQAA indicated that five people had sustained pressure ulceration in the home. Two of the people we considered in detail had had pressure ulcers for an extended period of time. The pressure ulcers were all reported to be of a minor nature. Such a high number of pressure ulcers developing in a home is an unusual observation in a care home with nursing. It is understood that on occasion a person may be admitted with previously acquired pressure ulceration but generally, apart from a very few occasions, if the correct procedures are followed, people usually do not develop pressure ulcers in the home or if they do, they are swiftly healed. There is a large body of research-based evidence relating to pressure ulceration. Pressure ulcers, once developed may take some time to heal, are painful and present a risk of infection, so the emphasis must always be on their prevention. The National Institute for Health and Clinical Excellence (NICE) guidelines, the European Pressure Ulcer Advisory Panel and local guidelines all state where a person is assessed as being at risk of pressure ulcers, that as well as providing pressure relieving aids, in order to prevent risk of pressure ulcers, people at risk also need to have their positions changed at least four hourly and for those people at higher risk, they need their positions changing two hourly. The guidelines also state that if a person has pressure ulceration, that time sitting out of bed be limited to two hours. The home are not complying with these guidelines. For example one person who was Care Homes for Older People Page 17 of 61 Evidence: assessed as being at very high risk of pressure ulceration had a mattress which was consistent with this risk on their bed, but throughout the inspection, they were observed sitting in the sitting room on a cushion which was consistent with a medium degree of risk. Only one of the four residents who were assessed as being at high risk of pressure ulceration had a turn chart to enable staff to ensure that the person had their position changed at regular intervals. On 1/5/09, this person had a turn chart in their room which was dated 9/3/09 with a second date in margin of the record for 28/4/09. Only five records had been made in all on this chart. By 12:15 this chart had been removed from the residents room. We asked a registered nurse about turn charts, they were not clear about where they were kept and reported that they might be kept in the office. We observed another person who was assessed as being at high risk of pressure ulceration who did have directives that they were to have their position changed three hourly and noted that they remained on their back, with no position changes, throughout the whole inspection. Where a resident had sustained pressure ulceration, whilst this was documented in their records, no documentation had been made about the grade of the pressure ulcer. We asked a registered nurse about the grade of one residents pressure ulcer when we were with them in the residents room, but they were not sure of the persons grade of ulcer. We also observed that the home did not routinely photograph wounds, as is general practice to assist in the wound assessment process. A person who had sustained pressure ulceration had a full assessment and monitoring system for their wounds, these showed that the wounds were stable but not healing. We noted that this person was sitting out of bed all day, rather than being limited to only two hours up, as advised in guidelines. There was no documentation in their records to state why this was. The high levels of pressure ulceration in this home are of concern and the home needs to urgently review practice and documentation systems to ensure that residents are safeguarded from risks of pressure ulceration The home also needs to improve its approach to frail people who are not able to support themselves. One person was being fed via an artificial feeding tube and was also taking in some diet by mouth as well. This person had full records about their artificial feeding system in their room. Their daily record showed some evidence that they refused meals at times and ate well on other days. This person had limited communication abilities and was not able to feed themselves. They did not have a monitoring record of the food they were able to eat. In order to be able to assess factors which supported this resident in taking in their diet and aid evaluation of care plans, a record of the persons dietary intake by mouth needs to be in place. Another Care Homes for Older People Page 18 of 61 Evidence: very frail person was cared for in bed all or most of the time, they were not able to give themselves drinks. However they did not have a fluid chart so that an assessment could be made of their fluid intake, to assess if they were at risk of dehydration. One person who did have a fluid chart in place did not have it totaled every 24 hours. The home uses a standard format for care plans. These state the care need and then list a standard set of interventions needed to be performed. Whilst it is appreciated that such an approach to care planning can assist in ensuring that all areas are included, it also meant that staff can become over-reliant on standard approaches to care and that there will be a lack of individualisation in documentation of care needs. For example, several of the residents were prescribed topical application, some people had mention made of these applications in their care plans but others did not. Some peoples daily records made reference to the use of topical applications which were not included in their care plans. Other peoples care plans made references to suitable topical applications, without stating what they were. One persons care plan evaluation started that they were now using a particular continence aid, but did not include details of the size or type of continence aid or how often it was to be changed and treatments for the persons skin underneath the aid. None of the standard care plans relating to continence pads stated the type of pad to be used for the resident. None of the care plans relating to urinary catheters stated the clinical reason for their use. Where a person was being fed artificially via a tube, there were no care plans to state about how often the site for the tube was to be reviewed and how it was to be cared for. Some of the residents were diabetics. Care plans relating to diabetes need improvement. Two of the care plans stated that the aim of care was to keep the persons blood sugar levels within normal levels, without any description of what normal was or what actions should be taken by staff if the resident was outside these levels. Both of these peoples records showed that they had had an instability in their diabetic condition. One persons care plan relating to their diabetes had not been reviewed for several months before the inspection, although it was clear that they continued to be unstable in their diabetic condition. We also observed in their daily record that they had had at least three recent episodes of hypoglycemia but there was no evidence of what staff had done to address the observation. Low blood sugar levels have the potential to make a person feel unwell and can lead to a medical emergency, therefore they must always be effectively managed. As well as a diabetic care plan not being evaluated we observed that one persons manual handling care plan had not been reviewed when their condition changed. Another person had a care plan in relation to their additional mental health care needs Care Homes for Older People Page 19 of 61 Evidence: but this had not been evaluated when their condition changed. In their AQAA, the home reported that they continue to ensure that medication is administered in accordance with policies and procedures and best practice. Regular audits are conducted with the registered manager being alerted of any deficits. During the inspection we observed medicines rounds, inspected storage systems for drugs and reviewed records relating to medicines. We observed that the home has a system for auditing practice in relation to medicines administration, storage and record-keeping. We observed during medicines rounds that the registered nurse carefully reviewed the medicines administration record, took the medicine to the resident and stayed with the resident to ensure that the medicine had been taken, prior to signing the medicines record. We observed that while the registered nurse was with the resident that they left the trolley open, this included when they were on the other side of the large sitting room. Throughout this period, the trolley was open and unsupervised. This is not good practice. After completing the medicines round, the medicines trolleys were returned to purpose-built cupboards, so that the trolley did not intrude on the domestic atmosphere of the home. The trolley was not secured to the wall in the cupboard and the doors to the cupboard were not lockable. This is required to ensure the safety to people. Additionally on one occasion, we found that the medicines trolley had been left unlocked in the unlocked