Inspection on 21/10/09 for Grange Park Nursing Home

This inspection was carried out on 21st October 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grange Park Nursing Home 04/05/10

Grange Park Nursing Home 24/02/10

Grange Park Nursing Home 27/10/08

Grange Park Nursing Home 11/12/07

Grange Park Nursing Home 01/02/07

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: Grange Park Nursing Home 133 Himley Road Himley Dudley West Midlands DY1 2QF     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: Jean Edwards     Date: 2 1 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 42 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 42 Information about the care home Name of care home: Address: Grange Park Nursing Home 133 Himley Road Himley Dudley West Midlands DY1 2QF 0138423991 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): grange.park@btconnect.com Grange Park (Dudley) Nursing Home Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 51 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: 1. The registered person may provide the following category of service only: Care home only: Code N to service users of the following gender Either whose primary care needs on admission to the home are within the following categories Old age not falling within any other category - Code OP, maximum number of places 37 Physical Disability - Code PD, maximum number of places 10 Dementia - Code DE, maximum number of places 14 to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia: Code DE (14) Old Age : Code OP (37) Physical Disability: Code PD (10) 2. The maximum number of service users who can be accomodated is: 51 Date of last inspection Care Homes for Older People 3 0 1 0 2 0 0 8 Page 4 of 42 Over 65 0 37 0 14 0 10 Brief description of the care home Grange Park is a purpose built care home offering nursing & personal care mainly to older people, though it is able to offer some nursing beds to younger adults. It is situated just outside Dudley town centre and has good public transport links with Dudley and other local shopping centres. There is a car parking area at the front of the premises. To the rear there are patio and lawned areas, bordered by fencing and mature trees in places and presenting a very pleasant outlook. The interior of the home provides single and double occupancy bedrooms on two floors, some of which are en-suite. The ground floor offers a reception area, offices, communal lounges, a dining room, two conservatories, a small smoking room, kitchen, laundry and a range of bathing and showering facilities. Fees stated in the service user guide were £495 per week for nursing care and £395 per week for residential care. Care Homes for Older People Page 5 of 42 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: The last Key Inspection was on 30 October 2008. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. Two inspectors visited the home from 07:40 - 19:15 on a weekday. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included discussions with the acting manager, the owner and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to The Commission. We looked at a number of records and documents. The previous registered manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to the inspection visit. Care Homes for Older People Page 6 of 42 We looked around the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. The home had published the range of fees in the service user guide, which range from £395.00 to £495. People are advised to contact the home for up to date information about the fees charged. Care Homes for Older People Page 7 of 42 What the care home does well: What has improved since the last inspection? An acting manager had been recruited and she demonstrated a proactive approach in that she had started to audit some aspects of the home and take action where necessary. Some improvements were being introduced to the way risks were assessed and peoples care was planned. Food safety had been improved and the home had achieved Four Stars and the Silver Award for food safety and healthy eating. Redecoration was taking place to improve the environment using colour contrasts to make it easier for people with dementia and sensory disabilities to recognise their surroundings. The homes AQAA told us about improvements to the environment, completed total refurbishment of our dementia wing, redecorated empty rooms, replaced many carpets/flooring, replaced fencing and provided new pictures around the home. A training programme had been introduced so that all staff can be provided with the Care Homes for Older People Page 8 of 42 knowledge and skills to meet the needs of people living at the home. There are planned meetings involving people living at the home and their relatives so they can have their say about their home. What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 9 of 42 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 42 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 42 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. The information about the home was not accurate and up to date and not every person living at the home had an up to date contract and terms and conditions of occupancy. This means that people and their advocates do not always have good information regarding their rights and entitlements, and how care will be provided. People cannot always feel assured that all of their needs are appropriately assessed and can be met by the home. Evidence: The homes statement of purpose and service user guide had been updated in March 2009 to reflect the change of regulator to Care Quality Commission, which demonstrated good practice. However the registered manager left the home in October 2009 and a new manager was appointed the week prior to this inspection. Therefore these documents needed to be updated. We were told the documents could also be provided in alternative formats on request. Care Homes for Older People Page 12 of 42 Evidence: Information about the range of fees and payment arrangements were included, which gave people full information about the service to help them make decisions about the choice of home. We looked at a sample of care records for people who had been admitted to the home since the last inspection visit. There were not contracts and statement of terms and conditions for every person. We looked at two people records who had recently come to live at the home. We found that a pre-admission assessment had been carried out by the home to ensure that the needs of the person moving in could be met