Inspection on 17/08/10 for Holmer Care Centre

This inspection was carried out on 17th August 2010.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmer Care Centre 22/09/10

Holmer Care Centre 17/09/10

Holmer Care Centre 20/07/10

Holmer Care Centre 12/07/10

Holmer Care Centre 08/01/08

Holmer Care Centre 21/02/07

Holmer Care Centre 10/02/06

Holmer Care Centre 05/10/05

Holmer Care Centre 26/01/05

Holmer Care Centre 06/07/04

Holmer Care Centre 02/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Key inspection report Care homes for older people Name: Address: Holmer Care Centre Leominster Road Hereford Herefordshire HR4 9RG     The quality rating for this care home is:   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: Sarah Blake     Date: 1 7 0 8 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 36 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 36 Information about the care home Name of care home: Address: Holmer Care Centre Leominster Road Hereford Herefordshire HR4 9RG 08453455745 01432342390 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs S Roberts,Mr Jeremy Peter Ewens Walsh Name of registered manager (if applicable) Type of registration: Number of places registered: care home 49 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: 49 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 49, Mental disorder, excluding learning disability or dementia (MD) 49 Date of last inspection Brief description of the care home Holmer Care Centre is on the outskirts of the city of Hereford. It is owned and managed by The Holmer Partnership, Blanchworth Care. The Home was first opened in December 1991. It is a Victorian property that has been extended to provide a Care Home with nursing for a maximum of 49 older persons over the age of 65 years, of Care Homes for Older People Page 4 of 36 Over 65 0 0 49 49 Brief description of the care home both sexes, who have dementia or a mental disorder. Twenty nine bedrooms are single occupancy, eighteen have en-suite facilities. The Home has a passenger lift. The Home operates a locked door policy, as indicated in the Homes Statement of Purpose and Service User guide. There is information literature describing the service displayed at the home and copies are available on the Providers website address. New residents receive a copy of this information and it also forms part of staff induction packs. Details of fees and additional charges are available from the Providers website address. A copy of this report can be viewed at the home. Care Homes for Older People Page 5 of 36 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: 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: We stopped awarding quality (star) ratings under the Care Standards Act 2000 on 30 June 2010. No new ratings have been awarded since that date. For this reason, the report should be read in full so that an accurate view of the quality of the service can be obtained. This was an unannounced inspection. Two inspectors, and a pharmacist inspector, spent a full day at the home, talking to the people who use the service and the staff, observing daily life in the home, and looking at the records, which must be kept by the home to show that it is being run properly. These include records relating to the care of people who use the service. We looked in detail at the records for four people living at the home. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being Care Homes for Older People Page 6 of 36 met for people using the service. It also gives us some numerical information about the service. Some of the managers comments have been included within this inspection report. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? 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 8 of 36 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 9 of 36 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 have access to written information to help them decide if they wish to move into Holmer Care Centre. The home makes sure that peoples needs are assessed before they move in, so that staff know the support that needs to be provided. Evidence: The home provides a range of written information which is given to people before they move in. There is also a website with useful information about the home. We saw that the Service User Guide had been updated recently to include information about the changes to the management of the home. The information available would help people to make an informed choice about whether Holmer Care Centre was the right place for them. In the AQAA, the home states Any prospective resident is offered a trial period stay to ensure that they feel comfortable within the home and the home manages their care well. We spoke to a relative of someone who lives at the home. They told us that they had Care Homes for Older People Page 10 of 36 Evidence: been able to visit the home before the person moved in. We looked at the care records for two people to see if their needs had been assessed before they moved into the home. The records showed that a senior member of staff from the home had carried out an assessment so that the home could be sure that it could meet each persons individual needs, and so that staff would know the care that needed to be provided. These assessments were brief but there was evidence that a fuller picture of the persons needs and preferences had been built up over the first few weeks at the home. Care Homes for Older People Page 11 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be confident that their physical and mental health care needs will be identified and met. Medication is not managed safely. There is a lack of basic understanding about how to promote and protect peoples privacy and dignity. Evidence: We looked at the care records for four people who live at the home. We also talked with staff who provide their care and observed how staff support them. We saw that most care plans had been reviewed and updated when peoples needs change, but that some were