cupboard. We reviewed medicines administration records and were concerned to observe that a total of 23 records had not been completed. This included one record for administration of insulin. This is of concern. Unless medicines records are completed, it is not possible of provide evidence that a resident has been given their prescribed drugs. In front to the medicines administration folders, there is a policy stating that where medicines instructions need to be written or changed by hand, that this should be signed and counter signed. A review of records showed that this had not been complied with in all cases. Where people are prescribed Digoxin, which can affect a persons pulse rate, it is accepted practice that the pulse rate should be monitored before the drug is given. This was not taking place every day for all people prescribed the drug. Where a person is prescribed a variable dose of a drug, the actual amount given was not always documented. During the inspection, we identified one person who was prescribed a drug to be given three times a day who was on some days being given it two times a day. There were no records to state why this was and a registered nurse we spoke with was not sure of the reasons either. This had been addressed by the second day of the inspection, however it should not have been happening. Where medicines were being given by injection on a regular basis, on the first day of the Care Homes for Older People Page 20 of 61 Evidence: inspection, there were no monitoring systems to ensure that the site of the injection was rotated, to prevent tissue damage. This had been addressed by the second day of the inspection, but this need should have been identified in the homes audit process. The home has a clinical room for storage of medicines. The manager reported that they were planning to go over to a new contract for medicines and that as part of this, the clinical room would be fully up-graded. We observed systems for storage of Controlled Drugs and found that they were safe. However we observed that a medication error had occurred in relation to a Controlled Drug which had happened two days before the first day of the inspection, which had not been noted until the inspection day. When the home did notify us of this error, their form stated that the persons GP had not been informed, with no indication of why this was. Both these matters are of concern. We observed systems for storage of medicines which needed to be kept in a refrigerator. We observed on the first day of the inspection that the fridge door was open when we came into the clinical room and that it would not close, unless it was locked. We looked at the temperature record for the fridge and observed that it had been over the required temperature since 23/3/09. By the second day of the inspection, the fridge had been defrosted and temperature levels returned to normal. It is of concern that this had not been identified before the inspection, as it could have affected the efficacy of some drugs. We observed that many of the residents had been prescribed topical applications but there was no system to document if they had had these creams and lotions applied, as prescribed. In addition, in the en-suite of on double room shared by two male residents, there was a used topical application for a female person. In a communal toilet there was also a used prescribed cream for a named person left on the toilet cistern. Prescribed medicines belong to the person and must only be used for the person for whom they have been prescribed. At the last inspection, it was required that there must be clear and objective guidelines for the use of all as required medications, to promote their consistent use. During the inspection we observed that two of the people we considered in detail were prescribed drugs on an as required basis. We did not observe any care plan or protocol about this in their records. We discussed this un-met requirement with the manager at the end of the inspection, who reported that she had instructed staff to include directives for as required medication on the medicines administration record. This inspection did not evidence that this had taken place. Care Homes for Older People Page 21 of 61 Evidence: This review of systems for management of medicines indicates that the home needs to improve its performance in audit of systems and practice. Matters have been identified at this inspection which should have already been identified by the home and actions taken and additionally, a requirement from the previous inspection has not been addressed. Failure to ensure safe systems for management of medicines could put residents at risk. Care Homes for Older People Page 22 of 61 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. People will be supported in exercising choice in some areas, particularly mealtimes. However a lack of individualised planning to meet peoples social care needs, means that peoples individual choices will not be fully considered. Evidence: In their AQAA the home stated that the duty rosters show that staffing levels are sufficient to provide a high standard of care and time to spend with the residents, that menu choice is completed daily for the following day with special requirements and requests complied with as far as possible and visitors are welcomed to the home at any time convenient to the resident and offered all the normal niceties of visiting, such as being offered a drink or joining a resident for a meal. The home reported in their AQAA that whilst they do not employ an activities person, that carers are expected to support residents in activities as part of their normal role. They also report that a variety of entertainers come to the home, that trips out are organised and that a pat dog visits the home regularly. During the inspection, we observed staff were available and chatting with residents in Care Homes for Older People Page 23 of 61 Evidence: the sitting rooms. One resident reported I write a lot and do crossword puzzles, another we have an art teacher who comes in Monday afternoons and another we have quizzes which are good because they keeps your mind working. Other residents commented differently. One reported that they spent their time watching the big screen meaning the television, another theres no physiotherapy here and another cant walk far, like someone to talk to. The home does not have an activities programme as such and it appeared talking with staff that when carers provided activities, this was not done on a planned basis. For example, the first day of the inspection took place on May Day, in many homes, as this is a calendar event of interest, activities would be themed round such a day, to support orientating residents with memory loss in remembering the time and season of the year. It is appreciated that with frail residents, activities need to be provided in a flexible basis but the home would benefit from a structure to activities, particularly to support residents who are mentally frail. A review of training records did not show that carers had been trained in activities provision. At the last inspection, it was recommended that the content of the activities section of care plans should be developed, to support the provision of opportunities likely to be of benefit to each individual person. In their AQAA, the home stated that care plans have been further developed to reflect every aspect of a residents needs. We reviewed a range of care plans and observed that whilst some residents had detailed records about their past lives, others had no details at all. Without information on how people used to live their lives, it is difficult to plan to meet residents individual social needs. The homes social care plans are a standard document with set phrases, although there is space on the forms to make additions if needed. None of the care plans we looked at showed any person-centered information relating to how their own social care needs were to be met had been added to their care plan. Care plans were reviewed, but all the ones we reviewed stated no changes, however as no personcentered information had been included, it was not possible to assess how the person had been assessed as having no changes. Records relating to activities did not evaluate their benefit to residents, for example peoples comments, facial expressions, body language and actual participation for frailer people. In their AQAA, the home reported on their close links with relatives and this was supported by comments made by relatives. One relative reported they keep in touch if XX is not well, they let me know of any day in bed and another when its been necessary theyve informed me - about changes in the residents condition. Another relative commented I can telephone or visit them knowing that I will be met with a sympathetic ear and a willingness to help. As noted above, care plans relating to Care Homes for Older People Page 24 of 61 Evidence: social care needs are a standard format and do not include factors, such as family involvement. During the inspection, we met with two relatives who were able to describe in detail their