by them. The assessment looked at several areas of need including personal care, mobility, diet and leisure activities. The assessments we saw only provided basic information which would make it difficult to identify all their care needs and choices. The assessment of one person identified that the home would not be able to meet their needs. We were told that the previous manager had spoken to the family and an arrangement was agreed that they would visit frequently to aid his communicate needs; and as a result of this agreement the person could come and live at the home. We found that this person exhibited aggression, which had put him, other people living in the home and staff at risk. The lack of information about this person and an inability of staff to communicate with this person whose first language was not English showed that this person needs were not being met and peoples safety was compromised. Although the manager usually wrote to people to say that the home would be able to meet their needs, this was not the situation with this person. Care Homes for Older People Page 13 of 42 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. The care plans and risk managements do not give sufficient guidance to staff to ensure each persons needs are fully understood and met. The arrangements for the administration of medication does not ensure that every person at the home receives their medicines as prescribed by their doctor. People are usually treated with respect and courtesy, with rights to privacy and dignity maintained. Evidence: People who live at the home had a plan of support that provided staff information on how their needs should be met. The care plans were split into support plans for individual areas of need, for example health promotion, tissue viability, nutrition, personal care, mobility, emotion and mental well being, recreation, safe environment and so on. We were able to see that staff had recorded that care plans were reviewed monthly. Care Homes for Older People Page 14 of 42 Evidence: At our previous inspection we highlighted that some of the support plans could be further improved by including more detail. We found this has not been addressed and sometimes crucial information was not available. Detailed information was particularly important for people who could not tell the staff how they wanted their needs to be met, for example if they had dementia or could not communicate verbally. In personal care plans the way individuals needed to be helped should be recorded, for example, whether they liked to have a bath or shower, how their hair should be washed, when and how oral care should be provided and by whom. We noted that one person was a Hindu. The support plan identified things people need to know about my religion, but this section was not completed. We looked at records of two people who at had some damage to their skin due to pressure. Elements of the care provided to minimise the risk of pressure sores developing were good and as a result some pressure sores had healed. We found that both people were being nursed in bed on a special mattress, which alternates the pressure to their skin. Records were available to show the time that staff had provided attention to the person but did not identify the position changes. This was important to make sure that people had appropriate positional changes to relieve pressure to minimise the risk of pressure ulcers. This issue was highlighted at our previous inspection and had not improved. Additionally food and fluids records to show that people were receiving adequate nutrition and fluids were not adequately completed. The management of wound care needed to be improved. Care plans had not always been updated to reflect that pressure ulcers were healed as we were told by staff. In addition when people required dressings to pressure ulcers there was insufficient information available. Staff must record each change of dressing and an evaluation of the condition of the pressure ulcer at the dressing change. There were no photographs of wounds, which would be recommended good practice to make sure healing could be fully and consistently evaluated. The previous inspection report identified that when people could not be weighed an alternative way to monitored weight be used such as measuring the middle circumference of the upper arm (MUAC). We found that there was no appropriate weight monitoring arrangements in place for people who appeared to be very thin and frail and unable to be weighed. This meant there was no assessment and management of the degree of risk to them. Risk assessments were in place for bedrails, falls, nutrition, tissue viability and moving and handling. The nutritional assessments were inadequate, as people were not always weighed regularly and in the case there was no recorded weight for one Care Homes for Older People Page 15 of 42 Evidence: person. Some falls risk assessments had not been updated, for example one assessment was no longer relevant as the person was cared for entirely in bed and was no longer mobile. The moving and handling risk assessments did not detail the type of the hoist and the type and size of lifting sling to be used. This would be recommended good practice to ensure equipment is used safely. We also identified that there additional slings needed to be available to ensure that slings could be laundered regularly. All risk assessments must be fully and accurately reviewed when each persons needs change to ensure that peoples health and wellbeing is safeguarded. We found that the risk assessments for the use of bedrails for some people were not accurate and appropriate. For example where an additional pressure relieving mattress was in place with bedrails the height did not conform to the dimensions permitted by the Health and Safety Executive (HSE). This meant the height of the bedrails gave no protection to the person and there was a risk that the person may still fall out of bed. In addition the risk assessments did not sufficiently identify the risk to the person; one risk assessment was dated 10/6/05 and was undertaken by the previous owner of the care home. At the previous key inspection in October 2008 we told the service that they must improve the risk assessments for the use of bedrails. This had not been implemented and action must now be taken as a priority to protect people living at the home. The care staff and nursing staff complete separate daily records for each person, which resulted in inconsistencies. At the previous inspection we recommended that there should be