Inspection on 02/11/09 for Hay House Nursing Home

This inspection was carried out on 2nd November 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hay House Nursing Home 10/08/09

Hay House Nursing Home 24/06/09

Hay House Nursing Home 01/10/08

Hay House Nursing Home 05/11/07

Hay House Nursing Home 21/06/06

Hay House Nursing Home 16/12/05

Hay House Nursing Home 26/07/05

Hay House Nursing Home 21/10/04

Hay House Nursing Home 22/04/04

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

Key inspection report Care homes for older people Name: Address: Hay House Nursing Home Broadclyst Exeter Devon EX5 3JL     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Teresa Anderson     Date: 0 3 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 38 Information about the care home Name of care home: Address: Hay House Nursing Home Broadclyst Exeter Devon EX5 3JL 01392461779 01392460040 info@hayhousecare.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Chartbeech Ltd care home 35 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: On the termination of the placement of the named service user, the registered person will notify the Commission in writing and the particulars and conditions of this registration will revert to those held on the 8th November 2004. Staffing minimum as agreed with the previous registration authority 29/01/2002 and detailed in the variation of registration report of the same date, is observed. The manager, Ms Rachel Somers, must obtain the Registered Manager`s Award by 2005 The maximum number of persons accommodated at the home, including the named service user, will remain at 35 There is a named Registered Mental Nurse as a lead for mental health care at the home. To admit one named person outside the categories of registration as detailed in the notice dated 5th November 2004 Date of last inspection Care Homes for Older People 0 6 1 1 2 0 0 8 0 0 Over 65 35 35 Page 4 of 38 Brief description of the care home Hay House is registered as a care home that provides accomodation with nursing for up to 35 people over the age of 65, with dementia or a mental disorder. The building is Georgian and is set in an elevated position with views to Broadclyst and Killerton. The house has been extended and adapted for use as a care home and provides both shared and single bedrooms, 16 of which have en-suite facilities. There is a passenger lift linking the floors aswell as a wide staircase. Communal facilities are made up of a main lounge, a dining room, a smaller lounge and a large entrance hall. There are Registered Nurses on duty throughout the day and night. The fees charged at this home range from 533.00 - 850.00 pounds per week. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection took place as part of the normal programme of inspection. It was undertaken by two inspectors over two days. During the visit to the home we (the Commission) spoke with or observed the majority of people living here. The majority of these people have dementia and so we could not speak directly with them about the services and care this home offers. We therefore observed people and their interactions during the two days of this inspection. We looked closely at the care, services and accommodation offered to 5 people living here. This is called case tracking and helps us to make a judgment about the standard of care overall. It also helps us to understand the experiences of people living here. We looked at the care and attention given by staff to these people and we looked at their assessments and at their care planning records. We looked at the environment in Care Homes for Older People Page 6 of 38 relation to their needs and how their health and personal care needs are met. We also spoke with visitors to the home, with staff and with the owners. We visited the majority of bedrooms and saw all service and communal areas of the home. We looked at records relating to accidents and incidents, staff training, staff recruitment, medication and some policies. Prior to the inspection the owners sent us their Annual Quality Assurance Assessment (AQAA) which gave us information about the home and its management and about the needs of the people living here. This document asks for evidence in relation to what the home does well and what they think they can improve upon. We sent surveys to people living here, asking for feedback and comments. 6 were returned. We also sent surveys to staff and 4 were returned, and to health and social care professionals who visit the home and 2 were returned. Feedback and comments are included in the report. In July 2009 we carried out a random inspection of this home. As a result evidence was taken under Code B of the Police and Criminal Evidence Act and Statutory Requirement Notices were served. These notices legally require the service to make improvements. We carried out a random inspection to check that these requirements had been complied with, and found that they had. During this inspection evidence was taken under Code B of the Police and Criminal Evidence Act and this has been considered under our enforcement procedures. This is because we have concerns about some peoples health and welfare needs not always being met. We have decided not to serve Statutory Requirement Notices on this occasion but will ask the provider for a detailed action plan showing how requirements will be met. We will also arrange to meet with the provider to discuss their action plan and the progress they have made. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? Since the last key inspection there have been improvements in the way that some care in planned and delivered. This has resulted in people being more alert and putting on or maintaining their weight. Further equipment and aids have been provided in the home to help people to remain mobile and independent. This includes toilet and seat raisers, meaning that more people can use these without the aid of staff. Actions have been taken to reduce some risks in the home. This includes ensuring that fire precautions are more robust. The owner reports that all fire doors close; and Care Homes for Older People Page 8 of 38 bathing water is now delivered, checked and recorded at close to the right temperature, 43C as it should be. