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Inspection on 05/11/09 for Goatacre Manor Care Centre

Also see our care home review for Goatacre Manor Care Centre for more information

This inspection was carried out on 5th November 2009.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Many improvements have been made at Goatacre Manor since the last inspection. The home has fully revised its processes relating to the assessment of residents` needs and risks. They have also introduced a new individualised care planning system, to which residents, their supporters and staff have ready access. We met with a resident who had been recently admitted. They had had a full assessment of their needs prior to admission. This assessment had been carried out in detail, using an assessment record which provided "triggers" for staff to consider where further assessments were needed and where care plans were indicated. This person`s assessments had been further reviewed on admission and thereafter, when further care needs were identified for them. This person`s records indicated that they were at risk of falls. They had a very clear care plan relating to this, which we noted as good practice included reports of how the person felt about this risk and matters which made them feel apprehensive or supported. They reported to us "staff are always willing and helpful, considerate. Certainly helpful". We met with some very frail residents. All of the frail people we met with had attention to significant details, such as clean fingernails and brushed hair. Where people were not able to assist themselves to eat and drink or change their positions, they had care plans relating to this, to direct staff on how their individual needs were to be met. Care plans were generally revised when a person`s condition changed. Records relating to giving people fluids and meals were generally completed. Where people could not change their positions independently there were some records relating to these changes in positions.Where people were at risk of pressure ulceration, they were provided with relevant equipment to prevent risk and settings required on equipment was generally documented. People who were nutritionally at risk had their weight monitored regularly and were referred to appropriate health care support when needed. Where people were prescribed nutritional supplements, there were clear records that people were being given these supplements. Where people had wounds, there were clear systems for assessing the wound and monitoring its progress. Where relevant wounds were regularly photographed. There was evidence that people were referred to the tissue viability nurse. We met with a member of staff who was responsible for wound care. They reported that the home`s new recordkeeping system supported them. They reported on the good communication between the tissue viability nurses and the home. They reported that if changes in dressing regimes were recommended, that they were always informed and that revised instructions were clearly documented in the residents` records. This person was also aware that having a dressing performed could cause pain for the resident and the importance of making sure that the person had adequate prescribed pain relief before the dressing was to be performed. Where a resident had a urinary catheter, there were clear records relating to the management of the catheter, which conformed to current guidelines. The manager has made many improvements in the home`s handling of medicines since the last inspection. Nurses that we spoke to were very positive about the changes that had been made and felt reassured by the extra checks that had been put into place. The medication administration records are checked daily by senior staff. These were seen to be completed correctly with refusals noted. We looked at care plans that related to these refusals and saw that the details were included along with strategies for helping staff to support the person to take their medicines. We saw evidence of the involvement of health care professionals in people`s care; a new resident was about to see the doctor as staff had concerns about their medicines. A controlled drugs cupboard has been secured to the wall in the approved manner. We observed that all wash bowls in residents` rooms were now named for the person and were stored clean and dry. New commode chairs have been provided to replace old, stained commode chairs. Staff reported on the ready supply of disposable gloves and that different sizes of gloves were available to suit staff with different hand sizes, they were also able to show us supplies of latex-free gloves for people with latex allergy. The provider has purchased three profiling beds and reports that they are planning to gradually increase the numbers of such beds. The home has supplied stools for staff so that they can sit and support residents who needed assistance to drink or eat their meals. Staff were observed using these stools at meal times and tea and coffee rounds, engaging residents in conversation whilst supporting them. We reviewed the home`s training records. We observed that they have introduced a clear training matrix, so that they can see at a glance which members of staff have received mandatory training and who needs to do so. They have also introduced management systems to ensure that staff members are aware of their own responsibilities for attending such mandatory training. The training manager on duty reported on progress towards ensuring all staff were trained in manual handling and infection control. One of the registered nurses reported on how they supervised staff to ensure that safe manual handling and infection control practice was carried out. A resident told us that staff always used the hoist for them when assisting them to move and change their position inbed at night. We observed two carers assisting a person to move from a wheelchair to their armchair in a safe manner, using a hoist. Residents we met with clearly felt able to bring matters up with staff. One person told us "I couldn`t have better. There is always someone about" and "I`m not too fond of ringing the bell, but I did ring this morning to get up". They reported that someone came quickly and that they were supported as they wanted. Another person joked with us that they liked to "keep and eye" on staff, winking at a member of staff as they did so. They reported that there was "always someone around if you need them" and how well they slept when they went to bed.