improved, accurate and consistent records relating to the care provided for each person. At this inspection we found that daily records did not always include all incidents as care staff were not aware of the detail. An example was that one persons records failed to record several incidents of aggression that had occurred. These were discovered during an examination of separate accident records. There appeared to be good relationships with medical personnel ensuring that people received adequate health care. There was contact with general practitioners, district nurses, tissue viability nurses, chiropodists, dentists, opticians and speech and language therapists dependent on the persons needs. We looked at the homes systems to manage the medication for people accommodated. Each unit had secure storage for peoples medicines. Staff had received medication training and some were generally knowledgeable about medication people were receiving. However others could not tell us the correct time to Care Homes for Older People Page 16 of 42 Evidence: administer specialist medication such as Alendronic Acid. We were told this was administered with other medicines at breakfast time, which exposed people to avoidable risks of adverse effects. There was no evidence that competency assessments had been carried out to make sure staff were administering medication safely. We also found that the specimen signature list for staff administering medication was not up to date. We looked at a sample of MAR (Medication Administration Record) charts, which documented each persons current medicine requirements and regime. However records of receipt of medication received into the home and carried forward balances of medication stocks on the MAR sheets were not consistent and as a consequence the home did not know whether this medication was being used appropriately. In addition variable dosages such as one or two tablets, 5mls or 10mls were not consistently recorded. This meant that the accurate auditing of medication dispensed in original containers could not be easily carried out. We undertook some random audits of MAR charts and medication stocks, although some were accurate, there were some we were not able to audit and there some discrepancies. This meant that there were not always assurances that people were consistently receiving their medicines as prescribed by their doctor. There were also handwritten entries on MAR sheets, which were not signed and witnessed by two trained competent staff, which would reduce risks of errors. We saw that one person was being given covert medication disguised in food for their welfare. There was a letter from the GP stating medication for Parkinsons should be dissolved in water with food. A nurse told us this was dissolved in water and added to forticreme or yoghurt at 0900, 1300, 1700, and 2100. However this conflicted with information in the care plan and daily records, which indicated that this medication was given with Weetabix. The food and fluid charts failed to show whether either of these foods were given at the time the medication was stated to be given. In addition the nurse and acting manager acknowledged there was no formal decision making for all of this persons medication to be given covertly in best interests and there was no protocol to demonstrate compliance Nursing and Midwifery Council (NMC) guidance. This person was also prescribed pain relieving medication which was routinely recorded as refused, except for five occasions during the previous two weeks. The nurse told us the person experienced pain and accepted the medication on the evenings she offered it. This indicated that the persons health was not being managed for wellbeing and comfort. There were a number of improvements required to the storage of medication such as, Care Homes for Older People Page 17 of 42 Evidence: internal and external medication should be stored separately, there should not be excessive medication stocks and the medication room should be reorganised. The records of the room temperatures where the medication was stored were too hot at times. This meant that peoples medication might not always be stored at the correct temperature to maintain its integrity and effectiveness. We saw records monitoring the maximum and minimum temperatures of the medication fridges on a daily basis but these did not show that temperatures were being maintained between 2 degrees C and 8 degrees C. This was likely to have a detrimental effect on medication, especially, insulin. We discussed the recorded temperatures with the acting manager who agreed to investigate and take remedial action. The Controlled Drugs cabinets complied with the Misuse of Drugs (Safe Custody) Regulations 1973 and the random audits of controlled drugs were accurate. We saw that staff on duty were aware of how to treat each person with respect and to consider their dignity when they were providing personal care. From our observations of people in the home, they looked generally well presented and dressed appropriately for the weather. Care Homes for Older People Page 18 of 42 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. There are some social opportunities but each person cannot always be assured that there will be appropriate activities for them. People are encouraged and supported to maintain important relationships and friendships. There are choices of nutritious meals but not everyone consistently receives support to maintain an appropriate nutritional diet. Evidence: There was insufficient evidence to show whether the daily routines at the home were flexible to meet each persons preferences. The assessment and care records were not sufficiently detailed to give guidance to staff as to each persons preferred daily routine, such as rising, retiring, bathing, showering and food preferences. Some staff were knowledgeable about individual preferences but this was based on verbal communication, which could be unreliable. There was an activities co-ordinator who visited the home for a few hours for three days each week and there were some records of activities. The acting manager told us there were plans to review how activities were provided to make sure there were more activities, which were appropriate to each persons individual needs, especially for people with dementia or cared for in bed. Care Homes for Older People Page 19 of 42 Evidence: There was an activities programme displayed on the notice board and this showed that there were regular trips, movement to music sessions, aromatherapy, PAT dogs visits, bingo and