out of date or incomplete, and did not give staff the information they need to meet peoples care needs. The care records for one person included a care plan for eating and drinking. The care plan stated encourage plenty of fluids. We saw that staff were keeping a record of the amount that the person was drinking each day. We checked the records, and saw that the amount recorded over one period of twenty-four hours was 600 millilitres. The Food Standards Agency recommends that adults should drink 1.2 litres per day in Care Homes for Older People Page 12 of 36 Evidence: order to prevent dehydration. We asked the Director of Nursing about the homes procedures for recording peoples fluid intake. She stated that the days total should be recorded and if this showed that an inadequate amount of fluids had been taken, then staff should record this in the care plan. We saw that there was no record in the care plan of the persons fluid intake. The person was not able to get drinks independently, and needed to rely on staff to provide them. It is therefore extremely important that records are accurate and that prompt action is taken to ensure that people are not at risk of dehydration. We found that the home has an inconsistent approach to managing wound care. Records for one person included clear instructions for staff about care of a leg wound, and there was evidence that staff had closely monitored the wound and that it had subsequently healed. However, when we looked at records for another person with a pressure sore, we found that the records were not clear and did not show accurate and effective monitoring of the sore. We spoke to a care worker about this persons pressure sore, and we were told that the person should have a dressing on the sore at all times. The care worker told us that the dressing had been removed at 08:00 because it was soiled. She said that she had asked a nurse to replace the dressing but that this had not been done. The nurse confirmed that the dressing had still not been replaced more than five hours later. When the nurse eventually replaced the dressing, we found that the wrong dressing had been used. The management of pressure sores requires specialist knowledge, but there was no evidence that the home had requested support for this person from the local Tissue Viability Nurse. Although care plans include clear instructions for staff about how to support people who need help with their mobility, we found that staff were using unsafe techniques when assisting people. At our previous inspection, we had seen staff using an unsafe technique, and we were disappointed to find that staff were still not always supporting people in a safe manner. We saw staff beginning to use an underarm drag when assisting someone to use a stand aid hoist. An underarm drag places the person at risk of injury to the shoulders and upper arm. The Director of Nursing immediately stopped staff from using this technique. It concerns us that staff are still carrying out moving and handling in an unsafe manner, especially as we were shown evidence that staff have recently received training in this area. At our last inspection, we had been concerned that some people living at the home were left in the lounges for long periods of time with no staff. This included people whose behaviour could present a risk to themselves or to others. We made a requirement that the home must provide adequate staffing resources to ensure peoples safety. Care Homes for Older People Page 13 of 36 Evidence: When we arrived at the home, the Director of Nursing told us that the large lounge on the ground floor was staffed at all times from breakfast time onwards. We found that there were no staff in the large lounge on the ground floor when we went in there at 10:25. There were nine people who live at the home sitting in the lounge. We saw that five of the men in the lounge appeared unkempt and unshaven. We stayed in the lounge until 10:40, and during that time there was no member of staff stationed in the lounge. In the evening we saw two women who live at the home walking up and down a corridor. One of the women had bare feet. The women appeared to be searching for something or someone, but were not able to articulate their needs to us. There were three other people who live at the home seated in armchairs. One man got up and started undressing himself. We were concerned so we went into the large lounge to try to find a member of staff. There were no staff in the lounge. Two people in the lounge were visibly distressed. We saw that one person had a substantial amount of a yellow substance on their chin and clothing. The substance was seen to be congealed liquid, and had the same appearance as the soup served at supper. Supper had been served more than three hours earlier. Another person sitting in the lounge at the time called out several times that they wanted help to get to bed. The person was becoming distressed. We reassured the person and went to find a member of staff. Our observations during the day, in the communal areas of the home and in peoples bedrooms, show that peoples needs in respect of their mental health are not being met at the home. There were long periods of time when people were sitting with nothing to do. Research quoted by the Alzheimers Society states that inactivity and low levels of engagement contribute to loss of physical function, social isolation, behavioural symptoms and poor quality of life. We say more about this in the section on Daily Life and Social Activities. At the previous random inspections that took place in July 2010, seven requirements were made with respect to how the home was managing the medicines of the people who used the service. We found at this inspection that the home had met two of these requirements but still needed to improve in some areas in order to comply with the other four requirements. Care Homes for Older People Page 14 of 36 Evidence: We found that the security of medicines had improved because the nursing staff were