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 38 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 38 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before they are admitted to the home, so that they, and the home, can be sure that individuals needs can be met. Evidence: We looked at the care records of one person who had recently been admitted to the home. We saw that the assessment of their needs was carried out by a nurse as is good practice in a nursing home. We also saw that the assessment included information from health and social care, which is also good practice. We saw that the assessment indicated that this person needed to be seen by a Speech and Language Therapist (SALT), and this referral was made on the day of admission, and is good practice. Care Homes for Older People Page 11 of 38 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have benefited from the improvements to the way that care is planned and delivered in relation to their eating and drinking needs. Further improvements are needed in relation to the way that care is planned and delivered to meet other needs in relation to health and welfare and medication. People are treated with respect, although at times more attention could be given to peoples privacy. Evidence: In surveys people told us that they always receive the care and support, including the medical support, that they need. We casetracked 5 people who have different needs to see how their care needs are met. We saw that each person living here has a plan of care. People are assessed by a nurse to determine the level of risk in relation to, for example, developing pressure sores, becoming dehydrated or becoming malnourished. Those people who are at risk of dehydration and/or malnutrition have a recorded plan of care which states how Care Homes for Older People Page 12 of 38 Evidence: those risks are to be managed. People are given the support they need by staff who, when we spoke with them, demonstrate an understanding of the plan of care. We observed staff delivering this type of care appropriately. Staff also told us they record what people who are at risk eat and drink throughout the day. We saw records showing this. Staff told us that if a person does not eat or drink well, that they tell a member of the nursing staff. We saw records relating to this. We know that these plans of care are working because we were told and were shown records that demonstrate that people are putting on weight. We also observed that people appear well hydrated. We also observed that people who we case tracked and who are at risk of choking due to swallowing problems are being supported to eat as instructed by the Speech and Language Therapist (SALT). We saw in a care record that one person had choked, that staff acted appropriately and that since that episode a plan of care has been put into place as to how this should be managed if it happens again. We saw in records that some people are identified as being at risk of developing pressure sores. We saw that care plans include a recognised tool for assessing this risk. We saw that some people have their care planned in a way that is intended to manage this risk. For example, the care plan records the type of pressure relieving equipment to be used, and if an airwaves mattress is used, a record of the pressure the mattress should be set to. However, we also saw some records where this standard of care planning and delivery has not been acheived. For example, one person is at high risk of developing pressure sores and they are cared for on an airwaves mattress. Records show that this person has a care plan relating to their medical conditions and to their skin care and how the risks associated with these should be managed. When asked, staff told us that that this person does not have a pressure sore. Records confirm this. However, the records show that this person has, or has had, a lot of skin damage. They have received injuries or have had blisters on their buttocks. Some of the injuries are unexplained, whilst some are caused by moving and handling, by shaving, by friction and by shearing. This person also has skin soreness, and potential to breakdown. It is not clear in the records why this is. There is reference to these injuries in the daily notes, and there is a generalised care plan in place relating to tissue viability. However, care plans relating to the areas of damage that have been recorded do not always describe the damage, or the response to the treatment in a way that is measurable. They do not include instructions on how often the skin damage should be reviewed and what treatment should be used. We also saw in records that dressings which can only be used if prescribed are being used, but that these are not prescribed on the medicine sheet for that person. Care Homes for Older People Page 13 of 38 Evidence: Another person who has been identified as being at risk of developing pressure sores sleeps on an air wave mattress. The care plan does not record the pressure setting this mattress should be set to. When we looked, we saw that it is set to the lowest pressure setting. This would be appropriate for a very light person but not for the person this relates to. We also noticed that people who are helped to move with the use of a sling and hoist, sit in their chairs on the slings used. This is not good practice as it has the potential to cause skin damage. Another person has been identified as being at risk of choking and a referral to the SALT has been made, as is good practice. They are also at risk of malnutrition. The most recent record relating to this states they are eating and drinking better. However, records show that at this time, and in the days before this was written, this person was refusing food or on occassions eating mouthfuls. We looked at the care records of two people living here who have diabetes. We saw that care plans include information about what each persons normal blood sugar is. We asked a nurse what the normal blood sugar for one person is. They did not