craft sessions to make items for special events such as Halloween and Christmas. During the inspection visit we did not observe activities particularly geared to people with dementia, and there was only limited information available about some peoples activity opportunities, and what people had actually done. There were regular church services in the home where people could participate if they chose. Although we were told that arrangements were made for people of other faiths, we found that no information was available for a person who was of the Hindu faith. Staff were not able to tell us what this persons cultural needs might be and there was only one member of staff who could communicate in the persons language. The home had an open visiting policy, which meant that people were able to maintain important relationships. Relatives confirmed that they could visit at anytime. There was a written 4 week lunch menu displayed on a notice board in the dining room but nothing to say what was available for breakfast, tea and other snacks. The menus had been devised in conjunction with the NHS dietician but the recently employed acting manager acknowledged the choices were not always followed. She told us that she intended to consult people living in the home about their preferred options from which she would review and expand the menus. These would also be provided in appropriate formats so that people could make realistic choices. The home had been awarded four stars and a gold award for food safety and healthy meals. However we sampled the cooked midday meal, which was corned beef hash with baked beans chips and gravy. The corned beef hash and gravy were tasty and warm, however the baked beans were cold and the chips were tepid. We were told that one person chose to have chicken wings and another person had an egg on toast. The pudding was chocolate sponge with custard and was tasty, although it was cold. There were food and fluids records; however staff had not consistently completed these records. This issue was raised at the previous inspection and did not appear to have improved. Care Homes for Older People Page 20 of 42 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. There is information available to people assist to raise concerns and complaints. The arrangements to safeguard people living at the home do not always protect them from risks of harm. Evidence: The home had an up to date complaints procedure, which was displayed in the reception area and contained in the service user guide. Information supplied as part of the Homes AQAA indicated that the home had received three complaints, over 12 months, which had been investigated by the provider within 28 days. It stated two complaints were upheld, with satisfactory resolutions implemented. This information had been completed by the previous registered manager and was found to be inaccurate. We looked at the complaints log, which showed that there had been four complaints. There was insufficient information of investigations, findings, actions or whether the complaint was resolved to the satisfaction of the complainant. The AQAA told us that there were no incidents reported under the Safeguard and Protect multi agency procedures during the past 12 months. However we found records of incidents between people living at the home in their daily notes and accident records, which had not been referred to the Local Authority, lead agency or to the Commission as a Regulation 37 notification. This meant that actions were not appropriately taken to safeguard people from risks of harm. Care Homes for Older People Page 21 of 42 Evidence: There was a copy of Dudley DACHS (Directorate of Adult Community and Housing Services) multi-agency procedures relating to safeguarding vulnerable persons living at the home. The organisations policies and procedures to safeguard vulnerable people had not been reviewed and updated to be in line with regulations and other external guidance. The homes training matrix told us that 26 out of 34 staff had attended safeguarding training in 2007 and 2008. The deputy manager acknowledged the this record of training was not up to date and did not reflect the high turnover of staff in the past 12 months. There was no evidence to show that staff had been made aware and had been given time to read and understand procedures for the protection of vulnerable adults. The staff we spoke to told us they would make a report to the manager should an incident occur but they were unaware of reporting procedures to outside agencies. We looked at recruitment checks as part of this inspection visit and they did not demonstrate people were effectively safeguarded from risks. Although arrangements for the recruitment of staff were generally appropriate. There was a need for additional safeguards to reduce the risks of unsuitable people working in the home. For example there were no written risk assessments with a named competent supervisor on each shift for staff employed on a POVA (Protection of Vulnerable Adults) First basis, prior to full CRB (Criminal Records Bureau) clearance. There must also be full details of each persons work history with any gaps in employment explored and documented. Care Homes for Older People Page 22 of 42 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. People live a generally pleasant environment. The systems in place for maintenance and infection control are not sufficiently robust. Evidence: Grange Park Care Centre was purpose built and opened in 1987. Each of the two storeys provided care for people with different needs. Kitwood unit provided accommodation for up to 10 people with dementia on the ground floor and people requiring nursing were accommodated on the ground and first floor. Part of the first floor was in the process of being completely refurbished to provide 10 beds, potentially for people needing intermediate care. This was to be named Kinver unit. There was a passenger lift to each floor and there were communal lounges, dining areas, kitchenettes, and communal bathing and toilet facilities. There were some additional smaller areas, such as conservatories for people to see their visitors, have meetings or join in activities. The new acting manager discussed plans to reorganise some areas to create improved facilities for people. She also told us about plans to provide further improvements to Kitwood unit to improve orientation for people with dementia. The doors were painted in colours to improve orientation and there was good signage for bathrooms, toilets and bedrooms. There was parking