now keeping the keys to the trolleys and medication storage cupboards on their person. We found that they had put in place process to ensure that the nursing staff were not disrupted during the medication rounds, and therefore this meant that the rounds were being completed more efficiently, and people using the service were receiving their medicines much closer to the times specified on the administration records. We also found that the nursing staff had attended training on the safe handling of medicines. We also found that the home had introduced and carried out assessments on the majority of the nursing staff to establish their competency to handle and administer medicines safely. The home had found that the nursing staff that had been assessed were competent to handle and administer medicines safely, however in light of what was found below the home need to take further action on this. We found that the home had introduced a medication handover sheet which was used to communicate issues around medication to the new shift members. We found that this process had contributed to the home ensuring that medicines were available in the home to be administered. In order to assess whether medicines were being administered as prescribed an audit of the medication records was carried out on a number of people living in the home. With the first person we examined we found a capsule of a medicine used to treat Parkinsons disease was missing from the monitored dosage system, and we could find no explanation for this. We also found with a medicine that was used to treat conditions related to excess stomach acid that 28 capsules had been received by the home and the records showed that 17 of these capsules had been administered. We therefore expected to find 11 capsules remaining instead we found 12 capsules. We found with some analgesic tablets which had been prescribed with a variable dose that the home had not fully recorded the amount that was administered. This meant that we were unable to establish whether this medicine was being administered in accordance with the prescribers directions. We also found with some medicine that was used to treat anxiety that although the home had introduced a stock count system, the nursing staff had failed to record the quantity of these tablets that were present in the mobile drug trolley. We attempted to establish whether the administration of one of these tablets shown on the administration records was the only tablet that had been administered in the current medication cycle. But due to previous poor record keeping and the home not having a having a carry forward Care Homes for Older People Page 15 of 36 Evidence: system in place this proved impossible. We found with some medicine that was used to treat epileptic seizures that 55 tablets had been carried forward into the new monthly cycle and the records showed that 31 of these tablets had been administered. We therefore expected to find 24 tablets remaining however we found 25 tablets. This was the second indication for this person that medicines were being signed for but not actually given. With the second person we looked at we found that 500ml of a medicine that was used to treat constipation had been carried forward from the previous medication cycle. The records showed that 465ml had been used by the home so we expected find approximately 35 ml remaining in the bottle. We measured the quantity found in the bottle and this was found to be 200ml. The home acknowledged that this medicine had not been administered correctly. We also found with some tablets used in the treatment of calcium deficiency that 56 tablets had been received and 32 of these tablets had been administered according to the administration records. We therefore expected to find 24 tablets remaining instead we found 28 tablets still present in their box The third person we looked at identified another failing in the record keeping of medicines. We found that the person concerned had been refusing to take a diuretic tablet and as a consequence that nursing staff had been discarding the tablets. We found that the destruction of these tablets had not been recorded and therefore there was no audit trail for these tablets. With the fourth person we looked at we found that this person had been prescribed an analgesic patch the day before the inspection. We found that this patch had not been applied because the doctor had directed that only half of the patch was to be applied and the nursing staff did not know whether this was safe to do so. The concern here was that none of the nursing staff had raised their concerns with the doctor or had contacted the manufacturer for advice and the impression the inspector got was that this issue would not been sorted out until the doctors next visit which would be in four days time. After direction from the inspector the issue was sorted out . We examined the thermometer of the fridge that was being used to store medicines. We found that the thermometer was displaying a minimum reading of minus ten degrees Celsius, a maximum reading of five degrees Celsius, and an ambient temperature of minus four degrees Celsius. These reading were clearly outside the accepted temperature range of between two and eight degrees Celsius. We examined the fridge temperature records as far back as January 2010 and found that the fridge had not been maintained within the expected temperature range over this period. Care Homes for Older People Page 16 of 36 Evidence: Worryingly it was seen that the nursing staff were recording temperatures that were below zero degrees Celsius and were indicating on the record sheet that no action was required. Upon discovering this problem the home managed to obtain a new fridge and thermometer by lunchtime. The home now needs to ensure that the medicines stored in this fridge are kept within the expected temperature range. The home was also advised to discard the contents of the fridge and obtain new supplies. We also found on the day of the inspection