know. However, they were able to tell us what a normal blood sugar is generally. When we looked at this persons records we saw that their blood sugar results are described as being low when they are within normal limits. Records also show that staff give this person food and drink to raise their blood sugar when they have recorded a blood sugar that is normal. There are no records to show that this person has shown any symptoms of having a low blood sugar at these times. Records show that this persons blood sugars tend to be high. For example in the 18 day period prior to this inspection this persons blood sugar was higher than normal on 21 occasions. Records show that staff have contacted the GP regarding this persons low blood sugar results. There is no record that they have discussed this persons high blood sugar results with the GP. When staff record that this person has a high blood sugar, they state that this should be monitored. There is no record that actions have been taken to address this identified risk. Staff told us that one member of staff has received the training from the local Primary Care Trust in relation to best practice when caring for someone with diabetes, but that this has not yet been adopted by the home. We also saw in records that one person is prone to high blood pressure. Staff have recorded what the acceptable limits are as is good practice. However, records show Care Homes for Older People Page 14 of 38 Evidence: that this persons blood pressure is recorded on many occasions as being well above these acceptable limits. The nursing instruction is to continue to monitor and review monthly. There is no record to show that the GP has been informed, or of what medical decision has been taken in relation to this. These examples show that appropriate actions are sometimes, but not always taken to maintain peoples health or to prevent a deterioration in health. We case tracked another person, whom staff identified as having behaviours which challenge the service. Records show that this person can behave in a way that might result in them hurting another resident, or in them being hurt. Records show that if this does happen, that it usually happens at around the same time of day and that there are certain conditions under which it is more likely to happen. The care plan gives staff instructions about how to manage the situation if it occurs. Staff we spoke with show a good understanding of the instructions and told us that this usually works. They report that the number of instances where they have had to intervene has reduced since this person came to live here. We saw that this person had a number of injuries, and that other people had a number of injuries. Some of these were recorded as happening as a result of incidents between residents. There is no care plan instructing staff on how to prevent such incidents happening. We asked staff if they know what might prevent these incidents happening. One carer gave an excellent account of how they might be prevented. This method of prevention is based on what staff know about this person, their personality, what interests them and what that person might be feeling and need at these times. Another carer and a member of nursing staff told us that they deal with these incidents when they happen and that they observe and monitor. The carer who explained how these incidents could be prevented told us that they had reported this method to a nurse. However, this preventative action plan has not been adopted. This means that the system for communicating information about people is not always robust enough to ensure that preventative actions are taken to promote peoples welfare. Care records show and staff confirm that this person has not been referred to a Community Psychiatric Nurse, to the care management team or to the safeguarding team. This person has been seen by a Psychiatrist for an annual review, but staff were unaware of the outcome of this. People living here, for as long as they are able, are encouraged to walk around the Care Homes for Older People Page 15 of 38 Evidence: home and to explore, as is good practice. However, this brings with it some risks of injuries, which are often unwitnessed. Records show that there are a high number of unexplained injuries in this home. Some records show that what are recorded as potentially serious injuries are not always being dealt with appropriately. Some records show that some injuries are happening to people when staff are supporting people to move and to get out of bed. Records also show that some people fall out of bed on numerous occasions. The owner told us that an analysis of the information recorded has not taken place. This would help to determine if actions need to be or could be taken to help prevent incidents and injuries. People have not been assessed to see if they have capacity to make decisions, and records are not kept of how people are involved in decision making about their care and daily lives. This should be done in line with the Mental Capacity Act code of practice. We looked at how medicines are managed. There is a room which is used to store medicines and we found that all medicines are stored here securely. We found that all the records we saw, including controlled drug records, are up to date. We saw that staff always sign when a medicine has been given, including variable dose medicines. We saw that some people are having their medicines crushed. We asked staff if these medicines are available in liquid form so that they do not have to be crushed. Staff did not know. We saw in records that one person is frequently refusing their medicines by spitting them out. We asked two nurses if the doctor had been informed of this. They did not know. We saw that medicines that are handwritten on to medicine charts are not being checked and signed by two people as they should be to help prevent errors. We saw that the temperature of the fridge where medicines are kept is recorded on a daily basis. We saw in one care plan that a person had started a new medication for a medical condition. This medicine is being increased over a period of weeks to ensure that the person receiving