at the frontage and secure landscaped gardens to the rear, with Care Homes for Older People Page 23 of 42 Evidence: garden furniture, interesting paths and a red post box for orientation for people with dementia. The dining room provided tables and chairs for 24 people and at the previous inspection we were told that other people preferred to eat either in their rooms or in the lounges. Though this was repeated at this inspection, the acting manager told us she had plans to review arrangements for communal areas. There were facilities in the dining room to enable visitors to be able to make themselves hot and cold drinks. The homes AQAA cited the following improvements to the environment, completed total refurbishment of our dementia wing, redecorated empty rooms, replaced many carpets/flooring, replaced fencing and provided new pictures around the home. We noted that there were large attractive jigsaw pictures, completed by someone who had stayed at the home, which were framed and hung in one of the small lounges. We were also told that the lounges had been named, such as Engine, Malvern, Clent, and Clee Lounge, by a previous resident. At the previous inspection we made a requirement for the compromised double glazed windows to be replaced as there was restricted vision through them. There were a number of such windows throughout the home, which had not been replaced. The acting manager acknowledged that the bathing and toileting facilities throughout the home generally needed to be refurbished and made more attractive for pleasurable bathing experience for people living in the home. An assisted bath, which had been in use without bath panels, was rectified at the time of the inspection. However a shower room on Kitwood unit had a strong offensive malodour and a mop left in a bucket with fluid and black residue. Another shower room on the first floor, with evidence of recent use, was taken out of use after we highlighted the risks of the torn flooring posing a potential tripping hazard. In addition there were facilities, which were not cleaned to an acceptable standard to maintain effective infection control. We noted at the previous inspection that a conservatory was cold. The temperature in the conservatories was also very cool at this inspection, though the temperature throughout the main parts of the home was uncomfortably warm. The handyperson measured the ambient temperature at 24 degrees C. One conservatory was being used as a designated smoking room for people living at the home. We were told two people used the smoking room. The carpet was very stained, the room smelled heavily of smoke and the doors did not close properly, the smoke infiltrating into the adjoining lounge. We also noted that the hairdresser was Care Homes for Older People Page 24 of 42 Evidence: using the designated smoking conservatory for everyones appointment, though after discussions another more appropriate room was found for the hairdressing session. This meant that the smoking arrangements did not comply with recent legislation regarding provision of clean air for everyone in the home. The acting manager assured us she would review and revise the arrangement as a priority. We looked at a sample of bedrooms with peoples permission where possible. They were all spacious and had en suite facilities. Some were attractively decorated and personalised according to individual preferences, such as family photographs, ornaments and small items of personal furniture. We saw that there were a number of bedrails in use. However replacement mattresses had been placed on top of existing mattresses, which resulted in the permitted height in excess of the Health and Safety Executive (HSE) permitted dimensions. One set of bedrails were not the same length and another set had excessive gaps at the top of the bed. The risk assessments were insufficient and there were no regular recorded safety checks or staff training for the use of bedrails to maintain peoples safety. One person with stage 4 Parkinsons, nursed entirely in bed had a height adjustable bed but this was not a fully adjustable and he indicated he was not comfortable. Following discussions the proprietor agreed to offer this person a bed, which was more appropriate to his needs and comfort. The laundry was well equipped with commercial washers, tumble dryers and ironing facilities. The laundry service was generally well organised and the staff demonstrated good standards of infection control. The kitchen was maintained in good order, and it was clean and tidy and well organised. We noted that appropriate food hygiene and safety measures were in place, with records, which were monitored by the Environmental Services. The home had achieved the Dudley MBCs Environmental Health Four Star and Silver Award for food hygiene and healthy eating. There were a number of additional areas, which required attention such as extractor fans, which were not working in some bathing and toilet facilities, clean incontinence pads stored on the floor, and a sling left on the floor, clean and dirty linen on the same trolley / skip were left in a shower room, a number of toilets, frames and hoists, which needed to be thorough cleaned, and the kitchen staff toilet needed thorough cleaning. These issues did not demonstrate effective infection control measures to protect people. Care Homes for Older People Page 25 of 42 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. The number and skill mix of staff do not always ensure that people receive consistently good standards of care. The recruitment processes do not always provide sufficient safeguards for people living at the home. The training programme does not sufficiently demonstrate that all staff are equipped with the knowledge and skills to meet peoples needs. Evidence: There were 29 people on two separate units with a wide range of dependency levels and different, often complex needs. There were an additional two admissions for respite care during the inspection visit. There was insufficient evidence to show that staffing levels on each unit were reviewed and adjusted on a regular basis, taking account of the occupancy and dependency levels of the people accommodated. The AQAA claimed that the staffing levels were sufficient to meet the needs of each person at the home. Relatives and some professionals told us that there were not always enough staff to attend to peoples needs in a timely way. We were told that additional staff would be recruited for the Kinver unit, due to be completed and opened with nine beds, possibly for respite