involvement with their relative, none of this was documented in the peoples records. If a resident fell, there was clear information that relatives were informed of the accident and the residents condition. However the home has notified us of one medication error but documented in their report that the relative was not informed, without detailing the reasons why, and when we discussed the high number of residents with pressure ulceration, the manager reported that the home did not inform relatives of such matters. This is of concern, as both issues could present risk to the resident and their relative or advocate needs to be made aware of such matters. Goatacre Manor is situated in the centre of a village and as such it can have close links with the local community. One care assistant was observed during the afternoon bringing their children in to meet with residents, which all parties clearly enjoyed. In their AQAA, the home did not specifically comment on any links with local churches. Practice of religion is noted on the standard care plan format, using a set phrase, with no detail of the individuals specific needs. It was noted for one individual that this standard phrase conflicted with what was documented on their admission assessment, but this had not been expanded further in the persons care plan. Practice of religion (or not) is a significant area to some people, this needs to be actively considered, so as to ensure that peoples needs are being met. We asked people about choice. One person reported that they can get up and go to bed when I like, I should hate to be told of bed times and another can decide when I get up and go to bed. During the inspection, when a television programme had finished, we observed a care assistant discussing with residents what they wanted to watch next. At 9:45am we observed that most of the residents were up and dressed and sitting in one of the two sitting rooms, apart from a few very frail people who remained all or most of their time in bed. This is an unusual observation, as in most care homes there tend always to be some people who prefer to get up much later in the morning. We reviewed care plans relating to this area, however as the care plans were generic, there was only a standard phrase about exercising choice, with no further information on matters, for example of when people preferred to get up and go to bed. Many residents commented on the meals. One person reported we get a jolly good lunch, another the foods not bad, you get a choice and its hot, another you get enough, you dont go hungry and another the puddings are great, she makes wonderful steamed puddings and baked puddings. A relative commented the kitchen Care Homes for Older People Page 25 of 61 Evidence: staff makes a difficult task look relatively easy. People also commented on choice. One person reported If you dont like the second choice, the cook does her best to give you what you prefer and another ask for egg on toast and you always get it. One person did comment we get too many sandwiches. We met with the chef, who showed a detailed, individual knowledge of different residents and what they liked to eat. They reported that they cooked all meals from raw ingredients, including soups, sauces, chicken nuggets and fish cakes. They reported that if someone did not like either of the choices on the menu, they were happy to provide a different alternative and was able to provide several examples of when they had done this. They reported that they offered a choice of meals to people on a soft or liquidised diet, stating that it was important for frail people to be offered what they wanted to eat. This is regarded as good practice, as in other homes, when someone cannot eat a normal meal, they are not always offered choice. We observed a mealtime. There was a relaxed atmosphere at the meal time, with no evidence of rush, although many of the residents needed support to eat their meals. We observed that the meals were nicely presented. They were obviously hot and the carers needed cloths to hold the plates. Carers supported residents in making the meals a social occasion. We observed carers encouraging people in discussing their preference for chips over mashed potato. We observed a registered nurse supporting a resident in eating finger foods, so that they could continue to give themselves their meal independantly. We also observed a care assistant supporting a resident who was confused in continuing to feed themselves, rather than taking over from the resident. Where a resident did need to be fed by a member of staff, they sat with them, trying to engage the person in conversation and ensuring that they were swallowing their meal safely. Care Homes for Older People Page 26 of 61 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home cannot provide full evidence that people are aware of how to raise matters of concern to them and that they respond when issues are raised. Staff need to be trained in protection of vulnerable adults and key areas need improvement to ensure that people are safeguarded. Evidence: The homes complaints policy is displayed in the front entrance hall. As noted in Choice of Home above, the homes service users guide does not include the homes complaints policy, so some people may not be fully informed of the homes procedure. We talked to a range of people during the inspection about how they raised areas of concern and received a varied response. One person reported talk to the lady in charge, Oh yes, she listens very kindly, another Id get the under manager I suppose, another if Im not happy, Id talk to one of the nurses and another Id talk to the staff, Im sure theyd listen. Other people were not so sure. One person reported If I was worried, Id talk to ..[pause].. the first one who came, they would listen to me, another person reported if Im not happy about something, theres nobody really to talk to, another I dont think Id know who to talk to if I wasnt happy with something here and another Ive not seen the manager. These responses indicate that there may be a need to support people in knowing how to raise issues of concern to them. Care Homes for Older People Page 27 of 61 Evidence: In their AQAA, the home reported complaints are recorded and followed up meticulously. Concerns are documented separately with action and outcome recorded. Residents and those close to them are encouraged to bring all concerns to the nurses or manager to ensure that something is done about them immediately. We asked to look at both these documents reported on in the homes AQAA. Discussions with the manager indicated that the home had had no complaints in the past twelve months and so the complaints book had not been used. However discussions with the administrator indicated that they had started dealing with a matter and had then passed it on to the manager for further action. On discussion, the manager reported that they knew about this matter and that it was on her computer file. We met with a resident who raised a particular area of concern which they reported they had raised several times. Discussions with a range of staff indicated that they were aware of these concerns, however contrary to the statement in the homes AQAA, no record had been made of these concerns. During the inspection, two residents also reported on two other matters of concerns to them, they were of the impression that they had mentioned these matters to staff, but there appeared to have been no records made of these matters. The home needs to improve and develop its approach towards complaints and concerns. Many managers regard receipt and review of complaints and concerns as a key area in their quality audit, to show them how the service affects different people. In their AQAA, the home stated that each employee is trained in the protection of vulnerable adults. During the inspection, we discussed training in abuse awareness with the training manager, they reported that this is done using a DVD, followed by discussions and a short test. We discussed training with a range of staff. The chef reported that they and all their staff had attended training in the protection of vulnerable adults. We discussed the matter with the person performing laundry who did not think that they had received such training. We looked at staff training records and of the 25 we looked at only four showed that the member of staff had been trained in safeguarding adults during the past year. We discussed awareness of this key area with people and while some of them, when given scenarios, were fully aware of actions to take, others, including a registered nurse, who may be in charge of the home, was not aware of appropriate actions to take to safeguard vulnerable people in accordance with local procedures. As noted in Health and Personal Care above, the home has a higher than would be anticipated number of people who have sustained pressure damage in the home. This is of concern in relation to Care Homes for Older People Page 28 of 61 Evidence: supervised after their protection returned and before their criminal records also has the potential to put vulnerable