What the care home could do better:

Goatacre Manor has made significant strides in improving its service, however as with any service where significant improvements were necessary, there remain some areas which need attention. While staff were recording when they gave people drinks and meals and supported residents in changing their positions, they did not do this on every occasion. This particularly related to moving people`s positions where, for example one person`s care plan stated that they needed their position changing every two hours but their daily record did not evidence that this was taking place. While many records were clear and precise, others continued to need improvements. Wording such as "repositioned" does not state how or where a person`s position was changed. Wording in care plans such as "regularly" need revision to describe clearly how often an action needs to be performed. If a person is being given thickening agent to help them to swallow safely, their care plan should state in precise language how thick they need their drinks to be. Where people have complex needs such as the use of a conveen to manage continence issues, as well as stating how often the appliance needs to be changed, care plans need to direct how the appliance is to be put in place, including use of creams and adhesives. Where a person has diabetes, as well as stating the lowest and highest blood sugar levels needed for the person, the care plans should direct staff on actions to take if the person`s blood sugar levels are outside these ranges. Some care plans would benefit from more development. For example, we observed that two people had flexion contractures, however their care plans did not describe how personal care was to be performed in the light of this, to prevent discomfort to the resident. Residents who had bowel care needs did have care plans but these did not reflect what was written in their bowel care record or daily record. Residents who needed to be encouraged to take in adequate fluids did not have the amount of fluids they needed to drink on a daily basis documented. People who had been prescribed medicines to be taken `as required` had protocols to support staff when making the decision to use the medicine. Some of these protocols were not sufficiently detailed, for example one stated `use for anxiety episodes` and another `for seizures`. Clearer guidelines are needed to ensure that people receive consistent care and treatment. The home is not using the lancet devices for taking small blood samples that are recommended by the Medicines and health Care Regulatory Agency (MHRA). Following a safeguarding alert, it was identified that the home were using an un-licenced product to irrigate a person`s wound. This was fully documented in the resident`s notes,however such action is contrary to Nursing and Midwifery Council`s guidelines and if such products are used, they must be used under the supervision of a clinician with responsibility or in the context of a clinical trial. We will be issuing a warning letter to the home relating to this as part of our enforcement procedures. Some of the residents we met with needed to be moved using a hoist. Discussions with staff showed that while the type and size of hoist sling to be used was clearly documented in their records and were being used for the person, that such slings were used communally. This is not regarded as good practice, as due to where slings are placed on a person`s body, communal use of hoist slings can present a risk of cross infection. We observed that generally the home documents the dial setting on air mattresses in care plans. However when we looked at dial settings on the mattresses in use, three of them did not relate to the care plan and one where the setting was not documented in records, did not relate to the person`s weight. Dial settings on air mattresses need to be correct as if a mattress is not correctly set in accordance with the persons` weight, this can increase the person`s risk of pressure ulceration. While the home has developed a training matrix, training relating to other areas is not documented. For example the care assistant who performs dressings reported that they had been trained by the registered nurse who lead in this area but this had not been documented. There was no evidence in records that this carer had had recent external training from the tissue viability nurses. This is needed, so that people who perform wound care can be advised of current good practice in this key area. Whilst training of carers in extended roles such as application of conveens is documented on induction, the home does not maintain records of up-dates in the area or assessments of continued competency.