care. The management must be able to demonstrate that there are trained and competent care staff on duty with sufficient allocated care hours to meet the needs of people Care Homes for Older People Page 26 of 42 Evidence: living at the home. There had been a relatively high staff turnover, with 15 of a total 34 staff leaving the homes employ in the past 12 months. This number did not include the registered manager who had also resigned since the AQAA was completed. From discussions staff morale was low because of the instability and uncertainty. There were 6 registered nurses, including the deputy manager to staff the nursing unit, and 21 care staff and, 7 ancillary staff, including domestic, catering, administration and maintenance deployed throughout the home. There were generally three carers on each day shift on the nursing unit and two carers, including a senior carer for people with dementia on Kitwood unit. The AQAA told us that the home had improved the number of care staff qualified to National level two qualification or above, to 13 out of a total of 17 permanent care staff. We looked at a sample of staff personnel files. The recruitment processes did not provide sufficient safeguards for people living at the home. There was an application form where employment gaps had not been explored; and there was a member of staff employed on a POVA (Protection of Vulnerable Adults) First basis, without a risk assessment, working on night duty, without adequate supervision. This was important to ensure that the people were suitable and capable of working with vulnerable people in this environment. There was a training matrix, which showed that the acting manager was pro-actively arranging training but she acknowledged that there were gaps, where some staff had not received all essential training. There was insufficient evidence that all nursing staff had undertaken training to update their clinical skills or had assessments of their competency, especially relating to medication management and administration. Care Homes for Older People Page 27 of 42 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements do not provide sufficient safeguards for people living at this home. There are systems for consultation with people living at the home. Evidence: The registered manager had left the homes employ the month prior to this inspection. The provider had not formally notified The Commission about this change nor provided information about the interim management arrangements in compliance with Regulation 39. The current acting manager had been in the post for one week and she told us she would be applying for registration with the CQC. She holds a registered nurse qualification, had 14 years managerial experience, had achieved the Registered Managers Award (RMA) and was previously registered as a manager with the Commission for Social Care Inspection. She told us that she had already identified a number of areas, which required improvement and assured us that she was committed to implement changes. The acting manager told us that there was an annual development plan for the home Care Homes for Older People Page 28 of 42 Evidence: and quality assurance system but she would be reviewing these to make them more effective. There were some audits but these had not identified areas of concern highlighted in previous sections of this report such as care planning, risk assessments and medication. There were also areas of the environment needing attention identified during this inspection visit, which were not recorded on the maintenance programme. There were records of visits by the provider in compliance with Regulation 26, to monitor the management and running of the home. The reports recorded some good practices and some areas, which needed to be improved but the reports needed to be expanded and include action plans and evaluations. There had been some staff meetings and residents meetings, with topics such as food and activities, events and outings with recorded comments from people living at the home about their preferences. The acting manager told us of her plans to expand communication with people living at the home, their relatives and representatives, staff and other professionals associated with the home. Supervision records told us that staff had been receiving supervision although records seen suggested this was not as frequently as required. The deputy manager agreed, not as often as I should do them. She told us she supervised the nursing staff but thought that the previous manager had been up to date with supervisions for the care staff. This meant that though there were systems to support and develop staff to improve their skills for the benefit of people living at the home, they were not sufficiently robust. We were told that people were offered the opportunity to manage their own money if they wished, and there were facilities to help keep it safe. We looked at a random sample of balances and records of monies held in temporary safekeeping on behalf of people living at the home, which were accurate, with records of all transactions. However there should be more formal receipts from the hairdresser, which should be signed or stamped, rather than the unsigned ripped off pieces of paper. One persons financial transactions generally had only one signature, where there should be two signatures to demonstrate safe financial practice. Additionally there was a handwritten receipt for food for a persons birthday buffet provided by the homes kitchen and the deputy manager was unsure where this money went. An explanation and audit trail must be identified for this persons money. Records relating to people health care needed to be improved, such as care planning, risk assessments and medication records. Regulations had not been followed diligently for example there were no notifications relating to medication errors when people had Care Homes for Older People Page 29 of 42 Evidence: not received medication as prescribed. We looked at a sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and well organised. However the lift and hoist maintenance documents did not demonstrate satisfactory service certificates in compliance with Lifting of Loads Equipment (LOLER) Regulations. The management must obtain documentary evidence to demonstrate compliance with this legislation. The acting manager acknowledged that there was no documentary evidence of regular checks of slings but assured us these would be implemented. As highlighted at the Environment section of this report bedrails were not being used in