Inspection on 23/03/10 for Holcombe Hall Nursing Home

This inspection was carried out on 23rd March 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holcombe Hall Nursing Home 25/09/07

Holcombe Hall Nursing Home 26/02/07

Extracts from inspection reports are licensed from CQC, this page was updated on 03/06/2010.

Key inspection report Care homes for older people Name: Address: Holcombe Hall Nursing Home Holcombe Drive Holcombe Dawlish Devon EX7 0JW     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: Anita Sutcliffe     Date: 2 9 0 3 2 0 1 0 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 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Holcombe Hall Nursing Home Holcombe Drive Holcombe Dawlish Devon EX7 0JW 01626862330 01626888977 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Holcombe Hall Nursing Home Ltd Name of registered manager (if applicable) Mr William Stanley Warr Type of registration: Number of places registered: care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 29. The registered person may provide the following category of service only: Care home with nursing only - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia over 65 years of age - (Code DE(E)) Mental disorder, excluding learning disability or dementia (Code MD(E)) Date of last inspection Brief description of the care home Holcombe Hall Nursing Home is a care home with nursing that is registered for 29 people of either gender. It can provide nursing care within the categories Mental Disorder or Dementia. The Registered Manager is a Registered Mental Nurse with many Care Homes for Older People Page 4 of 37 Over 65 29 29 0 0 Brief description of the care home years experience in the National Health Service and the Independent Health Care Sector. As nursing is provided there a Registered Nurse on duty at all times. The home is situated between Teignmouth and Dawlish in an area called Holcombe. It has its own driveway and small parking area off a quiet residential road, Holcombe Drive, just off the A379. The House is situated in three acres of land, and has scenic views across Babbacombe Bay. The accommodation is provided on 2 floors that are accessed by stairs or a passenger lift. There are two levels off the second floor that have further bedrooms that the lift does not reach. People who live in the home, that are able can climb stairs, use these rooms. The communal accommodation is all on the ground floor and comprises of two (interjoined) lounges and a very large dining room, each with sea views. There is an accessible, private garden to the rear of the property with magnificent sea views also. The majority of bedrooms are shared and none have en-suite facilities although all have a wash hand basin. All rooms are within close proximity to adapted bathing/toilet facilities. The weekly fees are currently between £535 and £675 a week. There are additional charges for services such as hairdressing and chiropody. The cost will be provided upon request. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at /www.oft.gov.uk . Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Commission has collected information about Holcombe Hall Nursing Home since the previous key inspection. This includes the yearly AQAA which provides data, such as how many staff work there and when policies were last reviewed. It also gives the home the opportunity to tell us what they do well, any barriers to improvement and what improvements are planned. We examined our records and information we have received since the last key inspection. This included information sent to us by the home about untoward incidents. These are called notifications. We did two unannounced visits to the home spending 13 hours there is total. We looked closely at the care of one person who uses the service. This included meeting them, speaking with staff about their needs and examining records pertaining to their care. We met most people who use the service and spent a lot of time observing staff Care Homes for Older People Page 6 of 37 going about their work and their interaction with the people in their care. This was because few people who use the service were able to comment about the home. We spoke with two visitors, a district nurse who attends the home, a visiting training assessor, a nurse who arranged for the last admission to the home and a representative of St. Johns Court assessment unit. We asked about the service at Holcombe Hall and their opinion of the home. We saw most of the building at both visits and several bedrooms. We examined some policies, procedures and records. We asked questions of six staff and the manager, who was present throughout. People who use the service may be described within this report as residents, clients, service users or patients. This report is based on a sample of the evidence available in our inspection process. It does not provide a comprehensive risk assessment of the home. Registered persons are reminded that it is their responsibility to assess and manage risks in accordance with the Care Homes Regulations 2001 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2009) and other relevant legislation. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: Information about the service must be in a format suitable for the people who will use it and must include all that is required. It is important that they, or their representative, has this information. It must be recorded if people have made an Advanced Decision to refuse treatment, whether there are arrangements regarding Lasting Power of Attorney or an Independent Advocate. This provides the legal safeguards for people who do not have capacity to make decisions on their own welfare. The home must comply with the Mental Capacity Act 2005. An individual plan of care should be generated from the assessment of the persons needs and wishes by admission or at the longest within a couple of days. This better ensures staff are aware of the care and support to be delivered. Peoples care and support must be delivered in a person-centred way not as part of a group arrangement and task for staff to complete. Medicines known as Controlled Drugs must be stored in a metal cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973 so as to reduce the possibility of mishandling and comply with the law. Peoples privacy and dignity must be upheld. To this end all toilets, bathrooms and bedrooms must be fitted with locks suited to peoples capabilities and accessible to staff in emergencies; people must only receive personal care in a private space; people must only be given a bib if they consent to the use and it is part of planned care; peoples bedroom must not be used for household activities or the storage of equipment which is not for their use; personal information must not be kept in view of people who do not have the right to read it; where people need assistance to eat this Care Homes for Older People Page 8 of 37 must be done discreetly, sitting next to them and one person at a time; people must be consulted and the principles of the Mental Capacity Act applied at all times. Following consultation with people, or their representative, the home must provide a more regular and varied programme of leisure and social activities and opportunity for stimulation. Consideration must be given the the specific needs of people with dementia. The arrangements for dining at the home should be completely reviewed so that people have a more homely, domestic and less institutional experience. The registered manager must confirm that the current arrangements for diet are providing the nutrition necessary for people. People who use the service must be better protected from bad practice, which might be abusive. The Home should research good practice guidelines on care environments for people with dementia. The Home should then be adapted so that it is more suitable. Those adaptations will help people find their way around easier and so increase/maintain their independence. There should be improved audit of the environment so that it is kept safe; the hand rails should not have become so loose. The Home should be more domestic in nature. The decor and furnishings should be reviewed. There should be communal space where people can meet visitors in private. Staff must have, at all times, the protective equipment and clothing they need and there should be a method for dealing with soiled laundry without staff having to handle it. This helps protect people from cross contamination and serious accident. Staff recruitment must be robust so as to ensure staff who are not suitable to work with vulnerable adults are not employed. No staff must start work at the home before the required checks are complete. Staffing numbers and/or deployment must be reviewed so there are enough staff to meet the individual needs of people who use the service at all times. The manager must be able to fulfill his management responsibilities and therefore must not be rotas as the nurse in charge of the care. Staff must be properly supervised, as part of the management process and on a continuous basis. Mr. Sebastion, the Responsible Individual for the organisation, must produce a report following a monthly unannounced visit to the home. This report is for the manager as part of quality monitoring. The report must also be sent to the Commission. The home must comply with the Data Protection Act 1998 in that personal information about people must not be kept in the lounge. Care Homes for Older People Page 9 of 37 Staff safety must be improved. The Commission contacted the Health and Safety Executive as they were concerned about caustic liquids which staff are pouring from one container to another. 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 10 of 37 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 37 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. People are unable to make an informed decision as to whether the home will meet their needs but peoples complex medical needs are understood and met. Evidence: We were given copies of the information which people should receive from the home to help them decide if it is suitable for them. The information was not in a format suitable for people with dementia and not all the information required to be included has been so. For example, the full range of needs the care home is intending to meet, the relevant qualifications and experience of staff, fire precautions and emergency procedures and the number and size of rooms. We looked closely at the care of the last person to be admitted to the home, observing how he was, looking at records and discussing his needs with staff, the manager and people involved in his admission. Care Homes for Older People Page 12 of 37 Evidence: The person who arranged his admission told us that when she popped in to see if he was settled she had no real concerns, although he was sleeping the entire period. She felt the home were meeting his needs. However, she raised the point that the home had not established whether he had made an Advanced Decision to refuse treatment. This would mean, among other things, that should he collapse, staff would not know whether they should attempt resuscitation. The manager needs to be fully conversant with the Mental Capacity