Random inspection report Care homes for older people Name: Address: Goatacre Manor Care Centre Goatacre Lane Goatacre Wiltshire SN11 9HY zero star poor service 08/05/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Susie Stratton Date: 0 5 1 1 2 0 0 9 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: Conditions of registration: Category(ies) : Mr John O`Dea,Mrs Margaret O`Dea care home 42 Number of places (if applicable): Under 65 Over 65 42 0 0 old age, not falling within any other category physical disability terminally ill Conditions of registration: 0 3 3 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 Care Homes for Older People Page 2 of 12 0 8 0 5 2 0 0 9 Brief description of the care home 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. 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 3 of 12 What we found: This random inspection was performed to review progress towards meeting requirements and recommendation identified at the last inspection. The inspection commenced at 9:35 am and completed at 3:30pm. It was performed by three inspectors, one of whom was a pharmacist inspector. These people are referred to as we throughout the inspection as it was performed on behalf of the Care Quality Commission. The manager, Mrs Jane Swainson was on duty during the inspection. The provider, Mr ODea was also available. Both Mr ODea, Mrs Swainson and two of their advisors were available for feedback at the end of the inspection. During the inspection we concentrated on the management of medicines and care of very frail people who had wounds and/or unstable medical conditions. Following a safeguarding meeting we also reviewed the situation in relation to an allegation that an unlicensed product had been used to irrigate a wound. We met with five residents, reviewed their records, inspected their rooms and discussed their needs with Mrs Swainson and other staff. We also met with a member of staff who is closely involved in wound care. We reviewed training records with the training manager on duty and discussed induction, training and staff support with them and a registered nurse. The pharmacist inspector met with registered nurses responsible for medication, observed medication rounds, reviewed medicines documentation and reviewed systems for storage of medication. They also reviewed records relating to one resident in detail. What the care home does well: Many improvements have been made at Goatacre Manor since the last inspection. The home has fully revised its processes relating to the assessment of residents needs and risks. They have also introduced a new individualised care planning system, to which residents, their supporters and staff have ready access. We met with a resident who had been recently admitted. They had had a full assessment of their needs prior to admission. This assessment had been carried out in detail, using an assessment record which provided triggers for staff to consider where further assessments were needed and where care plans were indicated. This persons assessments had been further reviewed on admission and thereafter, when further care needs were identified for them. This persons records indicated that they were at risk of falls. They had a very clear care plan relating to this, which we noted as good practice included reports of how the person felt about this risk and matters which made them feel apprehensive or supported. They reported to us staff are always willing and helpful, considerate. Certainly helpful. We met with some very frail residents. All of the frail people we met with had attention to significant details, such as clean fingernails and brushed hair. Where people were not able to assist themselves to eat and drink or change their positions, they had care plans relating to this, to direct staff on how their individual needs were to be met. Care plans were generally revised when a persons condition changed. Records relating to giving people fluids and meals were generally completed. Where people could not change their positions independently there were some records relating to these changes in positions. Care Homes for Older People Page 4 of 12 Where people were at risk of pressure ulceration, they were provided with relevant equipment to prevent risk and settings required on equipment was generally documented. People who were nutritionally at risk had their weight monitored regularly and were referred to appropriate health care support when needed. Where people were prescribed nutritional supplements, there were clear records that people were being given these supplements. Where people had wounds, there were clear systems for assessing the wound and monitoring its progress. Where relevant wounds were regularly photographed. There was evidence that people were referred to the tissue viability nurse. We met with a member of staff who was responsible for wound care. They reported that the homes new recordkeeping system supported them. They reported on the good communication between the tissue viability nurses and the home. They reported that if changes in dressing regimes were recommended, that they were always informed and that revised instructions were clearly documented in the residents records. This person was also aware that having a dressing performed could cause pain for the resident and the importance of making sure that the person had adequate prescribed pain relief before the dressing was to be performed. Where a resident had a urinary catheter, there were clear records relating to the management of the catheter, which conformed to current guidelines. The manager has made many improvements in the homes handling of