Administration below, the home are not which could put residents at risk. Care Homes for Older People Page 29 of 61 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. The home environment supports residents, with good supplies of equipment to meet the needs of people with a disability. However facilities and practice in prevention of spread of infection does not support appropriate practice or the privacy and dignity of residents. Evidence: Goatacre Manor is an older building, which as been extended. Accommodation is provided on one floor at the older part of the building and on two floors at the newer part of the building. There is a passenger lift between the two floors. The home is in the centre of the village of Goatacre and looks out over lawns at the back, with a cricket field beyond and garden and courtyard areas to the front. One resident was very pleased with the view from their window, reporting look at that view to us. A relative commented there are always lovely flowers and plants and pictures throughout the home for patients and visitors to enjoy. Most of the accommodation is provided in single rooms, although there are some double rooms. Screening is provided in double rooms and one resident we met with reported that staff always used the screens when providing personal care. There is a choice of two sitting/dining rooms in the home. Both rooms are large and provide accommodation to suit people, including people with complex disability needs. One person said Its a lovely room about the sitting room they were in and another Care Homes for Older People Page 30 of 61 Evidence: this certainly is a beautiful room. One person reported that they were very lucky to have this sort of accommodation. Another person reported Im very lucky to have a room like this. Residents are enabled to bring in items of their own if they wish and some of the rooms had a highly personalised atmosphere, reflecting the persons likes and preferences. In their AQAA, the home reported on how they continually reviewed the facilities offered and were gradually up-grading rooms to provide en-suite facilities where possible. They reported that since the last inspection, among other areas, they had made improvements to the entrance area, provided a purpose-built hairdressing area and had invested in large flat-screen televisions in sitting areas. These were observed during the inspection. We reviewed equipment during the inspection and observed a wide range of hoists to aid manual handling. These were clearly being used. One resident reported Im hoisted from my chair into my bed and out of bed and another I use a chair and I use a hoist. We observed that there was an ample supply of pressure relieving mattresses and cushions, including air mattresses and cushions. Air mattresses were appropriately used with sheets placed loosely over them, in accordance with manufacturers instructions. We observed a range of different chairs were available to meet the needs of people who had complex seating needs. Beds were hospital type with metal frames. We observed that the home does not generally use profiling beds. These are recommended, to reduce the risks associated with hospital beds, as profiling beds have integral bed rails which are safer, or preferably they can be lowered to the floor and crash mats used, to reduce risks associated with use of bed rails. The home has disabled showers and assisted baths with integral hoists. This means that people who are unable to bend at the waist or the knee may find accessing such baths complex. As the disability needs in this client group is likely to increase, the home should, consider widening its range of bathing facilities to offer a wider choice to people. We met with a cleaner and observed her in the role. One relative commented its so lovely and clean about the home and a resident reported very clean, very good. The cleaner reported that they had a good supply of cleaning equipment and chemicals. We noted that difficult to reach areas such as the undersides of raised toilet seats were clean. The home needs to review its commode chairs. Some chairs were clean, with intact Care Homes for Older People Page 31 of 61 Evidence: surfaces but others were old, some had stained and/or torn upholstery, some had rusty metal frames and some had stained commode buckets. Commode chairs need to be in a condition where they can be properly cleaned to reduce risks of cross infection and support the dignity of residents. The home only has one sluice room with a washer disinfector. We asked a range of staff about a cleaning schedule for commode buckets, but there did not seem to be one. This may be a factor in the observation of stained commode buckets. The home needs to develop a clear written cleaning schedule, to ensure that commode buckets are regularly cleaned. We observed that the sluice room had several used commode buckets sitting on top of the washer disinfector, waiting to go through the machine. The room had a wash hand basin, single use soap and a paper towel dispenser, but it did not have a rubbish bin. It also did not have any plastic aprons or disposable gloves. These are is needed, as a member of staff placing the used commodes in the washer disinfector would need to use both and be able to dispose of such aids safely, to ensure that risk of contamination is reduced. The fact that several commode buckets were awaiting disinfecting, as well as noting several stained commode buckets as detailed above, indicates that practice would be further supported by provision of a second washer disinfector. The home would benefit from modernising some other areas relating to infection control. We observed that in some communal bathrooms and toilets yellow bags for infected items were placed in open bins, this reduces risks of hand contamination when placing items in bins but will not be pleasant for anyone using the facility. In one shower room, there was a bin with a yellow bag in it for clinical waste which had been placed in a standard bin. In order to prevent risks of hand contamination when placing infected and potentially infected items in bins, foot pedal operated bins must always be used for clinical waste. We reviewed provision of gloves and aprons and observed that there was a good supply of a wide range of sizes in the store rooms. A carer reported to us that they carried a supply of gloves for general use in their pocket and showed us their supply. Sterile gloves were available in the clinical room for aseptic technique. On discussion with the manager, it appeared that sterile gloves were not being used for wound dressings. We have discussed this with the senior tissue viability nurse for the Wiltshire Primary Care Trust, who reports that sterile gloves must be used for all wound dressings, to prevent risk of infection to the wound. Care Homes for Older People Page 32 of 61 Evidence: Practice in the prevention of spread of infection needs to be improved. We noted that a jar of topical cream had been left in a toilet, it had been opened and used. In a double room, a jar of opened and used cream had been left on a surface, not close to either persons receptacle for personal items. As noted in Health and Personal Care above, a cream relating to a female resident had been placed in a room shared by two male residents. Many of the jars of cream did not have the residents name on it. Communal use of topical creams is a major risk to cross infection, therefore all creams need to be named and used only for that person. We also discussed how staff are instructed to take creams out of jars, if they use a spatula to spread the cream on their gloved hand or change their glove prior to putting their hand in the jar, and did not receive a clear answer. When performing personal care, in order to reduce risks of re-infection one of the two practices must take place. We observed a range of used tablets of soap in all of the communal bathrooms and shower rooms. In one en-suite in a double room, a tablet of used soap had been left on the wash hand basin, with no indication as to which person it belonged to. One shower room did not have a soap dispenser in it. A shower room had a used, unnamed hair brush in it. Communal use of tablets of soap is a risk to cross infection and such tablets must be disposed of promptly if their owner cannot be identified. As hand washing is the single most important factor in the prevention of spread of infection, facilities for single use soap must always be available in all relevant areas. Communal use of hair brushes may not constitute a major risk to cross-infection, however such practice does not support residents privacy and dignity. We looked at two different en-suites in double rooms. In both of these double rooms, there were two wash bowls in the en-suites, both were of the same colour and neither was named. Both were damp. We asked staff how they made sure that each bowl was always used for the same resident. They informed us that after use, the bowl would be dried and left with the persons named container of toiletries. This was not observed to be the case. In one en-suite, one bowel had been left