Act 2005 and the deprivation of liberty safeguards. This provides a legal safeguard for people when they are unable to inform people of their wishes or make decisions on their own welfare. The manager and staff had a good understanding of the needs of the new person admitted. Records of his assessment were detailed and included risk and its management at the time of admission. The home had also received information from the medical unit from which he had been discharged. We spoke with the medical assessment unit from which people are sometimes discharged to Holcombe Hall. They told us that the home will admit a higher dependency service user adding that Holcombe House provides the space, a relaxed attitude and a tolerant staff. They added: They work with peoples positives, have a good understanding of peoples previous personalities and take people where other homes have tried and failed. Care Homes for Older People Page 13 of 37 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. The high standard of personal and health care provided is undermined by a mostly task led system and privacy and dignity are severely compromised. Evidence: We looked to see if peoples health and personal care needs were met in a dignified and satisfactory manner. We looked closely at the care of the last person to be admitted to the home, meeting him, visiting his room, reading documents relating to his assessment and care and talking to the manager, some staff and the health care professional who helped him move to the home. We found that the assessment information collected prior to the persons admission had not led to a recorded plan of how his care was to be delivered. This was seventeen days after his admission. However, risks had been assessed and from this staff were aware of aspects of his needs, such as routines of daily living, diet, mood and mental condition. The health care professional involved in his admission told us Care Homes for Older People Page 14 of 37 Evidence: she was worried that no care plan had been produced, but confirmed that aspects of his behaviour which had challenged him and others had now improved and he seemed to have settled in well. We looked at a selection of care plans. They provided good detail and would readily inform staff what care and support the person needed. They had been regularly reviewed so that the information contained in them was current. However, we noted that consideration had not been given to issues of the persons capacity to consent to treatments. The Mental Capacity Act makes this a requirement. Information was seen in the home about this recent legislation but it had yet to be applied to the homes practice. People appeared to receive a high standard of personal care and each person we spoke with confirmed this. One visiting family told us: Shes always clean and tidy and always nicely dressed. She also has new glasses. Another said: He has a serious and difficult skin condition and here it has cleared up. I am extremely pleased with the care given. A district nurse told us: People always appear to be clean and safe. She added that during end of life care the district nurse went into the home daily to support the homes nursing staff who lacked the skills and knowledge to undertake the nursing procedures required. She said: The home contacted the district nurses in a timely manner, they were aware of peoples needs and sought advice. People received adequate oral care and were turned regularly and kept comfortable. A Health Needs Assessor told us that he had only a little knowledge of the home which was in relation to a person with challenging behaviour but he felt that they are able to accommodate significant levels of challenging behaviour. However, we found that people are not receiving individualized, person-centred care. People are living within a rigid routine: all are got up and washed, they are taken to the ground floor lounge where, in view of others, their personal care is completed hair is brushed, spectacles put on and any creams applied. Staff have a routine of tasks to be performed. Whilst some people thrive on a regular routine this must still be person led and dignified, which it is not. We found other areas of concern relating to privacy and dignity: There are no locks on bathroom, toilet or bedroom doors. There is no way people can ensure they have privacy; We saw one person being dressed, following personal care, and the door to the bathroom was wide open leaving her in view of any person in the corridor; Every Care Homes for Older People Page 15 of 37 Evidence: person in the dining room was automatically given clothes protection to wear whilst eating. Staff confirmed this; One persons room was seen to be used for the homes ironing and the storage of another persons hoist equipment; Personal information relating to use of the toilet and intake of drinks is kept on a shared chart in the lounge where it will be seen by people who do not have the right to see it; We saw a person being force fed a meal, which was undignified and dangerous; We saw staff standing to feed more than one person at a time, moving between them; Communication and engagement with people should be improved. Staff inform people what they are doing but they dont ask them if they can do it. The home reports: We treat people with respect and dignity and wherever possible allow choices without restrictions. We did not find this to be the case. We looked at how the home manages medicines. Although, by the nature of the conditions for which people are admitted to Holcombe Hall they are less likely to be able to do this themselves the home must always assume, until