medicines since the last inspection. Nurses that we spoke to were very positive about the changes that had been made and felt reassured by the extra checks that had been put into place. The medication administration records are checked daily by senior staff. These were seen to be completed correctly with refusals noted. We looked at care plans that related to these refusals and saw that the details were included along with strategies for helping staff to support the person to take their medicines. We saw evidence of the involvement of health care professionals in peoples care; a new resident was about to see the doctor as staff had concerns about their medicines. A controlled drugs cupboard has been secured to the wall in the approved manner. We observed that all wash bowls in residents rooms were now named for the person and were stored clean and dry. New commode chairs have been provided to replace old, stained commode chairs. Staff reported on the ready supply of disposable gloves and that different sizes of gloves were available to suit staff with different hand sizes, they were also able to show us supplies of latex-free gloves for people with latex allergy. The provider has purchased three profiling beds and reports that they are planning to gradually increase the numbers of such beds. The home has supplied stools for staff so that they can sit and support residents who needed assistance to drink or eat their meals. Staff were observed using these stools at meal times and tea and coffee rounds, engaging residents in conversation whilst supporting them. We reviewed the homes training records. We observed that they have introduced a clear training matrix, so that they can see at a glance which members of staff have received mandatory training and who needs to do so. They have also introduced management systems to ensure that staff members are aware of their own responsibilities for attending such mandatory training. The training manager on duty reported on progress towards ensuring all staff were trained in manual handling and infection control. One of the registered nurses reported on how they supervised staff to ensure that safe manual handling and infection control practice was carried out. A resident told us that staff always used the hoist for them when assisting them to move and change their position in Care Homes for Older People Page 5 of 12 bed at night. We observed two carers assisting a person to move from a wheelchair to their armchair in a safe manner, using a hoist. Residents we met with clearly felt able to bring matters up with staff. One person told us I couldnt have better. There is always someone about and Im not too fond of ringing the bell, but I did ring this morning to get up. They reported that someone came quickly and that they were supported as they wanted. Another person joked with us that they liked to keep and eye on staff, winking at a member of staff as they did so. They reported that there was always someone around if you need them and how well they slept when they went to bed. What they could do better: Goatacre Manor has made significant strides in improving its service, however as with any service where significant improvements were necessary, there remain some areas which need attention. While staff were recording when they gave people drinks and meals and supported residents in changing their positions, they did not do this on every occasion. This particularly related to moving peoples positions where, for example one persons care plan stated that they needed their position changing every two hours but their daily record did not evidence that this was taking place. While many records were clear and precise, others continued to need improvements. Wording such as repositioned does not state how or where a persons position was changed. Wording in care plans such as regularly need revision to describe clearly how often an action needs to be performed. If a person is being given thickening agent to help them to swallow safely, their care plan should state in precise language how thick they need their drinks to be. Where people have complex needs such as the use of a conveen to manage continence issues, as well as stating how often the appliance needs to be changed, care plans need to direct how the appliance is to be put in place, including use of creams and adhesives. Where a person has diabetes, as well as stating the lowest and highest blood sugar levels needed for the person, the care plans should direct staff on actions to take if the persons blood sugar levels are outside these ranges. Some care plans would benefit from more development. For example, we observed that two people had flexion contractures, however their care plans did not describe how personal care was to be performed in the light of this, to prevent discomfort to the resident. Residents who had bowel care needs did have care plans but these did not reflect what was written in their bowel care record or daily record. Residents who needed to be encouraged to take in adequate fluids did not have the amount of fluids they needed to drink on a daily basis documented. People who had been prescribed medicines to be taken as required had protocols to support staff when making the decision to use the medicine. Some of these protocols were not sufficiently detailed, for example one stated use for anxiety episodes and another for seizures. Clearer guidelines are needed to ensure that people receive consistent care and treatment. The home is not using the lancet devices for taking small blood samples that are recommended by the Medicines and health Care Regulatory Agency (MHRA). Following a