that the temperature of the room where the medicines were stored was too hot for the safe storage of medicines. The temperature was recorded at 27 degrees Celsius and the maximum temperature stated by manufacturers is 25 degrees Celsius. A member of the nursing staff confirmed that the home was not monitoring this temperature. The evidence shows that peoples needs are not being met at Holmer Care Centre, and we have served Statutory Requirement Notices on the home, requiring them to make significant improvements within a short space of time. On the day of the inspection, we saw some staff talking kindly to people and taking time to reassure them. However, on several occasions we saw staff going in and out of rooms without talking to the people in them. At lunchtime in one of the upstairs lounges, we saw that one person was becoming very distressed. She was crying out loudly and was very agitated. Several staff came in and out of the room without acknowledging her distress in any way or making any attempt to calm her down. When we spoke to the person and reassured her, she quickly became calmer. It is not acceptable that staff should ignore someones distress, especially anyone who is as vulnerable as the people who live at Holmer Care Centre. We asked care staff how they find out information about the needs of the people they are caring for. They told us that they look at a notice board in the staff area of the home. We saw that this board identified people by name, and included personal details about them. One person had the comment sore groins written beside their name. We saw maintenance and kitchen staff passing the notice board. This shows a basic lack of understanding about peoples right to have their privacy and dignity respected. Care Homes for Older People Page 17 of 36 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 home provides a limited range of activities for people to take part in, but these are not planned to take into account peoples individual wishes and preferences. Meals provide a nutritious and balanced diet. Evidence: People living at the home and the staff were positive about the homes activities coordinator, who works part-time for fifteen hours a week. She organises activities such as baking, quizzes, pet therapy, one to one reading, and memory sessions. However we were told that she is the only person with access to the activities cupboard, and so for most of the time, there are no activities planned or carried out. During the inspection, we saw that people were sitting for long periods of time with no stimulation or staff interaction. We looked in the large downstairs lounge to see what books and magazines had been provided by the home. We found a book on soft toy making which was stuck to a bookshelf with an unidentifiable sticky substance, and on the same bookshelf we found the crumpled front cover of a gossip magazine and a used paper napkin. We saw that there were several rummage boxes in the lounge. These contained textured fabrics and other sensory items. However we did not see these being used during the day, and we saw that they were not within the reach of Care Homes for Older People Page 18 of 36 Evidence: anyone sitting in the lounge. The records did not show that the home provides individualised activities based on peoples interests. The records contained only a list of some things they like to do, such as flowers and reading. Their wishes and goals in respect of their lifestyle had not been identified, and care plans were not based on their interests or what they would like to do and achieve. Care plans were extremely brief and sometimes confusing. For example, in one persons care plan, under the heading dates to remember, a date had been written in but there was no explanation as to why this was an important date for the person. Care plans did not show any understanding of the importance of ensuring that activities are planned as part of a person-centred approach to care. The Alzheimers Society states that The uniqueness of each individual with dementia means that activities and occupation need to be tailored to their individual needs. We asked the Director of Nursing if people living at the home take part in any of the tasks within the home, such as folding clean laundry or laying tables. She told us that this does not happen. Research has shown that having something meaningful to do is an important part of quality of life, and this would be a way of providing activities which people might enjoy and which would make them feel valued. We saw that staff are very welcoming to family and friends when they visit, and the AQAA states The rights of citizenship are respected. For example residents are offered the choice to participate in voting. The Alzheimers Society has identified access to outside space, such as a garden, as having many positive benefits for people with dementia. Holmer Care Centre has a garden space which is planted with colourful flowers. We have visited the home on three occasions over the summer, and have never see anyone out in the garden, even on hot and dry days. The provider has told us that the The Director of Nursing has witnessed people in the garden over the summer and one person was seen by the Director of Nursing enjoying an afternoon in the garden with their relative, including meals being served under the gazebo on the patio. One person in particular has enjoyed watering the plants - she has identified which areas need watering and instructed staff on how much to apply. During this process she has reminisced about her life on the farm and her own patch of garden as a child. The Director of Nursing has witnessed this on several occasions during the summer months. A relative told us that the door from the main lounge into the garden is kept locked, and commented its a shame that they cant go out, but theres not enough staff to take them out. Care Homes for Older People Page 19 of 36 Evidence: The homes menus show that there is a wide variety of meals, and they provide a