they can evidence that it is not the persons choice and not in their best interest, that people will manager their own. This must be clear in the Service Users Guide. Currently no person at the home is managing their own medicines and all (with the exception of creams and lotions) are stored in a room called the clinic. We found the systems in use to be orderly and clear, records to be precise and complete. Medicines are checked in and out of the home as they must be to ensure a full audit is possible. Where the monitoring of health is linked to judgments about medicines (such as with diabetes) there were clear guidelines available for staff to follow. Although medicines, known as controlled drugs, are stored under secure lock and key their storage does not meet current legislation. Care Homes for Older People Page 16 of 37 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The opportunity for people to lead a meaningful life is limited as there is very little stimulation, choice or opportunity. Evidence: We looked at whether people were supported to lead a fulfilled life within their capabilities. The homes Statement of Purpose, which sets out what the service will provide, tells people that the philosophy of the home is: To provide a caring environment in a safe and stimulating manner giving choice, dignity and independence. We found that is not completely the case. Comments from people associated with the home with regard to activities include: Staff interaction is very kindly but there isnt enough; Activities, or lack of them, is an issue; Very dreary; As far as I know they dont do anything; No time now (for activities). The routine is more heavy. and None. Never seen any and am not aware of any. We sat in the lounge several times over the two days observing. We saw that following breakfast people are brought to the ground floor lounge, where some like and benefit from walking around. Once there peoples personal care (hair,glasses etc.) is Care Homes for Older People Page 17 of 37 Evidence: completed in front of other residents. Our first visit we saw a trolley positioned in the lounge which contained peoples spectacles, hairbrushes, creams etc. There followed other routines throughout the morning, such as providing drinks and toileting. We saw that staff are always available and were attentive. We saw kind and thoughtful interaction with people by staff. However, there was practically no stimulation for people; nothing to interest or distract from just sitting or walking or receiving necessary personal care, other than an occasional visitor. We asked the manager why people were unable to spend time in their room should they prefer and were told that it would not be safe for the current residents to do so. When we visited the first floor we found one persons bedroom and the entire corridor were being used as an extension to the laundry. People did not have access to the only private space they have, which should be available to them. We established that there are occasional events, mostly musical, at the home. These include a monthly music and sing along; ladies choir and guitarist every other month. We were told that sometimes there is fabric skittles. Over our two visits we heard no music, saw no reading material and the television (small compared to the size of the room and the volume too quiet to hear) was on once. We were told that a care assistant has a couple of hours alloted for activities in the afternoon. When we were there he took one man out of the home for a cigar and we saw him chatting to some others. We spoke with two visitors during our inspection. They told us that they are always made welcome and they confirmed that there are no visiting restrictions. One told us that she wished she had the opportunity to spend private time with her mother, but had got used to the lack of privacy. We looked at whether people received a wholesome appealing and balanced diet in pleasing surroundings at times convenient to them. We were shown the menu, which we were told is on a three week rotation. It states that lunch is 12:30, supper is 17:30, daily there are soft drinks and beer as required, afternoon there is cake, diabetic cake, tea and coffee, supper is tea, coffee or water as required. It is also written: Alternatives can be made to the menu at the cooks discretion. We confirmed that people do not have a choice of main meal available to them and it would appear that the cook, not the person themselves, has the say over what they eat. Examples of the menu include: SAT. Lunch: pasties, mashed potato, veg of the day and gravy, banana custard. Supper: leak and broccoli bake and baked tapioca. The meal provided on our first visit was Shepperds pie with carrots and sprouts, mashed Care Homes for Older People Page 18 of 37 Evidence: potato and gravy. We were concerned that the meals provided are not nutritiously balanced, especially regarding vitamin C as we saw no fresh fruit and cooking destroys the vitamin in vegetables. The cook told us that bananas are available and the manager said that there is an option of fresh fruit juice at breakfast. Food is delivered to the dining room in a heated trolley from which the cook serves the meal directly onto the plates. People did not appear to be offered any option, including whether they preferred gravy or not. There was a choice of two deserts. Soft food had been served in separated portions, which enables people to enjoy the separate tastes. We saw, on both days, that staff had many people to assist with their meal. We saw no evidence of aids to help people eat independently. Both days there were people who sat and waited