on the window-sill and the other on the toilet cistern and in the other en-suite one bowel had been left inside the other, in the wash hand basin. This is clearly not satisfactory. On both days of the inspection, a communal assisted bath, which several people informed us was the only assisted bath used, had visible brown staining down all of the inside of the bath under the taps, down to the plug-hole. The use of a communal bath which is not clean can put people at risk of cross infection and does not support their dignity. As noted above, many residents needed to be moved by means of a hoist and slings. Care Homes for Older People Page 33 of 61 Evidence: Slings were reported to be used communally. Hoist slings cross over at peoples legs and therefore can present a risk of cross infection. If a person needs to always be moved in this way, in order to prevent risk of cross infection, either disposable slings must be used or slings need to be named for the person and used only for them. Slings will also need regular laundering. We discussed this with the laundress but there did not appear to be a system for the regular laundering of hoist slings. We also discussed the cleaning of hoists. It was reported that night staff clean the hoists but there was no written rota to support this. We went into the laundry and discussed the service with the laundress. The laundress showed a good knowledge of her responsibilities in relation to prevention of spread of infection. She was able to show us that she had good supplies of gloves and aprons. She reported that staff use red alginate bags for infected and potentially infected laundry. However she also reported that she needed at times to open these bags, as people would put items in them such as cardigans, which would need a different sluice wash. This is not safe practice as infected and potentially infected items can contaminate other items if they are taken out of bags and re-sorted in the laundry. The laundress reported that all other used laundry is placed in linen bags and taken to the laundry, where it is re-sorted. This is not ideal practice and preferably used items should be separated at source. This particularly the case as there were areas in the laundry, such as behind the washing machines, which were difficult to clean and where debris was visible. Additionally the washing machine plinths were stained with debris visible. Such accumulations can provide areas where micro-organisms can live. The home uses net underwear for people with complex continence care needs. They also have a supply of pop socks which are used by female residents. None of these items were named and it was reported that they were generally used for all residents who needed them. This does not support residents privacy and dignity and it also may present a risk of cross infection. There are several simple systems, such as small net bags which can be named, which can be used to launder such items. The home has trolleys which have shelves for clean laundry, with a round container for used linen at the end. We observed during the inspection that a bag of used laundry was placed in this container. The use of such trolleys in this way can present a risk to cross-infection. We discussed this with the manager, who reported that it was not usual practice. During the inspection, we inspected the kitchen and it was reported that they had a good supply of equipment and cooking utensils. The kitchen appeared clean and well managed. We did observe that the kitchen floor was stained and showing signs of age. Care Homes for Older People Page 34 of 61 Evidence: Plans should be developed for its improvement before it deteriorates further. During lunch we observed that meals were plated from hot trolleys. We observed that care assistants handled some items of food with their bare hands from both trolleys. It is not appropriate practice as it can lead to food contamination and if this needs to be done, utensils must be used or gloves worn. Care Homes for Older People Page 35 of 61 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will not be supported by staff who have been safely recruited and who are trained to meet their nursing and care needs. Evidence: In the AQAA, the home described that staffing levels are generous at all times of day to facilitate providing good opportunities for either group activities or one to one depending on the residents ability and choice. During the inspection we observed that staff were always readily available to residents and, as noted above in comments relating to mealtimes, the meal was conduced in a relaxed, calm manner with no feeling of rush. Staff reported that the home was generally well staffed and that staffing levels were only an issue with un-planned sickness. We asked people about staffing levels. One relative commented there seem to be plenty of staff around, a resident commented on how they had a bell and you can always get someone and another press the bell and along comes somebody. However other people were not so sure about staffing levels. One resident reported on occasions, they are understaffed at mealtimes and changeover, another on ringing their bell sometimes they are quick and sometimes theyre not and another you get left alone a lot and then theres masses of them. One resident commented to us that they felt that the response time to the call bell was slow and that on one occasion they had had to wait 40 minutes for a response. We asked the manager if Care Homes for Older People Page 36 of 61 Evidence: they monitored response times when the call bell was used and she reported that they did not. In their AQAA, the home reported that they were planning to fully up-grade and modernise the call bell system. At the last inspection, it was required that staff records must contain evidence that all required recruitment checks have been completed for all employees. In their AQAA, the home commented staff commence employment only after the home has received suitable references, a record of employment history and POVA clearance. During the inspection, we looked at five files of staff who had recently commenced employment. We found that person had there was no evidence had been proof of identity. This is of concern, the previous inspection. Residents which have been set out for their protection, have not been complied with. One person had commenced work after their pova clearance had been obtained but before their CRB clearance had been returned. Our legislation states that staff may commence work after pova clearance has been returned, but they must work fully supervised until CRB clearance is received. There was no written evidence that this was taking place. Staff we spoke to did report that a new member of staff was allocated to a mentor, however that due to the staff rotas, the person would not always be on duty at the same time as their mentor and they were not aware of any additional supervison systems, until CRB clearance was obtained. When staff commence work, they are given an induction. The home has an induction checklist and the training manager reported that on the new member of staffs first day, they go through the check-list with them, reporting that generally this takes two to three hours. The check-list is extensive, covering a range of areas. A registered nurse reported on the induction, that the new member of staff was trained by the trainer, then allocated to a senior carer as mentor. The new member of staff would observe at first, then become more hands on, as they become more confident. A new member of staff would not work on own their own until assessed as able to do so. About four weeks after the person had commenced employment, the training manager will see the new member of staff again and ask them to give a feedback, including assessing their understanding of safeguarding. Three members of staff are qualified manual handling trainers and they will induct the new person in this area. Two to three hours may not be sufficient to cover all areas on induction, however too much information at one time may not be beneficial to learning. Many homes break down their induction programme, so that areas are covered in a structured manner, over Care Homes for Older People Page 37 of 61 Evidence: several days and weeks, as this is more supportive to a new member of staff. Where this happens, such procedures are fully documented and a copy retained on the new member of staffs file. In their AQAA, the home reported that they were supportive of National Vocational Qualifications (NVQs) and that 90 of care staff were trained to NVQ II or above. The chef reported that all their staff had undertaken food hygiene training. The home employs a training manager who works six hours a day, four days a week. This is not their only role, the person also acts as key worker for a number of allocated residents and on the second site visit was spending the morning with the nurse assessor from the primary care trust, supporting the person in their assessments of residents. The training manager was a member of staff and had taken on this role in the past few years, they are not a qualified