this medicine benefits from it whilst keeping unwanted side effects to a minimum. Care records say the medicine is working well. However, when we spoke with care staff caring for this person, they were unaware of the effects of this persons medical condition and unaware of the effects and side effects that were to be reported upon. During the day we looked to see if people living in this home are treated with dignity Care Homes for Older People Page 16 of 38 Evidence: and have their privacy protected. We saw that personal care is delivered in private. We saw that some people undress themselves in communal areas, and we saw staff dealing with this discreetly and in a kindly way. We saw that peoples clothes, including underwear, are discreetly marked with their name so that they only wear their own clothes. We saw that people are helped to stay clean and tidy when for example food has spilled onto clothing. We also saw that the doctor visiting the home during our visit saw some people in communal areas, and discussions about them took place in front of other people living here and visitors to the home. Care Homes for Older People Page 17 of 38 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provision of activities and the ways of engaging people with different needs who live here continues to develop and improve. People benefit from the good relationships the home has developed with peoples relatives and representatives and from a nutritious diet based on peoples likes and dislikes. The way that people with different abilities are supported to make choices needs further development. Evidence: In surveys the majority of people, four out of six, told us that there are always activities arranged that they can join in with. One person said there usually are, and another said there sometimes are. The AQAA told us that the activities arranged offer variety and experiences away from the home. We saw that this has included trips out, for example to the seaside. We saw photographs of events that have taken place which are displayed in the hall. We saw that people with dementia who might be unable to engage with organised activities are encouraged to interact and to remain active. People do not have their movements around the home restricted. We observed people walking around as they please and with whom they please. Only areas that pose a potential risk to them or belong to someone else, such as others bedrooms, are restricted areas. We saw that people Care Homes for Older People Page 18 of 38 Evidence: seem to have developed attachments with staff and/or with some of the people they live with. This means that people are making choices, are having their social needs attended to and are exercising. Staff understand that exercise has the benefit of helping people to stay mobile for as long as possible and helping people to become tired and more likely to sleep at night. The home has an activities co-ordinator who has received training in person centred care and in providing activities for older people and people with dementia. The duty rota shows that the this person works on three days each week from 10.00am until 5.00pm. Rummage boxes have been put together which people can rummage through and take things from. The activities coordinator continues to compile memory boxes for each person living here. These contain items that are important to that person, which they might identify with or which might encourage happy memories or feelings. We observed the activities coordinator and staff engaging with people living here. However, we also observed that some people are not engaged with unless a member of staff is delivering care to them. We saw that some people who sit quietly receive very little attention from staff, and we saw a number of people spending long times sleeping. We saw that when staff interact with people, people respond positively. We saw that the home has a settee in one lounge which people choose to use. We saw different people using this together, and appearing to enjoy this. This is an important domestic style which shows that peoples need to engage with others is managed in a natural way and has positive effects for people. We looked in care plans and saw that records include information about each persons previous activities and interests. We saw that this information is used to help people with dementia to engage and interact with others and with activities. There are also records about how people have reacted to different activities or outings. For example, it is recorded that one person clearly stated they enjoyed a drive out. However, this activity has not been built into their plan of social care. We observed how meal times are managed. We saw that people who need more support are given this before others are taken to the dining room to eat. This is a good strategy to ensure that people who need support to eat and are at risk of malnutrition get this help before the busy lunch serving starts. However, because these people are supported to eat in the lounge, others sitting in the lounge appeared confused by the sights and smells of food. One person tried to take a bowl of ice cream for themselves, not understanding that this did not belong to them. This was gently removed from their hands by a carer, without explanation and it was put out of reach. This person could still see the food and stood for a long time in one spot looking at it, and appearing confused. During lunch staff told us they would normally tell people what they were eating. Care Homes for Older People Page 19 of 38 Evidence: However, they did not know what the food was on this occasion, as they said they had not been told by the kitchen staff. The food for these people is pureed and it is therefore not easy to see what all the foods are. We saw that people are supported to eat in ways that are good practice. For example, people are helped to sit up, each person is fed using a teaspoon and at a pace that appears to suit that person. We saw that some staff sat in front of the person they were supporting so that they could be seen, and others sat to the side making it difficult for that person to see where the food