as other people were fed before them. During this time their meal, obviously loosing heat, was sitting on the side. We saw some staff assist people in a dignified manner, sitting next to them and taking time. However, we also saw staff trying to feed more than one person at a time, standing as they did so and with no interaction with them; just putting food into their mouth mechanically. (See also the Outcome called Complaints and Protection). We saw one person who had not started his meal, because there was no staff to assist him, when most others had finished and the trolley had been removed. The dining room is a large, fairly bare room, with little adornment, which we do not feel is a pleasing room in which to enjoy a meal. The custom for providing lunch (we did not witness breakfast or tea) is outdated and of an institutional nature. We tested one meal, which we found to be tasty. We were told that staff also eat the same food when on duty throughout the day. Asked about food one visitor showed she was not impressed. She told us she brings her husbands preferred foods in for him. The second visitor told us: The only thing wrong is the food. Sometimes it isnt hot. The home monitors peoples dietary intake and weight. Professional visitors said they have no concern that people do not receive enough drinks or food. Care Homes for Older People Page 19 of 37 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. The home has not always safeguarded people as well as they must. Evidence: We looked to see how the home might handle complaints and if people are protected from abuse. Few of the people currently using the service would be able to make a complaint to the home due to their mental or physical condition. The complaints policy is displayed at the entrance to the home and includes the current contact details for the Commission. However, the current Statement of Purpose lists the previous Commission address and so is out of date. The home reports that it has received no complaints and we have received no complaints about the home. People who were able to converse with us said they were satisfied with the home and both visitors told us they would, and have, felt able to take any concerns to the manager. We asked six staff what they would do if they had concerns which might indicate abuse. Each said they would tell the manager, one adding: The nurse in charge would jump on bad practice. Asked what further they might need to do all but one said they would tell the Commission. One said they would contact the Social Services Safeguarding team, or the police. This is what staff should do. Care Homes for Older People Page 20 of 37 Evidence: We looked at the homes Whistle Blowing policy. It makes clear that staff must report any concerns but it does not make it clear that the home must not investigate the concerns themselves if there is any indication that there has been abusive practice. There is information on how to protect people from abuse in the office and staff room. In addition, staff have received training in how to safeguard people from abuse. Some have received this training directly from the Local Authority and some through as private training provider. We watched what we consider to be abusive practice during a lunch time. A care assistant was forcing food into the mouth of a woman in a manner which was dangerous and undignified. Another care assistant spoke to her - we believe to stop her - but the inspector then fetched the manager to have it stopped. We did not leave the situtation long enough to give other care staff the opportunity to speak with the manager about it. (Also see the Outcomes called Staffing and Management amd Administration). Care Homes for Older People Page 21 of 37 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not benefit from an environment which is homely, promotes their independence and where risk and safety has been fully considered. Evidence: We looked to see if people live in a safe, well-maintained home that provides for their needs. We toured the home both times we visited. People who use the service benefit from a home which has good amounts of space. Where people like to wander, as several at Holcombe Hall do, this is a benefit to them. The home also has stunning views and attractive gardens. However, it is unlikely that those gardens would be safe for unaccompanied access. This restricts people, reducing their independence. There are two (adjoined) lounges in the home where people spend their day time. There is also one large dining room. There is no seperate space where other activities can take place. One visitor told us she would prefer to visit her mother in a more private setting and not have to be surrounded by other people. The lounge and dining area are not very domestic in nature. This is due to the largeness of the rooms, the decor, style of furnishings and lack of homely items. We were told that some new furniture and furnishings have been provided to shared Care Homes for Older People Page 22 of 37 Evidence: rooms and some bedrooms. All furnishings seen were in good condition. One person who visits the home told us: Youve got to look past the decor. We looked to see how well the environment meets peoples needs. The stair-walking device, for those who are not able to manage stairs that have rooms with steps to access, is no longer functional and has been taken out of the building. There are hand rails and there is a shaft lift between floors. For people with dementia, who by the nature of their illness have difficulty orienting themselves in a space, there is no effort made to make things easier for them. This could