trainer and had not received training in this role. They reported that the home uses a mix of in-house and external training methods. In order to assess who needed training in which areas, the training manager reported that they went through staff training records. The home do not maintain a matrix of staff training to facilitate assessment of which member of staff is due mandatory training. We reviewed 25 staff training records and this showed that out of 25 members of staff, 20 had undertaken infection control training, 15 manual handling and one first aid, during the past year. We discussed with the training manager that 10 members of staff had not been trained in manual handling, which needs to take place on an annual basis. The training manager reported that some records might not be up-to-date, as the manual handling trainers may not have up-dated the most recent training given and also that some staff were not keen to attend mandatory training. We were particularly concerned by this matter as we had observed some inappropriate manual handling practice by staff - see Management and Administration below, which indicated that some staff were not aware of their responsibilities for safe manual handing. The training manager reported that on occasion some staff showed reluctance to attend training sessions. We discussed with the training manager that we were aware that this could take place in care providers and that other providers approached the issue by having clear management systems to ensure that staff were trained. Management systems have included regular review of records and letters from the provider outlining the responsibilities of both sides. Discussions with the training manager and the home manager did not indicate that there were clear processes in this area. Care Homes for Older People Page 38 of 61 Evidence: We looked at training in other areas. Some of the registered nurses had been trained in dementia, venepuncture and wound care. There was little written evidence that registered nurses had been trained in suprapubic catheterisation or male catheterisation, although residents with both types of catheter were cared for. The training manager reported that they were sure that registered nurses had gained qualifications in these areas, but that it had not been documented. More than one resident was being fed via an artificial feeding system, one resident had a stoma and one resident was using a penile sheath. There was no evidence that staff had been trained in these areas, although care staff may be supporting the resident in managing such care needs. There was also no training documented in areas which residents experienced, such as pressure damage prevention, continence, stroke, diabetic or arthritis care. Records did not show that staff had been trained in activities provision, although they were performing this role. We discussed with the training manager about how staff were supported in learning about such areas. They reported that they had put on such courses in the past, putting up notices to advise staff about training, otherwise that training was performed on the job or at handover. The home is not complying with national or local guidelines on prevention of pressure damage, so training is indicated in this area. Additionally when we discussed diabetic management with a registered nurse, they were not aware of current guidelines in relation to the management of diabetes. Training is an area where the home needs to take action. This is to ensure that residents are fully supported by staff who have been trained to meet their needs. All training needs to be fully documented to ensure that review and audit is possible. Care Homes for Older People Page 39 of 61 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People could be put at risk as the home does not demonstrate that effective systems for management are working across a range of areas, particularly in relation to health, safety and welfare of people. Evidence: Goatacre Manor is owned by an established provider who has been in the business of providing care for many years. A relative reported that the provider had gone to so much trouble to give individual patients special encouragement. The home has a registered manager, Mrs Swainson, who has been in post for several years and is also a registered nurse. One resident commented to us manager, admin & chef really good. During this inspection, we discussed the previous inspection report with Mrs Swainson and the fact that there were two requirements which had not been met within their specified timescales and that progress was still needed in meeting our good practice recommendations. We advised her that as statutory requirements had not been met Care Homes for Older People Page 40 of 61 Evidence: within timescales, if they continued to be un-met at the next inspection, we would be taking action within our procedures to ensure that they were addressed. We discussed other management arrangements and concerns which had arisen from this inspection. We informed her that as pressure ulceration is a matter that can adversely affect a residents well-being, under our legislation, we need to be informed of every instance, in accordance with our notification processes. A registered nurse we spoke with was not aware of the notification process to us for the medication error which was identified at this inspection, and that as the manager may not be on duty at all times, people who may be in charge of the home need training in their management responsibilities in this area. The home has an administrator, who includes management of residents own finances within their role. The home offers choice to residents, they will look after residents moneys or the resident or family can do this. Where a resident wishes to look after their own moneys, the home offers the resident a lockable cash box. If the home looks after residents moneys, this is held in individual bank accounts. The home has a clear system for managing residents finances, with a full audit trail from invoices for services such as the hairdressing, chiropody or newspapers, to the residents own account. The administrator reported that they perform an audit three monthly and perform a reconciliation, which is double checked. Where cheques or cash are handed in by relatives at evenings or the weekend, there is a secure cupboard, to which the registered nurse in charge of the home has access, and receipts are given. At the previous inspection, the home were required to devise and implement an effective quality assurance system. The administrator reported that they have sent out questionnaires to residents and their supporters, that four had been returned so far and that when more had been returned, she would collate the responses. As noted in health and personal care above, the home have commenced an audit of management of medicines, however due to the issues identified at this inspection, it has clearly not been implemented in full. They also report in their AQAA that they are reviewing care plans, but this inspection indicates that more action is needed in this area. The home have provided us with a full and detailed annual quality assessment, however evidence from this inspection indicates that some parts of the assessment has not properly considered a range of issues relating to service provision. Care Homes for Older People Page 41 of 61 Evidence: During the inspection, we observed several staff manoevering wheelchairs by lifting them by their rear handles. This is regarded as unsafe practice in manual handling. Just before lunch, we observed two care staff bring a resident into the sitting room. They put their arms under the persons shoulders to lift them up. Then, apparently after noticing us, tried to encourage the resident to stand themselves, but the resident was not able to do so, so transferring the resident to their armchair was complex, both for staff and the resident. We reviewed this residents care plan, which stated that they must always be transferred using a lifting belt, which the staff had not done. As noted in Staffing above, not all staff have received mandatory manual handling training, so this may be a factor in what we observed. The home must take action by training and staff supervision to ensure that staff comply in full with care plans and perform safe manual handling practice at all times. As noted in Environment above, we noted a range of practices which indicated developments are needed to ensure risk of infection is fully reduced. A review 25 records did indicate that 20 staff had recently been trained in the area but observations indicate that quality of training and closer supervision of staff practice is needed. We observed that staff consistently used foot plates on wheelchairs when moving residents about the home. We asked about monthly checks on wheelchairs and were advised that this had been delegated to a specific carer. People we spoke with were not sure if records were kept of these checks. As there is a body of evidence to indicate that people can be put at risk by wheelchairs which are not regularly checked and