was coming from. We also saw that the potato, for everyone, was very runny, almost liquid. This didnt look very appetising and does pose a risk to people who have problems with swallowing, and who should have a pureed diet. We observed lunch being served to 18 people in the dining room. We saw that there were three members of staff helping, one serving and two waitressing. We saw that everyone was offered a choice of meal and that those who needed it had equipment to help them to remain independent. We saw that lunch was noisy and somewhat disorganised. People walked around and sat in other peoples seats which caused confusion and distress. Some of the food combinations, such as sausage pie with both potato salad and mashed potato, did not seem appropriate. We noticed that everyone drinks hot and cold drinks from a plastic beaker. Where people might need these, this is appropriate. However, this blanket use of such utensils shows that thought has not been given to individuals needs and preferences. In surveys people told us in equal numbers that they always or usually like the meals served at the home. One person commented they would like more variety of food. Visitors to the home say that there are no restrictions on visiting, that they can see the person they are visiting in private if they want to and that they are kept up to date with developments and changes. One visitor commented that any queries and request are dealt with promptly and efficiently. Another said they are always made welcome and offered refreshments. One healthcare professional commented that one of the things this home does well, is to understand the need for relatives to be involved, informed and cared for sensitively. Care Homes for Older People Page 20 of 38 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their complaints listened to and acted upon. People are safe from abuse but are not fully protected from unintentional harm. Evidence: In surveys people told us that they know how to make a complaint and who to speak with if they are not happy. Since the last inspection the home has received two complaints. The owner reports these were dealt with in a timely fashion, that they were upheld and that actions have been taken to address the issues raised. The commission has not received any complaints about this service since the last inspection. One safeguarding investigation has taken place at the home. The issues related to people not always having their hydration and nutritional needs met safely. The local health and social services made recommendations for improvements and appropriate actions have been taken. The Commission served Statutory Requirement Notices, legally requiring the home to address the issues raised. The home has taken appropriate actions and people are hydrated and maintaining or increasing their weight. We spoke with staff about abuse. They understand what abuse is and know what to do if they suspect or see abuse. Their knowledge is reinforced by posters in staff areas Care Homes for Older People Page 21 of 38 Evidence: informing them of who to contact, outside the home, if they suspect abuse and are not taken seriously within the home. This is good practice. We spoke with staff about how they interpret the behaviours of people with dementia. Some staff show an in depth understanding of how peoples behaviours reflect their feelings. They talked about what they do in these circumstances, using their skills to interpret behaviours as a type of complaint or unhappiness, so that action can be taken to help people to feel happier. We saw records that show some staff are less skillful at this. Records and discussions with staff show that some people are at risk of being harmed due to other peoples behaviour. We saw in records that injuries have taken place and that appropriate safeguarding actions have not taken place. We also saw that staff have not taken actions which might have prevented such injuries. In the information provided by the home in the AQAA, we were told that the home does not use restraint. However, we saw during our visit that some people are cared for in recliner chairs, which is a form of restraint. We also saw that when in bed, bed rails are used for some people to keep them in bed. We saw that people are prevented from leaving the home. Whilst these may be reasonable actions, records relating to how and who made these decisions are not kept. In addition records do not include instructions for staff about how long and in what circumstances appropriate restraints should be used. We have asked the owner to take advice about this. One person living at the home wishes to leave. Staff record that they cannot keep this person in the home against their will. It is recorded that this person would be allowed to leave the home if they so wished. However, the risks associated with this activity have not been assessed or recorded. In addition, this person has not had an assessment of their capacity to make this decision as they should have. We have asked the owner to take advice about this. Care Homes for Older People Page 22 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean and homely environment. However, more attention needs to be paid to preventing the spread of infection. Evidence: In surveys people told us that the home is always clean. The owner told us there is a cleaner on duty every day and that on some days a second cleaner starts work at 6am so that communal areas and carpets can be cleaned without disturbing people. We found the home to be clean and odour free. We looked at some bedrooms and found that they had all been personalised for use by the person occupying that room. We saw that a system has been set up to help people to recognise their bedrooms and the owner reports this is working well for some people. We looked in the bathrooms and toilets and found them to be clean. We saw that there is equipment to help those people who are less mobile to have a bath. We also saw that some toilets have seat raisers, which help people with reduced mobility to be more independent. There are gloves, paper towels, liquid soap and alcohol gel around the home, to promote good basic