accordance with HSE guidance, risk assessments were insufficient and there were no regular recorded safety checks or staff training for the use of bedrails to maintain peoples safety. There was evidence that staff received mandatory training appropriate to their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training but as already highlighted there were some gaps. The acting manager gave us some evidence that training had been booked to remedy the omissions. We also looked at accident records and Regulation 37 notifications. There were 48 recorded accidents since from January to October 2009. There should be a rigorous accident analysis and evaluation to identify trends and risks, which could be controlled or minimised to maintain each persons health and safety. Whilst we were looking around the home we noted that one person was being moved in a wheelchair without foot plates, which was not risk assessed and posed risks of injury. The acting manager spoke to the member of staff and assured us she would be taking action to ensure all footplates would be secured to wheelchairs with cotter-pins, so that they could not be removed. We saw that there were copies of a number of Regulation 37 notifications to the Commission but there were no notifications for incidents of aggressive, abusive behaviour between people living at the home, for recent pressure ulcers or for an accident resulting in a fracture femur. The deputy manager acknowledged that notifications had not been made for these events. Care Homes for Older People Page 30 of 42 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 42 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 3 14 Pre admission assessments 01/12/2009 must be more detailed and include all areas of risks and needs, and these must be kept under review. This is so that people can be confident that all their needs can be met. 2 7 12 To ensure that there are 01/12/2009 health care assessments, risk assessments and care plans, which include all of each persons assessed needs, the active involvement of the person / or representative; and are updated to accurately reflect all changes to health and needs. This is to ensure care for each persons health and well being is properly provided at all times. 3 8 12 To ensure that special care records such as food, fluid 01/12/2009 Care Homes for Older People Page 32 of 42 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 balance charts, turn charts, and wound care records are maintained, with care provided appropriately recorded and monitored and updated. This is to ensure peoples health and well being is maintained. 4 8 12 To ensure that people with 01/12/2009 poor nutritional intake and / or weight loss are monitored using a recognised screening tool as frequently as required by their risk assessment and care plan. This will ensure that staff take required actions to promote peoples health and well being. 5 9 13 To ensure there are written 01/12/2009 protocols for the administration of covert medication, which comply with NMC guidance and that there are recorded multidisciplinary decisions involving an advocate where necessary and that associated records show how and when medication is administered. Care Homes for Older People Page 33 of 42 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 This is to safeguard people from avoidable side effects which may harm their health and wellbeing. 6 9 13 To ensure prescribed Alendronic Acid 70mgs weekly is administered in accordance with special instructions, to be taken at least half an hour before first food or drink and the person advised to sit or stand for half an hour following administration. This is to safeguard the health and well being of people living at the home. To ensure that all staff who administer medication are assessed as competent and their practice must ensure that people living at the home receive their medication safely and correctly. This is to ensure that the people who use the service are safeguarded. 8 9 13 To ensure there are care plans in place for the administration of when and as needed medication and staff act appropriately to monitor and inform the 01/12/2009 01/12/2009 7 9 13 01/12/2009 Care Homes for Older People Page 34 of 42 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 relevant healthcare professionals as needed. This is to safeguard the health and well being of people living at the home. 9 9 13 The records of the receipt, 01/12/2009 administration and disposal of all medicines for the people who use the service must be robust and accurate to demonstrate that all medication is administered as prescribed. This is to maintain the health and well being of people living at the home. 10 9 13 To ensure that all persons 01/12/2009 living at the home receive their medication as prescribed by their doctor and the Medication Administration Records must be accurately completed to demonstrate either medication has administered or an appropriate code entered to record the reason for non administration. This is to maintain the health and well being of people living at the home. 11 16 22 To diligently record and report all complaints, with actions clearly identified to 01/12/2009 Care Homes for Older People Page 35 of 42 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 demonstrate robust investigations of all concerns or referrals to other appropriate agencies as necessary; and ensure these records are available for inspection. This is to ensure that the people who use the service are safeguarded. 12 18 13 All staff must receive appropriate safeguarding training and the homes and Safeguard and Protect procedures to protect vulnerable people must be implemented and followed diligently at all times. This is to safeguard all persons living at the home from risks of harm. 13 27 12 To demonstrate that the number of staff on duty are skilled and trained and in sufficient numbers to meet all of the needs of each person using the service. This is to ensure that the health, well being and safety of people living at the home can be assured at all times. 