serviced. There need to be full records of checks made and actions taken to address any deficits. At the last inspection, the home were recommended to review their bed rail records and up-date them in line with national guidelines. During the inspection, we observed that several residents who spent all or most of their time had safety rails in place. All of the safety rails in the four different rooms that we inspected were loose in their Care Homes for Older People Page 42 of 61 Evidence: delegated to a care assistant, but people were not sure if records of these checks were maintained. Bed rails have been associated with a high level of risk to people and there is a large body of evidence to show that people have been seriously harmed or worse by their unsafe or inappropriate use. Therefore, they must always be used safely and care plans relating to their sure be accurate and regularly up-dated. Any person who checks bed-rails needs to be fully trained in their role. We reviewed the homes accident records. An audit of accidents takes place, but the audit does not include time of day or day of the week, to assess if accident happened more at certain time of the day or certain days of the week, such as weekends. We observed several reports of found on floor, which did not state which side the person was found in or any equipment/furniture involved. It is advisable for accident records to detail all factors involved in a fall. These was also no evidence that accidents to residents were reviewed at 24 and 48 hours, which is regarded as good practice, as some injuries to elderly people may not be evidence until some time after the event. We observed that one registered nurse had sustained a needle-stick injury a few weeks before the inspection. There was no evidence of follow-up relating to this injury for the nurse. The Health and Safety Executive states that the employer must provide effective and accessible services to staff in the event of a needle-stick injury. Care Homes for Older People Page 43 of 61 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 12-113-2 Clear and objective 02/05/2007 guidelines must be available for the use of all as required medications, to promote their consistent use. Registered nurses need to follow clear guidelines on when and why to administer such medications, so that the person is given such drugs in a consistent manner, in accordance with their individual needs. 2 29 7 9 19Sch 2 Staff records must contain evidence that all required recruitment checks have been completed for all employees. 02/05/2007 Procedures have been established to ensure that people are safeguarded by standard recruitment procedures, so that only people who are suitable to do so, work with vulnerable people. If these procedures are not carried out residents may be put at risk. Care Homes for Older People Page 44 of 61 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 homes statement of purpose and service users guide must be fully revised, to ensure that they comply with our legislation. People need to be fully informed about the services provided by the home, so that they can decide if the home can meet their, or their relatives needs. 31/08/2009 2 3 14 All people must have a full 30/06/2009 and detailed assessment of their nursing and care needs prior to or immediately after admission. Unless a persons nursing and care needs have been fully assessed, staff will not be in a position to develop plans of care on how the persons needs are to be met. People will therefore be placed at risk of not having Care Homes for Older People Page 45 of 61 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 their individual nursing and care needs met. 3 7 15 Where a persons needs have changed, their care plan must be evaluated and amended. If care plans are not up-todate staff will not be fully informed of how to meet individuals care needs and these is a risk that care will not be provided in a consistent manner. 4 7 12 All residents must have a 30/06/2009 full assessment of their nursing and care needs. Assessments must include all areas relating to care and risk for the resident. They must be accurately completed, signed and reviewed regularly or when a residents condition changed. If residents needs and risks are not assessed or reviewed when their condition changes, the home will not be in a position to develop an adequate plan of care as to how the persons need is to be met or risk reduced. 5 7 12 Where a person has a need or a risk identified, there 30/06/2009 30/06/2009 Care Homes for Older People Page 46 of 61 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 must always be a care plan drawn up to detail how the persons need is to be met and/or risk reduced. Care plans must be measurable, avoid generalistic language and include all interventions. National and local guidelines must always be complied with, unless they are not in the best interests of the person. Where this is the case, the reasons for this must be documented. Care plans are needed to ensure that all staff provide care in a planned and consistent manner. Care plans need to be clear, so that staff know exactly what actions they are to perform. There are bodies of research-based evidence in relation to meeting care needs and these need to be followed, unless they are not in the best interests of a person. 6 8 12 If a person is not able to 30/06/2009 move themselves or give themselves food or fluid, monitoring charts must be in place. Charts must be completed at the time care is provided. Care Homes for Older People Page 47 of 61 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 In a care home with nursing, many residents will not be able to assist themselves with activities of daily living and not be able to inform staff of matters relating to meeting such needs. The use of monitoring charts means that staff can see when a resident needs additional support and enable management to ensure that care plans are being complied with. 7 9 13 The home must develop a robust audit process for management of medicines and include action plans for addressing issues. A range of issues relating to medicines administration were identified at this inspection. The home does have an audit system, but this inspection indicates that it has not been robust in its approach and action now needs to be taken to ensure good practice and safety in the management of medicines. 8 9 13 A documentary system for administration of prescribed topical applications must be developed and such 30/06/2009 31/07/2009 Care Homes for Older People Page 48 of 61 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 applications must never be used for other residents. Prescribed medications belong to the persons for whom they are prescribed and so must only be used for that person. As these are prescribed medication, there must be documentary evidence that the prescribed applications have been administered in accordance with the persons needs. 9 9 13 Medicines must always be securely stored. There are clear guidelines relating to safe storage of medicines. These have been set up to ensure that risk to people is reduced to the lowest possible level. 10 9 13 All medicines administration 19/06/2009 records must always be fully completed at the time of administration. If medicines administration records are not completed, the home cannot evidence that medicines have been given and the persons medical needs met. 11 12 16 There must be evidence that 30/06/2009 residents have been consulted about their social 19/06/2009 Care Homes for Older People Page 49 of 61 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 interests and how they wish to live their lives. Care plans must be individualised and relate to what is known about the person. Evaluations must include benefit to the resident. If care plans relate to a persons nursing and care needs only, a significant area relating to the person will not be considered and the person will not be able to actively exercise choice. Care plans need to include matters relating to the persons past life their interests and family involvement. Care plans must be actively evaluated to assess the benefit of different interventions for residents. 12 12 16 The home must fully review its approach to activities provision, including taking into account the needs of people with memory loss, and develop a planned, written activities programme. Peoples social care needs are a key area of care. In a care home with nursing, it is appreciated that some 31/07/2009 Care Homes for Older People Page 50 of 61 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 people may have difficulties in participating in a programme, which is why a programme needs to be tailored to the needs of the people in the home. 13 16 22 The home must follow its 31/07/2009 own stated procedures in relation to complaints and concerns, ensuring that all people are informed of how to raise complaints and issues of concern. They must ensure that all matters are fully documented, including outcomes. If the home are not following their own stated procedures, review of matters raised will not be possible. If people are dissatisfied with the service provided they need to know how to raise issues and know that they have been taken seriously. 