safeguarding alert, it was identified that the home were using an un-licenced product to irrigate a persons wound. This was fully documented in the residents notes, Care Homes for Older People Page 6 of 12 however such action is contrary to Nursing and Midwifery Councils guidelines and if such products are used, they must be used under the supervision of a clinician with responsibility or in the context of a clinical trial. We will be issuing a warning letter to the home relating to this as part of our enforcement procedures. Some of the residents we met with needed to be moved using a hoist. Discussions with staff showed that while the type and size of hoist sling to be used was clearly documented in their records and were being used for the person, that such slings were used communally. This is not regarded as good practice, as due to where slings are placed on a persons body, communal use of hoist slings can present a risk of cross infection. We observed that generally the home documents the dial setting on air mattresses in care plans. However when we looked at dial settings on the mattresses in use, three of them did not relate to the care plan and one where the setting was not documented in records, did not relate to the persons weight. Dial settings on air mattresses need to be correct as if a mattress is not correctly set in accordance with the persons weight, this can increase the persons risk of pressure ulceration. While the home has developed a training matrix, training relating to other areas is not documented. For example the care assistant who performs dressings reported that they had been trained by the registered nurse who lead in this area but this had not been documented. There was no evidence in records that this carer had had recent external training from the tissue viability nurses. This is needed, so that people who perform wound care can be advised of current good practice in this key area. Whilst training of carers in extended roles such as application of conveens is documented on induction, the home does not maintain records of up-dates in the area or assessments of continued competency. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 12 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 8 of 12 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, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 All care plans must be 30/11/2009 accurate and include consideration of records such as monitoring and daily records, particularly in relation to bowel care. There must be evidence that care plans are followed, particularly in relation to use of equipment to prevent risk of pressure ulceration. If care plans are not accurate and followed by staff, the resident could be placed at risk. 2 8 12 Where a person needs their 30/11/2009 fluid or dietary intake measured and needs their position changing by staff, monitoring records must always be fully completed at the time care is given. Records must show that care is given in accordance with care plans or if they are not, why this is. Accurate records provide evidence that care is being Care Homes for Older People Page 9 of 12 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 given in accordance with care plans. 3 9 13 All medicines prescribed for 31/12/2009 use as required must have clear guidelines to support staff when administering the medicine. This will ensure that people receive consitent treatment as prescribed by their doctor. 4 9 13 Unlicenced products must never be used unless they are being used under the directions of a clinician with responsibility or as part of a clinical trial. The use of an unlicenced product has the potential to put a resident at risk. 5 26 13 Hoist slings must not be used 26/02/2010 communally. Communal use of hoist slings is a risk to cross-infection. 6 30 18 Where staff, including carers, 29/01/2010 are reguarly involved in performing wound care, there must be evidence that they have been recently trained by a person with accredited expertise in the area. Correct performance of wound care is a key area, therefore anyone who performs such dressings must be trained by a person Care Homes for Older People Page 10 of 12 30/11/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 with accredeted expertese in the area. 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 7 Where a resident has a complex flexion contracture, the persons care plan should document how personal care is to be provided in this area to them. Care plans and other documentation should use precise, measurable language and words such as regularly or repositioned should be avoided. Where a resident uses a conveen, their care plan should state clearly how the appliance is to be put in place and any topical applications or adhesives to be used. Care plans relating to fluid intake should document the amout of fluids aimed at on a daily basis for the individual resident. Care plans relating to diabetic care should document in full actions to be taken if the persons blood sugar levels fall outside their individual documented parameters. Where a person needs thickening agent in their drinks to enble them to swallow safely, their care plan should state how thick the person needs their drink to be. Consideration should be given to the guidelines produced by the MHRA for the safe use of lancet devices. All training and up-dates given to staff should be documented in their own training records. 2 7 3 7 4 8 5 8 6 8 7 8 9 30 Care Homes for Older People Page 11 of 12 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 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. 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