hygiene, and we saw staff using these. However, we saw that one Care Homes for Older People Page 23 of 38 Evidence: toilet does not have liquid soap and does not have a bin for used paper towels. We also saw that bins for items such as soiled pads have to be operated by hand and not by foot as they should be to prevent the spread of infection. We looked at the laundry and found it to be well equipped, tidy and clean. Staff say they have the equipment they need to deal with soiled linen. We talked to staff about equipment which helps them to move people with mobility problems. They told us they have enough to this safely. We saw that all people living here are invited to take a biscuit from the biscuit tin. This is good practice in relation to choice and dignity. However we would expect that people would be supported to clean their hands before doing this to help prevent the spread of infection. This did not happen. In addition, people are not offered the opportunity to clean their hands before they eat main meals. We looked in the lounge and dining room and saw these are furnished with domestic furniture of good quality. Some chairs are raised so that people with mobility problems can get in and out of them more easily. The chairs are arranged into separate groups so that different activities can take place without disturbing other groups. We saw that people have easy movement around the home and that they do this at their leisure. There is a garden at the rear of the property with raised beds. Care Homes for Older People Page 24 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from being cared for by a staff group who are experienced and caring. However, staff are not always applying the skills they have or that are needed to ensure that peoples needs are always met. Improvements to the recruitment procedures have helped to ensure that people are kept safe from inappropriate staff, although more attention to detail would further improve this. Evidence: We looked at the staff duty rota which shows that there are usually two Registered Nurses on duty during the day. It shows there are usually six or seven carers on duty in the morning during the week and four or five at weekends. In the afternoon, there are usually five carers on duty. At night there is a Registered Nurse and two carers on duty. In addition, the rota shows that each day there is a cleaner, and on some days there are two, a cook and a kitchen assistant. There is a laundry assistant on duty during the week and a maintenance man who works one day a week. In addition, and since the manager left in August, at least one of the owners is at the home every working day, and at weekends as appropriate. The duty rota shows that the activities coordinator works on three days each week from 10.00am until 5.00pm. On the days of this inspection there were 34 people living at the home. The AQAA tells us that 22 people need the help of two members of staff, 33 have mental health needs and 19 are doubly incontinent. Care Homes for Older People Page 25 of 38 Evidence: In surveys, people living here say that staff are always or usually available when needed and all said they receive the care and support they need. They say staff always listen and act on what they say and describe staff as kind, caring, pleasant and approachable. One person commented that occasionally, and particularly at weekends, that staff levels appear low. This person was not sure if this was due to reduced numbers or if staff might be spending a lot of time in the rest room. We looked at what training staff have received. We saw in the AQAA that 12 of the 18 care staff have successfully completed a National Vocational Qualification in care to level 2 or above. In addition staff receive induction training when new to the home. The owner reports that any agency staff used always work with another person. The Registered Nurses have received training in topics such as tissue viability, the Mental Capacity Act and are currently receiving training in person centred care planning. During interviews with care staff it became clear that some staff do not have the information they need to care for people. For example, some carers know that people have a medical illness such as diabetes or Parkinsons Disease. However, not all staff know how these conditions might affect a person and how the care they provide should be tailored to peoples different medical needs. For example, care plans say that people with diabetes should have their feet monitored. When we asked carers about this, they have not been told what to look for and what to report. Another care plan says that one person has Parkinsons Disease. Staff know this but do not know how this disease affects this person. In the section of this report Health and personal care, it has been identified that some peoples health and welfare needs are not always being met. This shows that some staff either do not have all the skills needed to address peoples needs or are not always applying these skills sufficiently well. We looked at three staff recruitment files. We found that all checks recommended to help keep people safe have been carried out. Staff have had their name checked against the list of those people barred from working with vulnerable adults, the POVA list, prior to starting work and all had a police check before working unsupervised. We noted that a reference for one person was not from the manager or owner of the previous home they had worked in. The reference came from a co worker from their home address, and not the employers address. This is not good practice. Care Homes for Older People Page 26 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Lack of clinical leadership in this home means that systems are not sufficiently robust to ensure that people receive the care they need to a consistently acceptable standard, in a way that promotes their safety. Evidence: Since the last inspection the manager of this home has resigned. She left the home in August this year, and the owner is advertising for a replacement. The responsibilities this person had have been delegated amongst the owners and the nurses working at the