include names, pictures, symbols and the use of colour to denote a specific area, such as the toilet. Instead every door has a number and is painted a pale colour. There was a previous requirement that carpet should be made safe and we found no evidence on this occasion that carpets were unsafe. However, we found loose hand rails suggesting that there is insufficient programme of routine maintenance. We also found wardrobes which would topple fairly easily if pulled upon. This risk was not assessed as it should have been. (See the Outcome on management). The main body of the home was fresh and clean. The kitchen was very clean. A visitor told us: You cant fault the cleanliness. However, the laundry room, cited outside of the main building, was not clean, as it should be to reduce the possibility of cross contamination. We interviewed several staff, asking if they had the equipment they needed. They told us they have the necessary moving and handling equipment (which we observed in use) but there had been times they have run out of protective clothing and wipes to cleanse people. We were also told of dangerous practice brought about by a lack of equipment. (Also see the Outcome called Management). We found no bathroom or toilet that had a lockable door. Nor were there signs that might indicate when the room is occupied. No person is able to lock their bedroom door, or ensure privacy. However ill people have become due to their medical condition they still have the right to privacy. Any risk can be fully considered and measures taken to reduce or remove risk. We also saw staff using a persons room to do the homes ironing, using the corridor hand rails to hang the ironed clothing and a hoist was being stored in another persons room because, we were told, their room was too small. (Also see the Outcome called Health and Personal Care). Staff are employed to maintain the building and decorate and refurbish. Where we Care Homes for Older People Page 23 of 37 Evidence: raised concerns about environmental hazards these were addressed quickly. We were told that the home is always very warm even in cold weather. Care Homes for Older People Page 24 of 37 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 receive a service from staff who are mostly kind, caring and responsive to their needs. Staffing numbers/deployment are not sufficient and staff recruitment puts people at risk. Evidence: We looked at whether people who use the service benefit from the staffing arrangements. A district nurse told us that staff are: Very attentive and helpful and that she observes staff talking to people in a friendly and chummy manner. Both visitors we spoke with thought there were enough staff. They told us that they like the staff, saying they are kind and they have confidence in them. There seemed to be satisfactory numbers of staff but only in as much as people are kept together throughout the day, which requires less staff. However, at lunch there were insufficient staff to assist people, which led to some waiting and some enduring the indignity of being fed by staff standing and assisting others at the same time. Care staff are supported by ancillary staff: laundry, cleaning, maintenance and kitchen. Most care assistants at the home are male, but the manager told us he usually succeeds in ensuring there are also female staff on duty. Most care staff are Care Homes for Older People Page 25 of 37 Evidence: not British nationals but, with one exception, we found their communication skills to be good. We were given a copy of the staff rota. Some staff are working very long hours, one 72 hours in one week, which includes four 12 hour consecutive shifts. Whilst staff can choose to work longer hours, and people may well be having the required breaks, such long shifts in such a demanding environment has the potential to affect the standard of care provided and staff tolerance where peoples behaviour may be a challenge. We looked at how the home recruits new staff and whether people that have been employed are fit to work with vulnerable people. The manager told us that recruitment is done by the Responsible Individual for the service, not himself. To assess a persons fitness to work with vulnerable adults checks must be completed; this must be before they start work at the home. These checks include two written references (sent in response to a request, not open references), a full employment history with any gaps in employment explored and confirmation from the Criminal Records Bureau as to whether the person has a criminal record or is banned from working with vulnerable adults. We looked at the recruitment records of four staff and found the required safety checks were not being completed before staff started employment. We then witnessed two instances where a member of staff, employed this February, was ill treating people who use the service. It was also felt, by the manager and through our brief contact with her, that her understanding and ability in English was insufficient to do the job. It was also found that this was a member of staff who worked 72 hours one week and 60 the next; long hours in an environment that can be challenging. We spoke with five staff and looked at records of staff training. Staff described the various training they receive, which includes: Dementia Awareness, Infection Control, Moving and Handling and Fire Safety. We observed staff competently assisting people to move and saw safe administration of medicines. District nurses are having to provide some nursing at the Home, although Holcombe Hall is a nursing home and the employed nurses should have these competences. We