14 18 13 The home must review its 31/08/2009 training records in realtion to protection of vulnerable adults and ensure that it can evidence that all staff have been trained and are fully aware of their responsibilities. Staff need to be fully trained Care Homes for Older People Page 51 of 61 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 and be aware of their individual responsibilties towards vulnerable people so that they can ensure that they are safeguarded. 15 26 13 Staff must always use utensils or gloves when handling food. Food-stuffs must always be handled in a safe manner, otherwise there is a risk of contamination, which has the potential to affect people health. 16 26 13 The home must ensure that 31/07/2009 systems and equipment are in place and that staff adhere to appropriate principals for prevention of spread of infection, including avoiding communal use of commonly used equipment and clothing. If appropriate systems and equipment are not in place to ensure that staff adhere to the principals of prevention of cross infection, there will be a risk to residents. There must be safe practice in the management of laundry. Infected linen must always be separated at source. Clean linen must 30/06/2009 30/06/2009 17 26 13 Care Homes for Older People Page 52 of 61 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 always be separated from used linen. Laundries can present a major risk to cross infection, therefore systems and practice must ensure that risk is reduced to the lowest possible level. 18 26 13 The home must perform a full review of its commode chairs and take out of use any chairs and buckets which cannot be properly cleaned due to their condition. Commode chairs can present a risk to cross infection and need to have fully intact surfaces so that they can be wiped down. Commode chairs and buckets also need to be clean at all times so as to promote residents privacy and dignity. 19 26 13 The home must develop a clear written cleaning schedules, to ensure that all commode chairs, commode buckets and hoists are regularly cleaned. Communally used items can present a risk of cross infection, therefore there 30/06/2009 31/07/2009 Care Homes for Older People Page 53 of 61 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 need to be systems in place to ensure that they are regularly cleaned. 20 29 18 The home must provide 30/06/2009 clear documentary evidence, which are staff are aware of, that a new member of staff is fully supervised during the period after their pova clearance is returned and before their CRB clearance is returned. It is appreciated that receiving CRB clearance can take time, therefore in order to safeguard residents, a new member of staff may commence work after pova clearance has been obtained, but only if they are fully supervised. 21 30 13 There must be records to 31/08/2009 show that all staff have been trained in manual handling annually and all staff must practice safe manual handling practice at all times, in accordance with residents individual care plans. Safe manual handling is a key area in protecting both residents and staff. There must be evidence that staff have been trained in safe Care Homes for Older People Page 54 of 61 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 practice on an annual basis, to ensure that they are always fully up-to-date and aware of their responsibilities. 22 30 18 The home must be able to demonstrate that all staff are up-dated and trained in all areas relating to nursing, care and activities provision in the home. If staff are not trained in meeting residents nursing and care needs, there is a very real risk that they will not have their needs met. 23 31 37 We must be informed by the 30/06/2009 home of all events which can affect a residents wellbeing. Staff who may be in charge of a shift need to understand their responsibilities in this respect. As a regulator, we need to be made aware of an event which can affect a residents well-being, so that we can assess the homes response to such events. This assists us in reviewing quality of service provision. Staff who may be in charge of the home need to know what actions to take under our 01/10/2009 Care Homes for Older People Page 55 of 61 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 procedures, as such events can take place at any time during the 24 hour period. 24 33 24 An effective quality 31/08/2009 assurance system must be developed, this must include the homes systems for ensuring high quality of nursing and clinical care. Actions identified and plans to address issues identified need to be included. It is the homes responsibility to ensure that it provides quality services, which meet peoples needs. In order to do this in an effective manner, they must impartially review their service provision and take action where matters are identified. 25 38 13 There must be records in place to show that all wheelchairs have been regularly checked and any deficits rectified. Wheelchairs can present a risk to people if they are not regularly maintained. Therefore they need to have regular written checks undertaken and action take where maintenance is needed. 31/07/2009 Care Homes for Older People Page 56 of 61 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 26 38 13 Bed rails must always be safely used in accordance with national guidelines. Care plans for their use must be regularly and fully evaluated. There must be a documentary system for regular checks on bed rails. There must be evidence that people who check bed rails have been trained in their role. There is a large body of evidence about the risks to people from the use of bed rails, therefore they must only be used if it can be demonstrated that their use is in the best interest of the person and that all required safety checks have been performed by a person who is qualified to do so. Care Homes for Older People Page 57 of 61 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 there needs to be clear records of the checking of shower heads. 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 2 3 4 8 8 8 8 The clinical indicator for the use of a urinary catheter should always be documented. Fluid charts should be totalled every 24 hours. Wounds should be regularly photographed to assist in assessment of response to interventions. Documentation relating to pressure ulceration should include an assessment of the grade of the ulcer. Care Homes for Older People Page 58 of 61 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 5 6 7 8 9 10 9 9 9 13 14 21 Where a person is prescribed a variable dose of a drug, this should always be recorded. Where a person is being administered Digoxin, a record of their pulse should always be documented. When medicines instructions are written or changed by hand this should be signed and countersigned Relatives should be fully informed of any significant events which may affect the residents health and welfare. Care plans should document full information about a persons wishes in relation to practice of religion. The home should consider widening its range of assisted bathing facilities to meet the increasing disability needs of the client group. The home should consider providing profiling beds to reduce the risks associated with beds which cannot be lowered close to the floor and have non-integral bed rails. The kitchen floor should be improved, before it deteriorates further. The laundry should be up-graded, to ensure that all areas can be cleaned and all dirt and debris removed. Equipment should be provided so that used laundry can be separated at source. The home should consider providing a second washer disinfector. The home should set up a clear management process where by staff who do not attend mandatory or other training programmes are advised of their and the providers responsibilities. The home should set up a matrix for training to facilitate review of who was been trained in which areas and any deficits. The training manager should receive training in their role. The home should further develop its induction programme, to ensure that it can fully evidence that new members of staff have received a comprehensive and structured induction programme. 11 22 12 13 14 15 16 26 26 26 26 30 17 30 18 19 30 30 Care Homes for Older People Page 59 of 61 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 20 21 22 33 38 38 Response times when call bells are used should be included in the homes quality audit. The home should comply with health and safety guidelines for staff if they sustain a needle stick injury. Where a person sustains an accident, full details of what was observed should be documented, with a written follow up on the persons condition after the accident. Audits of accident records should include a review of time of day and day of the week. 23 38 Care Homes for Older People Page 60 of 61 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 61 of 61 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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