home. The owner is holding regular staff meetings and although he does not have any nursing experience or clinical expertise has worked, and continues to work, with staff, to address the issues that have been raised. These issues relate to planning for and meeting the hydration and nutritional needs of people living here. They have been successfuly addressed. However, the principles used to address these issues have not been applied to other areas of care. This has resulted in the Commission repeating Care Homes for Older People Page 27 of 38 Evidence: requirements in relation to care planning, meeting health and welfare needs and in safeguarding people. Prior to the inspection the service gave us information about the home in the AQAA. However, when we checked some of this information in this, we did not find evidence to support some of the statements made. We looked to see if there are systems in place to ensure that the home runs efficiently and safely, and that people are getting the care they need. We found that management systems are not always robust enough to always achieve this. For example,we looked at the system for communicating peoples needs and for ensuring that needs have been met. Nurses told us that this is acheived through the care planning system, through hand over meetings and through discussions between carers and nurses. When we spoke with staff they told us they do not tend to read care plans. We found that care plans do not contain the level of detail needed to ensure that care staff can meet peoples needs effectively. Staff told us that sometimes they are not given enough information about people. They say that sometimes the information they are given is that people are fine, even when they have not cared for that person for a while and are not sure about what their needs are. We found that reviews in care plans state that the care being delivered should continue even when there is clear evidence that a change to the care plan is needed. We looked at how risks in the home are managed. We found that there are a lot of injuries to people. There is not a system for monitoring and analysing this information and the associated injuries, which would help to determine if incidents and injuries are preventable. We also saw records showing that risks associated with the use of bed rails had sometimes been addressed, and another time had not. This shows that the system for managing and reducing risks is not consistent or robust enough. We looked to see if there is a safe system in place for moving and handling people. We found that assessments are not comprehensive and whilst they include important information about the persons medical condition and ability to move, this does not always inform the moving and handling plan. We found that the type of equipment used is based on what is available and not on what is the most suitable for each person. We found records that state that injuries to one person might have been caused through moving and handling and that no action has been taken to address this. We looked at how other risks in the home are managed. We found that the Care Homes for Older People Page 28 of 38 Evidence: temperature of hot water is restricted and radiators are covered to help ensure that people are not accidentally scalded. We saw that upstairs windows have restricted openings to help prevent accidental falls. We also found the door to the mechanical sluice had been left ajar each time we checked it, meaning that people who walk around the home could accidentally harm themselves. We found liquid substances which are potential harmful to people and should be locked away, are not always kept securely. We looked in the kitchen and found it clean and tidy. All open food is labeled and dated as is appropriate. Freezer and fridge temperatures are recorded and staff were observed following good hygiene practices. We saw in one care plan that specific risks relate to one person and their visitor. However, it was not clear in the records what these risks are, under what circumstances staff are to take action or what these actions are. We asked staff and they told us they observe. When we looked, we saw that this person was left alone with their visitor for long periods. We did not check any personal allowance acounts of the people living here as the home does not hold any monies on behalf of people. Instead records are kept of monies spent on behalf of and for people, and a quarterly account is sent to the persons supporter for checking and payment. We looked at how the home involves people in the running of the home. We found that the owner sends surveys to relatives of people living here asking for their comments and feedback. Changes have been made in response to these comments. The feedback we received from people was positive. The owner continues to work with the Commission to acheive the required improvements we have made. He is open and is receptive to advice and feedback. Care Homes for Older People Page 29 of 38 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15(2) You must keep each persons 31/12/2007 plan under review and ensure that revisions to the plan are appropriately made. Where possible the person should be involved in planning their own care this will ensure people get the care they want in a way that is acceptable to them. This requirement was not inspected at the compliance inspection undertaken on 10th August 2009. 2 7 15 People living at this home 09/08/2009 must have a plan of care that clearly identifies the actions to be taken to meet needs and the actions which need to be taken to detect and prevent deterioration in that persons health or welfare. In this way staff will be able to deliver consistent care that is planned for that person as a way of meeting identified needs. 