are told this has been the situation for some years. However, some nurse training has recently been completed and there are arrangements being made for nurse practice/experience to follow. Care staff are undertaking National Vocational Qualifications (NVQ) in care and we were told one is doing NVQ 3 and five have NVQ 2 or above. This is an indicator of competence. Care Homes for Older People Page 26 of 37 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 manager is not able to properly fulfill his duties and responsibilities, which has a negative impact on the service and safety of all people within the home. Evidence: The registered manager, Mr. William Warr, has many years experience as a mental health nurse and good insight and experience in how to help people manage the conditions of dementia and mental health problems. One health care professional told us that: He has a good understanding of peoples previous personalities. Staff were very supportive of their manager and two peoples family told us they are happy to take any problem to him and trust it will be dealt with promptly. We saw that he promotes a relaxed and friendly atmosphere at the home. It is expected that the manager will have sufficient time to fulfill his duties and manage the home effectively. However, Mr. Warr is required to spend more time as the nurse on duty than in the role of manager. This impacts negatively on the outcomes for people who use the service. For example, we found loose hand rails, Care Homes for Older People Page 27 of 37 Evidence: freestanding wardrobes that would tip if pulled upon where the risk had not been assessed and a care plan not complete when the person had been at the home for 17 days. Staff do not receive formal supervision of their work or have meetings at which they can discuss issues relating to their work. Recruitment is not safe and has put people at risk. We are told that the organisations representative (known as the Responsible Individual) Mr. Soy Sebastian, visits the home at least monthly and often weekly. It is the responsibility of the Responsible Individual to speak with people who use the service or their representative, interview staff, inspect the premises, its record of events and any complaints and prepare a written report on the conduct of the care home. We asked to see those reports but were told there are none. We asked Mr. Warr how the quality of the service is monitored and were told, and saw, that peoples opinion is surveyed once a year. We also saw that some aspects of the home are monitored; this includes accidents, records of which were seen. However, as we found loose hand rails it is clear that safety of the environment is not adequately monitored. Mr. Warr, asked how peoples financial interests are protected, said that the home does not keep any money for people and that they, or their representative, are invoiced as necessary. This is made clear in the written informatin about the home. Staff told us, and Mr. Warr confirmed, that staff do not receive formal supervision of their work - to look at aspects of practice, philosophy of the care home and career development. We watched a care assistant force feeding a person. She was putting an over full spoon of food in their mouth at a speed at which it would be impossible for them to swallow it. This was both abusive, undignified and dangerous practice. It happened in the presence of other staff and Mr. Warr, who was concentrating on administering tablets. (We brought the situation to the managers attention and he took immediate action). Most personal records are kept in the office, to which people do not have access unless they are staff. However, toileting and fluid charts are kept in the lounge in view of any person using the service or visiting. People must not be able to see private information about another and information must only be used in accordance with the Data Protection Act 1998, which this was not. We looked at whether the health and safety of people who use the service and staff are promoted and protected. We found several areas of concern: Care Homes for Older People Page 28 of 37 Evidence: - Laundry staff are pouring caustic cleaning liquid from a large container into an unlabeled 2 litre milk bottle, from which they then pour it into a medicine pot and into the washing machine. This practice has not been risk assessed nor has adequate protective clothing been considered. Our concern led us to immediately inform the Health and Safety Executive. - Laundry staff have to find and take soiled items of clothing or bedding from a white bag in which they are brought to the laundry. This puts the staff at risk of cross contamination. A non-touch system should be adopted. - Handrails, to help those with poor mobility, were found to be coming loose from the wall. This included an area near several steps. This was corrected by our second visit. - Freestanding wardrobes, which would topple if pulled upon, had not been risk assessed. Arrangements were being made to secure them prior to completion of the inspection. - Staff told us that on occasions they have run out of protective clothing, such as gloves and aprons and wipes for cleansing people. However, we saw staff using safe moving and handling practices, the home has a Major Incidents Plan 2010, requirements made February by Devon Fire and Rescue Service are being implemented, staff receive mandatory health and safety training (such as fire safety, moving and handling and food hygiene) and a health and safety policy is displayed for staff to see. Care Homes for Older People Page 29 of 37 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 30 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 The Service User Guide must 30/06/2010 include all of the information required and be in a format suitable for people who use the service. So that people are fully informed what the home has to offer and have a reference of it. 2 1 4 The Statement of Purpose must include all of the information required and be in a format suitable for people who use the service. So that people are fully informed what the service can offer. 