14 29 19 To ensure that all staff employed at the home are recruited following robust 01/12/2009 01/12/2009 01/12/2009 Care Homes for Older People Page 36 of 42 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 recruitment procedures, with documentary evidence to demonstrate diligent compliance with The Care Homes Regs 2001, Reg 19(1). This is to safeguard people living at the home from risks of harm. 15 31 39 To notify the CQC of any 01/12/2009 changes to the management of the home, including the name, address and qualifications of the person responsible for running the home. This is to safeguard people living at the home. 16 33 24 To implement effective 01/12/2009 quality monitoring systems, which demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. This is to safeguard the health, well being and safety of people living at the home. 17 37 37 To ensure notifications are submitted to the Care Quality Commission of any incident that has affected the health, safety or wellbeing of the people at 01/12/2009 Care Homes for Older People Page 37 of 42 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 the care home, without delay. This included medication errors. This is to safeguard the health, well being and safety of people living at the home. 18 38 13 Management systems must be implemented to ensure the safe use of bedrails, which includes correct fitting, rigorous risk assessments, diligently followed, documented checks and staff guidance and training relating to bedrails. This is to safeguard the health, well being and safety of people living at the home. 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 01/12/2009 1 1 The statement of purpose and service user guide should be revised, updated and reissued to people living at the home in easy to understand formats suited to their capabilities. The contract / terms and conditions of residence should be revised, updated and reissued to each person living at the home to reflect good practice guidance issued by the Office of Fair Trading. Each person should receive written confirmation that the home can meet their assessed needs, including their 2 2 3 4 Care Homes for Older People Page 38 of 42 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 cultural needs. 4 5 7 8 Daily progress records should be revised to ensure all records are accurate, consistent and up to date. Advice from community dieticians should be sought for all persons assessed to be nutritionally at risk, with records of support and advice offered and that a record be maintained of staff training in relation to nutrition. Advice from the diabetic specialist nursing service should be sought for any person with diabetes, living at the home, with records of screening, support and advice offered and that a record be maintained of staff training in relation to diabetes. Moving and handling risk assessments should reviewed and expanded to include instructions for the level of assistance and named equipment required for all transfers. The correct pressure setting for pressure relieving mattresses should be recorded in each persons care records with regular documented checks. Carried forward stocks of medication should be recorded on each persons MAR sheet and random audits of medication stocks should be carried out, with recorded remedial action for any discrepancies. There should be an up to date specimen staff signature list for the administration of medication and that staff should sign and date the homes medication policy to demonstrate their awareness and compliance. All handwritten entries on MAR sheets should be dated, signed and witnessed by staff who are trained and competent. The storage of medication should be organised to avoid excessive stocks of medication and to maintain good control. Internal and external medicine should be stored separately to avoid contamination. Care plans, monitoring and management strategies should be put in place for people described as having agitated, aggressive or other challenging behaviours with ways to evaluate the effectiveness of strategies and use of PRN medication. Page 39 of 42 6 8 7 8 8 8 9 9 10 9 11 9 12 9 13 14 9 9 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 15 16 9 12 An up to date reference such as the British National Formulary (BNF) should be available to staff. Personal preferences should be accurately recorded for each person and daily routines should be flexible to meet each persons choices. Inventories of personal possessions should be fully completed, signed, witnessed and kept up to date. Food should be provided to meet each persons preference and be served at an appropriate temperature. Food options and choices for people from other nationalities and cultures should be frequently reviewed with them and their supporters to make sure they are able to have their preferred meals. Staff should be given time to read policies and procedures associated with the protection of vulnerable adults, with signatures obtained to demonstrate their awareness and compliance. Plans should be implemented to ensure the environment meets the needs of everyone living at the home in a prioritised timescale. Assessments should be in place to ensure each person is provided with equipment that is suitable to meet their needs, such as nursing profile beds, and suitable, adjustable chairs. The heating in all areas of the home must be maintained at a safe and comfortable ambient temperature for people living there. All compromised double glazed windows should be replaced within a prioritised timescale to improve visibility for people living at the home. Assessment and reviews should be undertaken of the cleaning schedules and minor repairs with actions to maintain the environment to an acceptable level. There should be two signatures for any transactions carried out on behalf of people living in the home. This will ensure that the people living in the home are safeguarded. This was a previously unmet good practice recommendation. 17 18 19 14 15 15 20 18 21 19 22 22 23 25 24 25 25 26 26 35 Care Homes for Older People Page 40 of 42 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 27 35 There should be signed and dated receipts for every transaction and a clear audit of money used on each persons behalf. A structured staff supervision system should be resumed to ensure all staff receive formal supervision at least six times each year to provide them with support and development to meet the needs of people using the service. There should be documented regular checks on a slings, with any remedial work carried out. Regular documented accident analysis should be resumed to ensure that accident records are fully completed, with the unit clearly identified and risk assessments are reviewed and revised in accordance with any changed needs. There should be documentary evidence that maintenance is carried out on all lifting equipment in compliance with LOLER Regs. 28 36 29 30 38 38 31 38 Care Homes for Older People Page 41 of 42 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. 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