3 7 15 Peoples plans of care must be reviewed meaningfully using all the information available, and decisions made about care and treatment must be based on 09/08/2009 Care Homes for Older People Page 30 of 38 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 this information. In this way people will receive the care and treatment they need to help ensure their needs are met. 4 8 12 (1) (a) Each person living 30/01/2009 here must have proper provision made to meet their health and welfare needs. This includes making provision to meet needs relating to tissue viability and preventing skin damage, nutrition, hydration, diabetes and mental health needs. This will help to ensure that people remain healthy for as long as possible. This requirement was not inspected at the compliance inspection undertaken on 10th August 2009. 5 9 13 People must be given the 09/08/2009 medicines they are prescribed. There must be a system in place that ensures this happens. This will help to ensure that people get the medicines they need to keep them as healthy and comfortable as they can be. 6 18 13 (7) (8) All records relating to 13/02/2009 the use of restraint (e.g lapbelts) must relate to the Mental Capacity Act and helping people to make Care Homes for Older People Page 31 of 38 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 decisions. Where restraint is used there should be clear guidance about the circumstances in which this is to be used and for how long. This requirement was not inspected during the compliance inspection undertaken on 10th August 2009. This will help to ensure that restraint is only used in exceptional circumstances and is used appropriately for as short a time as possible. Care Homes for Older People Page 32 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care planning records must 29/01/2010 include assessments of capacity and records relating to decision making. This will help to ensure that people are involved in the decisions about their care in line with the Mental Capacity Act code of practice. 2 7 15 Each person living here must 26/02/2010 have a plan of care that sets out in detail how their care needs are to be met and how risks to their health and welfare are to managed. Their care plan must be reviewed in a way that uses all the information available. Changes to the care plan must be made if this information shows this would be appropriate. This will help to ensure that each person has their care planned and delivered to a Care Homes for Older People Page 33 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action consistently high standard and in a way that is appropriate according to each persons needs and preferences. 3 8 12 People living here must have 29/01/2010 their health and welfare needs met. This must include, but is not exclusive to, preventing complications from medical conditions, always preventing and addressing skin damage and meeting peoples mental health needs. This will help to ensure that people remain as healthy as possible for as long as possible. 4 9 13 People must receive all their medicines. If they are refusing medicines the doctor should be informed so that decisions about medical treatment can be made. Where a person is unable to take a medicine in tablet form, the availability of alternative forms such as liquids, must be explored. 22/01/2010 Care Homes for Older People Page 34 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will help to ensure that people get all the medicines they need, in a form that suits their needs. 5 18 13 Where restraint is used, the 22/01/2010 reasons for this must be recorded. Records must include the circumstances under which restraint is used for each person and how long it is to be used for. This will help to ensure that restrainint is only used in the best interests of people and that staff have clear instructions about its use. 6 18 12 There must be a system in place that prevents people from being harmed by the actions of others. This system must include taking appropriate safeguarding advice when needed. We are aware that actions have already been taken to address this. This will help to ensure that people, as far as is possible, are kept safe from harm. 05/01/2010 Care Homes for Older People Page 35 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 26 16 You must ensure that adequate precautions are taken in the home to prevent the spread of infection. This will help people to remain healthy and, as far as possible, infection free. 22/01/2010 8 27 18 It must be ensured that staff 30/04/2010 working at the home have the qualifications, competence and experience needed. This will help to ensure that peoples health and welfare needs are met. 9 31 9 An application must be made to the Commission to register a suitably qualified and experienced manager for this home. This will help to ensure that people benefit from living in a home that is managed by a suitable person, and from management systems that help to ensure peoples safety and well being. 10 38 13 Risks to people living here should be identified and as far as possible eliminated. 29/01/2010 26/02/2010 Care Homes for Older People Page 36 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will help to ensure that people are kept safe. 11 38 13 You must ensure that the 29/01/2010 moving and handling needs of people living here are met safely. This will help to prevent injuries to people and keep them safe through safe working practices. 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 9 All medicines used and available on prescription only must be prescribed before they are used. This includes prescribed dressings. Work should continue to ensure that people of differing abilities and needs are able to engage and interact socially in a way that suits both their needs and previous preferences. Work should continue to ensure that people of differing abilities are able to exercise personal autonomy and choice. The way that meal times are managed should result in meal times being a social and pleasurable experience for people. Food and food combinations should always be such that they are attractive and appealing in terms of texture and appearance, and do not pose a risk to people with swallowing problems. You should ensure that references from a previous employment are supplied by the employer and not be a co worker. 2 12 3 4 14 15 5 15 6 29 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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). 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