30/06/2010 3 8 12 Care and support must be 31/05/2010 planned and delivered taking into account the Code of Practice and principles underlying the Mental Capacity Act 2005. Care Homes for Older People Page 31 of 37 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 So that people who are unable to make decisions on their own behalf are protected in law. 4 10 12 Peoples dignity must be 31/05/2010 promoted: Personal care must be in private; People must be able to lock doors as necessary; Care must be provided to people as individual; Bibs must only be used where this is part of planned care; Personal information must be kept private; Peoples private space must be respected; Assistance with eating must be discreet, to one person at a time and at the speed the person can manage. So that people are treated with respect and value. 5 12 16 People must have the 30/04/2010 opportunity to engage in meaningful activities that are of interest to them and within their capabilities, on a regular basis. To prevent boredom and promote a meaningful life. 6 15 16 The arrangements for meals and meal times must be reviewed: this includes food options, the environment 31/05/2010 Care Homes for Older People Page 32 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action and the way people are assisted. So that eating at the home is a pleasant experience. 7 18 13 Staff who are not suitable to 20/04/2010 work with vulnerable adults must not do so. So that vulnerable people are protected from poor practice and abuse. 8 19 23 The standard of maintainance needs to be monitored. So that the environment is safe for people to live in. 9 24 12 Doors to peoples private accommodation, and all bathrooms and toilets, must be fitted with locks suited to peoples capabilities and acessible to staff in emergencies. So that people have some private space available to them. 10 26 13 Staff must have the protective clothing they require available to them at all times. To help reduce the possibility of cross contamination. 20/04/2010 31/08/2010 30/04/2010 Care Homes for Older People Page 33 of 37 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 11 27 18 There must be enough staff 31/05/2010 available at lunch time for individual help with eating where needed. Staff must not help more than one person eat at a time and must do it with discretion and in an unhurried manner. For the dignity and safety of people who need assistance. 12 29 19 Staff must not work at the 20/04/2010 home until all the required checks have been completed and the management are satisfied that the person is safe and suitable to work with vulnerable adults. To protect people who use the service from poor practice and abuse. 13 31 9 Mr. Warr must have the time 31/05/2010 necessary to fulfill his duties and legal responsibilities as the registered manager. This must be the majority of his working time. So that he can lead and supervise staff and assure the well-being of people who use the service through monitoring of the service provided. 14 33 26 Following a monthly, unannounced visit to the 31/05/2010 Care Homes for Older People Page 34 of 37 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 home a written report must be produced on the conduct of the home. A copy must be supplied to the manager and the Commission. To monitor standards of service provided. 15 36 18 Staff must be appropriately supervised. This should include regular formal supervision. So that aspects of practice and standards of care can be monitored. 16 38 13 Potential risks must be 30/06/2010 assessed and steps taken to reduce or remove risk where this is practicable. To protect people who use the service and staff. 17 38 13 Staff must not be put at risk 20/04/2010 through unsafe working practices. The home must comply with the Control of Substances Hazardous to Health Regulations (COSHH) 1998 To protect staff from harm. 31/05/2010 Care Homes for Older People Page 35 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 A plan of how care is to be delivered, based on assessment of the persons needs and wishes, should be produced and available to inform staff from the point of admission. The manager should have the nutritional value of the food reviewed by an expert in that field, so that he can confirm people receive the nutrition they require. There should be communal space where people can meet their visitors in private. Decor and furnishing of communal rooms should be more domestic in nature so that it is a homely and more comfortable environment. There should be environmental adaptation in line with current good practice guidelines on homes for people with dementia. This should help people who use the service understand their environment and increase their independence. A system which does not require staff to handle soiled laundry should be introduced, so the possibility of cross contamination is reduced and staff are protected. Nursing staff should have the training, knowledge and expertise they need to provide the nursing in the nursing home. 2 15 3 4 20 20 5 22 6 26 7 30 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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