nutritious and balanced diet. Two relatives told us that the food is very good - top notch and lovely, lots of fresh veg. We saw that improvements have been made so that people downstairs can eat in a sociable environment. One of the lounges has been made into a dining room, and we saw that people were able to help themselves to vegetables from serving dishes on the tables. This is good practice, as it encourages people to maintain their independence and gives them more choice. Lunchtime service upstairs was not a sociable or peaceful time. People had their lunch served to them whilst seated in armchairs in the lounges. The food was brought in on trays and placed on small individual tables. There were not enough tables for each person, so staff had to keep moving furniture around so that people could reach their food. We saw that some people were wearing blue plastic aprons while they were eating. This is not a practice which promotes dignity, and the Director of Nursing assured us that a more appropriate method of protecting peoples clothes would be provided. We observed staff supporting people to eat. In general staff were kind and caring and took time to ensure that people were not rushed. However we saw one care worker get up in the middle of supporting someone with their lunch and hand over the task to another care worker. This is poor practice and shows a lack of respect for the person. At suppertime, we saw that one person who was in a wheelchair had not been placed so that he could easily eat his food. The supper was soup, and as he lifted and tipped his spoon, the soup was spilled down his clothing. Staff were unaware that this was happening until we pointed it out to them. During the day of the inspection, we saw many people with food stains on their clothing, some of which appeared to be dried on. Food debris was not cleared up promptly after meals, and we say more about this in the section on Environment. Care Homes for Older People Page 20 of 36 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 cannot be fully confident that concerns will be listened to and resolved. Staff know who to contact if people are abused, but evidence elsewhere in the report shows that people at the home are at risk of neglect. Evidence: The home has a detailed complaints procedure, which is given to everyone who moves into the home. We saw that the complaints procedure is in the Service User Guide, a copy of which is kept by the front door. We looked at the homes records of complaints received and saw that two had been recorded in the past year. Records showed that these had been resolved. One relative told us that they would feel comfortable raising any concerns with staff at the home, but that concerns were not always resolved promptly. They mentioned the oppressive heat in one of the upstairs lounges, and said that despite the fact that they had raised this as a concern on many occasions, there had been no effective response. We found that the lounge was extremely hot, with the thermometer reading 80 degrees Fahrenheit. One of the ways in which the home can protect people who live there is by ensuring that staff know about their role in preventing abuse or neglect. Although records showed that some staff had been trained, not all staff had received this training. The Director of Nursing told us that training in this area was due to be provided soon. Care Homes for Older People Page 21 of 36 Evidence: However, staff knew how to report any concerns about possible abuse or neglect. Whilst staff know how to report their concerns about possible abuse or neglect, we were concerned that they had failed to recognise potential neglect in some circumstances. We have talked about these issues in the report in the section on Health and Personal Care. During the past year, the Local Authority has made us aware of incidents which they have investigated under their procedures for protecting vulnerable adults. Some of these incidents had not been reported by the home as they should have been. One of the ways in which people can be protected from the risk of neglect or abuse is to ensure that unsuitable staff are not employed. We saw that staff recruitment procedures at the home are robust, and help to protect people by making sure that only suitable staff are employed. Care Homes for Older People Page 22 of 36 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. Holmer Care Centre does not provide a safe or homely environment for people, and the home is not kept clean and hygienic. Evidence: Holmer Care Centre is a specialist nursing home for the care of people with a dementia illness. As such, we would expect the home to provide a stimulating and safe environment for the people who live there. Unfortunately this is not the case. The home is a large building with people accommodated on two floors. There are some long corridors which do not provide visual cues to help people orientate themselves around the home. At one of our previous inspections, we had suggested that visual cues might help people to identify important rooms such as toilets. We saw that toilet doors have been painted red, and the Director of Nursing told us that this had been done to help people find the toilets easily. We checked one of the doors which had been painted red. It was locked and a member of staff told us that it was always kept locked because equipment was stored there. This could be very confusing for someone with dementia. We were surprised to find that there was actually no toilet in the room when it was eventually unlocked, therefore this would have been even more confusing for anyone who had managed to get into the room. There are four lounges at the home, one of which has been designated as the quiet Care Homes for Older People Page 23 of 36 Evidence: lounge. There is a dining room on the ground floor, and the Director of Nursing told us that there are plans to make one of the upstairs lounges into a dining area. We found that the lounges in general did not provide a stimulating environment for people. In one lounge the large television was on with the sound turned down, which again could have confused people with dementia. In the evening, loud pop music was playing in the large lounge downstairs, and one person was distressed and asked us to turn it off. At the previous two inspections of the home in July 2010, we had raised serious concerns about cleanliness and infection control within the home. We had made requirements that the home must ensure that the environment is clean and hygienic. We were very disappointed to find that there was still clear evidence of very poor standards of hygiene and infection control. We found commodes and toilet frames which were visibly dirty with brown stains. We found armchairs which were smeared with a brown substance, and a dining chair stored in a bathroom which was also smeared with a brown substance. We saw food debris on the floors of several of the communal rooms long after mealtimes. This is a particular risk to people with dementia, as they may not realise that they should not eat these scraps of food. We saw that some of the food was meat products, and as the temperature in at least one of the rooms was 80 degrees Fahrenheit, this could pose a risk of food poisoning. We saw an open waste bin in the first floor area by the lift. The bin itself was visibly dirty, with substances adhering to the base and sides of the bin. The bin was lined with a plastic bag, and contained gloves of the type used for providing personal care, a white plastic apron of the type used for providing personal care, soiled tissues and food debris. Throughout the home, we saw that clinical waste was not disposed of safely and in a manner which would help to prevent the spread of infection. At several times during the day inspection, we had seen two people living at the home sitting on pressure-relieving cushions in the large lounge on the ground floor. In the evening we checked these cushions, as we had noticed that they appeared to be in poor condition. One cushion was stained with brown staining to the interior of the cover and to the foam interior. A foul odour was emanating from the second cushion, Care Homes for Older People Page 24 of 36 Evidence: and it was found to have extensive brown staining to the interior of the cover, and the foam interior of the cushion was seen to be heavily stained with a foul smelling brown substance. We showed the two cushions to the Director of Nursing, who assured us that the cushions would be disposed of immediately. We have served a Statutory Requirement Notice on the home requiring them to make sure that the home is kept clean and hygienic. Care Homes for Older People Page 25 of 36 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. Staff do not always receive the training they need to provide support for people living at the home. There are not enough staff on duty to meet peoples needs. Evidence: We spoke to relatives of people living at Holmer Care Centre, and they were very positive about the staff at the home, describing most of them as kind, helpful and lovely. However, one relative told us that some staff dont seem to have the patience. Another told us that some staff, who do not have English as their first language, do not always find it easy to understand what is being said to them. During the inspection, we saw that staff were kind and caring when they supported people, and all the staff we spoke to were able to communicate with us. Although we were informed that all the staff working at the home had been trained in dementia care, the whole culture of the home does not promote person-centred care. The Alzheimers Society describes person-centred care as Instead of treating the person as a collection of symptoms and behaviours to be controlled, person-centred care considers the whole person, taking into account each individuals unique qualities, abilities, interests, preferences and needs. We saw some staff behaving in a way which made us think that they did not understand the principles of person-centred care. For example, a staff member passed someone their pudding at lunchtime, and said to them pudding, pudding, pudding in a childish voice. As described in the Care Homes for Older People Page 26 of 36 Evidence: section on Health and Personal Care, we saw staff ignoring someone who was clearly distressed. It was sometimes difficult to reconcile the caring and kind approach of staff to individual people with the seemingly uncaring and unkind way in which people were left in a state of distress or did not have a dressing applied when necessary (as described in the section on Health and Personal Care). We say more about staff attitudes in the section on Management and Administration. We checked to see if staff had been recruited safely, and we found that the homes recruitment procedures ensure that only suitable staff are employed. We continue to have serious concerns about staffing levels at the home. The home uses a Staffing Level Analysis to help them determine the level of staffing required. This categorises the dependency levels of each person living at the home and uses a calculation to find out how many staff are needed. We saw that the Staffing Level Analysis showed that everyone living at the home had been assessed as having a medium dependency level. The homes own records show that sixteen people living at the home have been assessed as being immobile, so it is hard to see how these people can only have medium dependency. We have not been able to find out how the home assesses the dependency levels of each person, but the evidence throughout the inspection shows that there are not enough staff to meet peoples individual needs. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home lacks direction and leadership, and this has had a negative impact on people living at the home. Some aspects of health and safety are not adequately managed. Evidence: The two recent random inspections and this inspection have raised serious concerns about the management of the home. The home has been without a registered manager since April 2010. However, many of the areas of concern have obviously been ongoing for a long time. It is the providers responsibility to ensure that the home is managed in a way which promotes and protects the rights of the people who live there. Providers are required to carry out monthly visits to ensure that the home is providing a safe standard of care. We saw that these monthly visits had been carried out and had been recorded. However, the evidence of the inspection showed that the home is not providing a safe standard of care and that standards have deteriorated significantly over a period of Care Homes for Older People Page 28 of 36 Evidence: time. There are interim management measures in place at the home, but these do not appear to be effective, as there has not been any improvement in some key areas which we identified in our two inspections in July 2010. The home has shown that health and safety issues are not well managed. We have highlighted our concerns about hygiene standards and poor infection control measures. We found other areas of concern, such as the lagging around hot water pipes in communal areas, which was torn with parts missing. This could place people at risk of being burned. We have serious concerns about some of the shortfalls which we have found at Holmer Care Centre. Some of them show a lack of understanding of what constitutes good care for people with dementia. Some of them show a disregard for peoples basic rights as human beings. When added together, they give a picture of a service which poses a very high risk of poor outcomes for the vulnerable people who live at the home. The Local Authority and Herefordshire Primary Care Trust have made us aware of their own concerns about the service, and we are working closely with them under the local procedures for safeguarding vulnerable adults. We will continue to monitor the home closely and will take legal action if necessary to protect the people who live there. Care Homes for Older People Page 29 of 36 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 36 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 12 (1) You must put in place effective systems to ensure all information relating to a persons needs, health and welfare are reviewed as needed to ensure their health and welfare needs are met at all times. This requirement is subject to a Statutory Requirement Notice. This is so that peoples needs can be met. 13/09/2010 2 7 12 (1) You must put in place effective systems to ensure care plans are used effectively to monitor peoples health and welfare needs. This requirement is subject to a Statutory Requirement Notice. 13/09/2010 Care Homes for Older People Page 31 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that peoples needs can be met. 3 8 13 (5) You must ensure that 11/10/2010 staff support people with their mobility needs safely and in accordance with good practice. This is so that people are not at risk of harm or injury. 4 8 12 (1) You must put in place 13/09/2010 arrangements to ensure that the proper provision for the health and welfare, care and where appropriate, treatment, of all people using the service. This requirement is subject to a Statutory Requirement Notice. This is so that peoples needs can be met. 5 9 13 (2) You must ensure that staff are aware of the written procedure for the administration of medicines, which is monitored to make sure that the nursing staff follow safe practices. This requirement is subject to a Statutory Requirement Notice. 27/09/2010 Care Homes for Older People Page 32 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that people can be confident that medication is managed safely. 6 9 13 (2) You must ensure that 27/09/2010 accurate records are maintained of all medicines in the Home and where discrepancies are found take appropriate action to rectify the problems. This requirement is subject to a Statutory Requirement Notice. This is so that people can be confident that medication is managed safely. 7 9 13 (2) You must make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This requirement is subject to a Statutory Requirement Notice. This is so that people can be confident that medication is managed safely. 8 10 12 (4) You must ensure that the home is conducted in such a way that service 11/10/2010 27/09/2010 Care Homes for Older People Page 33 of 36 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 users are treated in a manner that respects their privacy and dignity at all times. This is so that people can be confident that their right to privacy and dignity will be respected. 9 12 16 (2) (m)(n) You must put an effective system in place to ensure that peoples individual needs in respect of social and leisure activities are clearly identified and met. This is to ensure that people lead fulfilling lives at the home. 10 26 13 (3) You must make arrangements to ensure the care home is free from offensive odours and make suitable arrangements for secure storage of clinical waste at the home at all times. This requirement is subject to a Statutory Requirement Notice. This is so that people are not at risk of harm or injury. 11 26 13 (3) You must make suitable arrangements for 13/09/2010 13/09/2010 11/10/2010 Care Homes for Older People Page 34 of 36 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 maintaining satisfactory standards of hygiene in the home so as to prevent and control the risk of infection. This requirement is subject to a Statutory Requirement Notice. This is so that people are not at risk of harm or injury. 12 38 13 (4)(a) You must ensure that potential risks of uncovered heated surfaces around the home are assessed, and control measures put into place where a risk has been identified. This is so that peoples health and safety are protected. 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 11/10/2010 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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